Document:

exv10w4

Exhibit 10.4

AMENDMENT NUMBER 4

CONTRACTOR RISK AGREEMENT

BETWEEN

THE STATE OF TENNESSEE,

d.b.a. TENNCARE

AND

AMERIGROUP TENNESSEE, INC.

CONTRACT NUMBER: FA- 07-16936-00

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

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

	1.	 	The preamble shall be amended to add references to long-term care services and
delete references to “State Onlys and Judicials” and shall read as follows:

This Agreement is entered into by and between THE STATE OF TENNESSEE, hereinafter
referred to as “TENNCARE” or “State” and AMERIGROUP, Tennessee, Inc., hereinafter
referred to as “the CONTRACTOR”.

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

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

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

     WHEREAS, the CONTRACTOR is a Managed Care Organization as described in the 42
CFR Part 438, is licensed to operate as an HMO in the State of Tennessee, has met
additional qualifications established by the State, is capable of providing or
arranging for the provision of covered services to persons who are enrolled in the
TennCare

Page 1 of 374

 

program for whom it has received prepayment, is engaged in said business, and is willing to
do so upon and subject to the terms and conditions hereof;

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

	2.	 	Section 1 shall be deleted in its entirety and replaced with the following:

SECTION 1 — DEFINITIONS, ACRONYMS, AND ABBREVIATIONS

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

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

	 	1.	 	Meeting general requirements in Section 2.2;
	 
	 	2.	 	Enrollment and disenrollment in accordance with Section 2.4 and 2.5;
	 
	 	3.	 	Additional services and use of incentives in Section 2.6.6;
	 
	 	4.	 	Health education and outreach in Section 2.7.4;
	 
	 	5.	 	Meeting requirements for coordination of services specified in Section 2.9, including
care coordination for CHOICES members and the CONTRACTOR’s electronic visit verification
system except as otherwise provided in Section 3;
	 
	 	6.	 	Establishing and maintaining a provider network in accordance with the requirements
specified in Section 2.11, Attachments III, IV and V;
	 
	 	7.	 	Utilization Management as specified in Section 2.14;
	 
	 	8.	 	Quality Management and Quality Improvement activities as specified in Section 2.15;
	 
	 	9.	 	Production and distribution of Member Materials as specified in Section 2.17;
	 
	 	10.	 	Customer service requirements in Section 2.18;
	 
	 	11.	 	Complaint and appeals processing and resolution in accordance with Section 2.19;
	 
	 	12.	 	Determination of recoveries from third party liability resources in accordance with
Section 2.21.4;
	 
	 	13.	 	Claims Processing in accordance with Section 2.22;

Page 2 of 374

 

	 	14.	 	Maintenance and operation of Information Systems in accordance with Section 2.23;
	 
	 	15.	 	Personnel requirements in Section 2.29;
	 
	 	16.	 	Production and submission of required reports as specified in Section 2.30;
	 
	 	17.	 	Administration of this Agreement in accordance with policies and procedures;
	 
	 	18.	 	All other Administration and Management responsibilities as specified in Attachments
II through IX and Sections 2.20, 2.21, 2.24, 2.25, 2.26, 2.27, and 2.28;
	 
	 	19.	 	Premium tax; and
	 
	 	20.	 	Costs of subcontractors engaged solely to perform a non-medical administrative
function for the CONTRACTOR specifically related to securing or fulfilling the
CONTRACTOR’s obligations to TENNCARE under the terms of this Agreement (e.g., claims
processing) are considered to be an “administrative cost”.

Adult Protective Services (APS) — An office within the Tennessee Department of Human
Services that investigates reports of abuse, neglect (including self-neglect) or financial
exploitation of vulnerable adults. APS staff assess the need for protective services and
provide services to reduce the identified risk to the adult.

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

Affiliate — Any person, firm, corporation (including, without limitation, service
corporation and professional corporation), partnership (including, without limitation, general
partnership, limited partnership and limited liability partnership), limited liability company,
joint venture, business trust, association or other entity or organization that now or in the
future directly or indirectly controls, is controlled by, or is under common control with the
CONTRACTOR.

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

Area Agency on Aging and Disability (AAAD) — The agency designated by the Tennessee
Commission on Aging and Disability (TCAD) to develop and administer a comprehensive and coordinated
community based system in, or serving, a defined planning and service area.

At-Risk — As it relates to the CHOICES program, SSI eligible adults age sixty-five (65)
and older or age twenty-one (21) or older with physical disabilities, who do not meet the
established level of care criteria for nursing facility services, but have a lesser number or level
of functional deficits in activities of daily living as defined in TennCare rules and regulations,
such that, in the absence of the provision of a moderate level of home and community based
services, the individual’s condition and/or ability to continue living in the community will likely
deteriorate, resulting in the need for more expensive institutional placement.

Page 3 of 374

 

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

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

Behavioral Health Services — Mental health and/or substance abuse services.

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

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

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

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

Capitation Payment — The fee that is paid by TENNCARE to the CONTRACTOR for each member
covered by this Agreement. The CONTRACTOR is at financial risk as specified in Section 3 of this
Agreement for the payment of services incurred in excess of the amount of the capitation payment.
“Capitation Payment” includes Base Capitation Rate payments and Priority Add-on rate payments,
unless otherwise specified.

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

Care Coordinator — The individual who has primary responsibility for performance of care
coordination activities for a CHOICES member as specified in this Agreement and meets the
qualifications specified in Section 2.9.6.

Care Coordination Team — If an MCO elects to use a care coordination team, the care
coordination team shall consist of a care coordinator and specific other persons with relevant
expertise and experience who are assigned to support the care coordinator in the performance of
care coordination activities for a CHOICES member as specified in this Agreement and in accordance
with Section 2.9.6.

Care Coordination Unit — A specific group of staff within the MCO’s organization dedicated
to CHOICES that is comprised of care coordinators and care coordinator supervisors and which may
also include care coordination teams.

Caregiver — For purposes of CHOICES, a person who is (a) a family member or is unrelated to
the member but has a close, personal relationship with the member and (b) routinely involved in

Page 4 of 374

 

providing unpaid support and assistance to the member. A caregiver may be also designated by the
member as a representative for CHOICES or for consumer direction of HCBS.

CEA — Cost Effective Alternative (see Section 2.6.5 of this Agreement).

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

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

CFR — Code of Federal Regulations.

Child Protective Services (CPS) — A program division of the Tennessee Department of
Children’s Services whose purpose is to investigate allegations of child abuse and neglect and
provide and arrange preventive, supportive, and supplementary services.

CHOICES Group (Group) — One of the three groups of TennCare enrollees who are enrolled in
CHOICES. There are three CHOICES groups:

	 	1.	 	Group 1
	 
	 	 	 	Medicaid enrollees of all ages who are receiving Medicaid-reimbursed care in a nursing facility.
	 
	 	2.	 	Group 2
	 
	 	 	 	Persons age sixty-five (65) and older and adults age twenty-one (21) and older with
physical disabilities who meet the nursing facility level of care, who qualify for TennCare
either as SSI recipients or as members of the CHOICES 217-Like HCBS Group, and who need and
are receiving HCBS as an alternative to nursing facility care. The CHOICES 217-Like HCBS
Group includes persons who could have been eligible under 42 CFR 435.217 had the state
continued its 1915(c) HCBS waiver for elders and/or persons with physical disabilities.
TENNCARE has the discretion to apply an enrollment target to this group, as described in
TennCare rules and regulations.
	 
	 	3.	 	Group 3
	 
	 	 	 	Persons age sixty-five (65) and older and adults age twenty-one (21) and older with
physical disabilities who qualify for TennCare as SSI recipients, who do not meet the
nursing facility level of care, but who, in the absence of HCBS, are “at-risk” for nursing
facility care, as defined by the State. TENNCARE has the discretion to apply an enrollment
target to this group, as described in TennCare rules and regulations. Group 3 will not be
included in CHOICES on the date of CHOICES implementation. TENNCARE intends to include
CHOICES Group 3 on January 1, 2011. TENNCARE will notify the CONTRACTOR at least sixty (60)
days prior to the proposed date for including Group 3 in CHOICES. As of the date specified
in that notice, the CONTRACTOR shall accept members in CHOICES Group 3 and shall implement
all of the requirements in this Agreement that are applicable to CHOICES Group 3.

Page 5 of 374

 

CHOICES Implementation Date — The date, as determined by TENNCARE, when the CONTRACTOR
shall begin providing long-term care services to CHOICES members.

CHOICES Member — A member who has been enrolled by TENNCARE into CHOICES.

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

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

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

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

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

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

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

CMS — Centers for Medicare & Medicaid Services.

Community-Based Residential Alternatives to Institutional Care (Community-Based Residential
Alternatives) — Residential services that offer a cost-effective, community-based alternative
to nursing facility care for persons who are elderly and/or adults with physical disabilities. This
includes, but is not limited to, assisted care living facilities, adult care homes, and companion
care.

Page 6 of 374

 

Complaint — A written or verbal expression of dissatisfaction from a member about an
action taken by the CONTRACTOR or service provider other than an adverse action. The CONTRACTOR
shall not treat anything as a complaint that falls within the definition of adverse action.

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

Consumer — Except when used regarding consumer direction of HCBS, an individual who uses a
mental health or substance abuse service.

Consumer-Directed Worker (Worker) — An individual who has been hired by a CHOICES member
participating in consumer direction of HCBS or his/her representative to provide one or more
eligible HCBS to the member. Worker does not include an employee of an agency that is being paid by
an MCO to provide HCBS to the member.

Consumer Direction of HCBS — The opportunity for a CHOICES member assessed to need
specified types of HCBS including attendant care, personal care, homemaker, in-home respite,
companion care and/or any other service specified in TennCare rules and regulations as available
for consumer direction to elect to direct and manage (or to have a representative direct and
manage) certain aspects of the provision of such services—primarily, the hiring, firing, and day-
to-day supervision of consumer-directed workers delivering the needed service(s).

Cost Neutrality Cap — The requirement that the cost of providing care to a member in
CHOICES Group 2, including HCBS, home health, and private duty nursing, shall not exceed the cost
of providing nursing facility services to the member, as determined in accordance with TennCare
policy.

Covered Services — See Benefits.

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

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

	 	Group 1   —   	 	 Persons with Severe and Persistent Mental Illness (SPMI)
	 
	 	Group 2   —   	 	 Persons with Severe Mental Illness (SMI)
	 
	 	Group 3   —   	 	 Persons who were Formerly Severely Impaired and need services to prevent relapse
	 
	 	Group 4   —   	 	 Persons with Mild or Moderate Mental Disorder
	 
	 	Group 5   —   	 	 Persons who are not in Clinically Related Groups 1 — 4 as a result of their
diagnosis being substance use disorder, developmental disorder, or V-codes

Days — Calendar days unless otherwise specified.

Page 7 of 374

 

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

DHHS — United States Department of Health and Human Services.

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

Electronic Visit Verification (EVV) System — An electronic system into which provider
staff and consumer-directed workers can check-in at the beginning and check-out at the end of each
period of service delivery to monitor member receipt of HCBS and which may also be utilized for
submission of claims.

Eligible — Any person certified by TENNCARE as eligible to receive services and benefits
under the TennCare program. As it relates to CHOICES a person is eligible to receive CHOICES
benefits only if he/she has been enrolled in CHOICES by TENNCARE.

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

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

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

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

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

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

Evidence-Based Practice — A clinical
intervention that has demonstrated positive outcomes
in several research studies to assist consumers in achieving their desired goals of health and
wellness; specifically, the evidence-based practices recognized by the Substance Abuse and

Page 8 of 374

 

Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services (CMHS).

Expenditure Cap — The annual limit on expenditures for HCBS, excluding home
modifications, for CHOICES members in CHOICES Group 3. The expenditure cap is $15,000.

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

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

Fiscal Employer Agent (FEA) — An entity contracting with the State and/or an MCO that
helps CHOICES members participating in consumer direction of HCBS. The FEA provides both financial
administrative services and supports brokerage to CHOICES members participating in consumer
direction of HCBS.

FQHC — Federally Qualified Health Center.

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

	East Grand Region – 	 	Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke,
Franklin, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hawkins, Jefferson, Johnson,
Knox, Loudon, Marion, McMinn, Meigs, Monroe, Morgan, Polk, Rhea, Roane, Scott, Sequatchie,
Sevier, Sullivan, Unicoi, Union, and Washington Counties
	 
	Middle Grand Region – 	 	 Bedford, Cannon, Cheatham, Clay, Coffee, Cumberland, Davidson, DeKalb,
Dickson, Fentress, Giles, Hickman, Houston, Humphreys, Jackson, Lawrence , Lewis, Lincoln,
Macon, Marshall, Maury, Montgomery, Moore, Overton, Perry, Pickett, Putnam, Robertson,
Rutherford, Smith, Stewart, Sumner, Trousdale, Van Buren, Warren, Wayne, White,
Williamson, and Wilson Counties
	 
	West Grand Region – 	 	 Benton, Carroll, Chester, Crockett, Decatur, Dyer, Fayette, Gibson,
Hardeman, Hardin, Haywood, Henderson, Henry, Lake, Lauderdale, Madison, McNairy, Obion,
Shelby, Tipton, and Weakley Counties

Grand Rounds — As used with respect to CHOICES members residing in a nursing facility, a
planned quarterly meeting between nursing facility staff and MCO staff, including, at minimum, the
care coordinator(s) assigned to residents of the facility conducted in order to: (1) address issues
or concerns regarding members who have experienced a potential significant change in needs or
circumstances or about whom the nursing facility or MCO has concerns (not necessarily all members
who are residents of the facility); (2) identify any change in services or interventions for the
members, including but not limited to changes in the members’ plans of care or supplements to the
members’ plans of care; and (3) facilitate access to and coordination of physical health and/or
behavioral health services needed by the members and to ensure the proper

Page 9 of 374

 

management of the members’ acute and/or chronic conditions. At least two of the quarterly Grand
Rounds per year shall be conducted on-site in the facility.

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

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

HIPAA — Health Insurance Portability and Accountability Act.

Home and Community-Based Services (HCBS) — Services not covered by Tennessee’s Title XIX
state plan that are provided as an alternative to long-term care institutional services in a
nursing facility or an Intermediate Care Facility for the Mentally Retarded (ICF/MR). HCBS does not
include home health or private duty nursing services.

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

Information System(s) (Systems) — A combination of computing and telecommunications
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 as well as non-digitized audio and video; and/or (b) the
processing of information and non-digitized audio and video for the purposes of enabling and/or
facilitating a business process or related transaction.

Immediate Eligibility — A mechanism by which the State can, based on a preliminary
determination of a person’s eligibility for the CHOICES 217-Like HCBS Group, enroll the person into
CHOICES Group 2 and provide immediate access to a limited package of HCBS pending a final
determination of eligibility. To qualify for immediate eligibility, a person must be applying to
receive covered HCBS, be determined by TENNCARE to meet nursing facility level of care, have
submitted an application for financial eligibility determination to DHS, and be expected to qualify
for CHOICES Group 2 based on review of the financial information provided by the applicant.
Immediate eligibility shall only be for specified HCBS (no other covered services) and for a
maximum of forty-five (45) days.

Intervention — An action or ministration that is intended to produce an effect or that is
intended to alter the course of a pathologic process.

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

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

Long-Term Care — The services of a nursing facility (NF), an Intermediate Care Facility
for the Mentally Retarded (ICF/MR), or Home and Community-Based Services (HCBS).

Page 10 of 374

 

Long-Term Care Ombudsman Program — A statewide program for the benefit of individuals
residing in long-term care facilities, which may include nursing homes, residential homes for the
aged, assisted care living facilities, and community-based residential alternatives developed by
the State. The Ombudsman is available to help these individuals and their families resolve
questions or problems. The program is authorized by the federal Older Americans Act and
administered by the Tennessee Commission on Aging and Disability (TCAD).

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

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

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

Medical Expenses — Shall be determined as follows:

	 	1.	 	Medical Expenses include the amount paid to providers for the provision of covered
physical health, behavioral health, and/or long-term care services to members pursuant to
the following listed Sections of the Agreement:

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

	 	2.	 	Medical Expenses do not include:

	 	a.	 	2.6.2 TennCare Benefits Provided by TENNCARE;
	 
	 	b.	 	2.6.7 Cost sharing for services;
	 
	 	c.	 	2.10 Services Not Covered;
	 
	 	d.	 	Services eligible for reimbursement by Medicare; or

Page 11 of 374

 

	 	e.	 	The activities described in or required to be conducted in Attachments II
through X, which are administrative costs.

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

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

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

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

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

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

NAIC — National Association of Insurance Commissioners.

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

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

Office of the Comptroller of the Treasury — The Comptroller of the Treasury is a
State of Tennessee constitutional officer elected by the General Assembly for a term of
two years.
Statutes prescribe the comptroller’s duties, the most important of which relate to audit of state
and local government entities and participation in the general financial and administrative
management of state government.

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

One-Time HCBS — In-home respite, in-patient respite, assistive technology, minor home
modifications, and/or pest control.

Ongoing HCBS — Community-based residential alternatives, personal care, attendant care,
homemaker services, home-delivered meals, and/or adult day care.

PASRR — Preadmission Screening and Resident Review.

Page 12 of 374

 

Patient Liability — The amount of an enrollee’s income, as determined by DHS, to be
collected each month to help pay for the enrollee’s long-term care services.

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

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

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

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

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

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

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

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

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

Page 13 of 374

 

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

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

Provider — An institution, facility, agency, physician, health care practitioner, or other
entity that is licensed or otherwise authorized to provide any of the covered services in the state
in which they are furnished. Provider does not include consumer-directed workers (see
Consumer-Directed Worker); nor does provider include the FEA (see Fiscal Employer Agent).

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

Quality Management/Quality Improvement (QM/QI) — The development and implementation of
strategies to assess and improve the performance of a program or organization on a continuous
basis. This includes the identification of key measures of performance, discovery and data
collection processes, identification and remediation of issues, and systems improvement activities.

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

Representative — In general, for CHOICES members, a person who is at least eighteen (18)
years of age and is authorized by the member to participate in care planning and implementation and
to speak and make decisions on the member’s behalf, including but not limited to identification of
needs, preference regarding services and service delivery settings, and communication and
resolution of complaints and concerns. As it relates to consumer direction of HCBS, a person who
meets the qualifications specified in Section 2.9.7 of this Agreement, is authorized by the member
to direct and manage the consumer’s worker(s), and signs a representative agreement.

Representative Agreement — The agreement between a CHOICES member electing consumer
direction of HCBS who has a representative direct and manage the consumer’s worker(s) and the
member’s representative that specifies the roles and responsibilities of the member and the
member’s representative.

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

Risk Agreement — An agreement signed by a member who will receive HCBS (or his/her
representative) that includes, at a minimum, identified risks to the member of residing in the
community and receiving HCBS, the consequences of such risks, strategies to mitigate the identified
risks, and the member’s decision regarding his/her acceptance of risk. See Section 2.9.6 of this
Agreement for related requirements.

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

Page 14 of 374

 

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

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

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

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

Service Agreement — The agreement between a CHOICES member electing consumer direction of
HCBS (or the member’s representative) and the member’s consumer-directed worker that specifies the
roles and responsibilities of the member (or the member’s representative) and the member’s worker.

Service Gap — A delay in initiating any long-term care service and/or a disruption of a
scheduled, ongoing HCBS that was not initiated by a member, including a late visit that was not
remedied within the timeframe specified by TENNCARE.

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

	 	1.	 	Age 18 and over; and

Page 15 of 374

 

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

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

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

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

SSA — Social Security Administration.

SSI — Supplemental Security Income.

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

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

Page 16 of 374

 

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

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

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

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

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

	 	1.	 	Target Population Group 2: Seriously Emotionally Disturbed (SED)
	 
	 	 	 	Children and adolescents under 18 years of age with a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes.
These children are currently severely impaired as evidenced by 50 or less Global Assessment
of Functioning (GAF).
	 
	 	2.	 	Target Population Group 3: At Risk of a (SED)
	 
	 	 	 	Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent
revisions) diagnosis excluding substance use disorders, developmental disorders or V-codes.
These children may or may not be currently seriously impaired as evidenced by Global
Assessment of Functioning (GAF). These children have psychosocial issues that can
potentially place them at risk of a SED.

Page 17 of 374

 

	 	3.	 	Target Population Group 4: Persons who do not meet criteria TPG Group 2 or 3
	 
	 	 	 	Children and adolescents under 18 years of age without a valid DSM-IV-TR (and subsequent
revisions) diagnosis and are not currently seriously impaired as evidenced by Global
Assessment of Functioning (GAF). These children have no psychosocial issues that can
potentially place them at risk of a SED.

TCA — Tennessee Code Annotated.

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

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

TennCare CHOICES in Long-Term Care (CHOICES) — A program in which long-term care
services for elders and/or persons with physical disabilities are integrated into TennCare’s
managed care delivery system.

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

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

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

TENNderCare — Tennessee’s EPSDT program; see EPSDT.

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

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

Page 18 of 374

 

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

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

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

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

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

Third Party Liability (TPL) — Any amount due for all or part of the cost of medical,
behavioral health, or long-term care services from a third party.

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

Transition Allowance — A per member allotment not to exceed two thousand dollars ($2,000)
per lifetime which may, at the sole discretion of the CONTRACTOR, be provided as a cost-effective
alternative to continued institutional care for a CHOICES member in order to facilitate transition
from a nursing facility to the community when such member will, upon transition, receive more
cost-effective non-residential home and community based services or companion care. Items that may
be purchased or reimbursed are only those items that the member has no other means to obtain and
that are essential in order to establish a community residence when such residence is not already
established and to facilitate the member’s safe and timely transition, including rent and/or
utility deposits, essential kitchen appliances, basic furniture, and essential basic household
items, such as towels, linens, and dishes.

USC — United States Code.

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

Warm Transfer — A telecommunications mechanism in which the person answering the
call facilitates transfer to a third party, announces the caller and issue, and remains
engaged as necessary to provide assistance.

Worker — See Consumer-Directed Worker.

Page 19 of 374

 

	3.	 	Section 2.1.2 shall be amended by adding a new Section 2.1.2.4 and renumbering
existing subparts accordingly, including any references thereto.

	 	2.1.2.4	 	Prior to the date of implementation of CHOICES in the Grand Region covered by this
Agreement, as determined by TENNCARE, the CONTRACTOR shall demonstrate to TENNCARE’s
satisfaction that it is able to meet all requirements related to the CHOICES program.
The CONTRACTOR shall cooperate in this “readiness review,” which may include, but is
not limited to, desk and on-site review of documents provided by the CONTRACTOR, a
walk-through of the CONTRACTOR’s operations, system demonstrations (including systems
connectivity testing), and interviews with CONTRACTOR’s staff. The scope of the review
may include any and all requirements of the Agreement related to the CHOICES program,
as determined by TENNCARE. Based on the results of the review activities, TENNCARE will
issue a letter of findings and, if needed, will request a corrective action plan from
the CONTRACTOR. TENNCARE will not enroll members into the CONTRACTOR’s CHOICES program
until TENNCARE has determined that the CONTRACTOR is able to meet all requirements
related to the CHOICES program.

4. Sections 2.3 shall be deleted in its entirety and replaced with the following:

2.3 ELIGIBILITY FOR TENNCARE

2.3.1 Overview

	 	 	 	TennCare is Tennessee’s Medicaid program operating under the authority of a research and
demonstration project approved by the federal government pursuant to Section 1115 of the
Social Security Act. Eligibility for TennCare is determined by the State in accordance with
federal requirements and state law and policy.

2.3.2 Eligibility Categories

	 	 	 	TennCare currently consists of traditional Medicaid coverage groups (TennCare Medicaid) and
an expanded population (TennCare Standard).

	 	 	2.3.2.1	 	TennCare Medicaid
	 
	 	 	 	 	As provided in state rules and regulations, TennCare Medicaid covers all
Medicaid mandatory eligibility groups as well as various optional categorically
needy and medically needy groups, including children, pregnant women, the aged,
and individuals with disabilities. Additional detail about eligibility criteria
for covered groups is provided in state rules and regulations.
	 
	 	 	2.3.2.2	 	TennCare Standard
	 
	 	 	 	 	TennCare Standard includes the Standard Spend Down (SSD) population, the CHOICES
217-Like HCBS Group, and an expanded population of children. Additional detail
about eligibility criteria for covered groups is provided in state rules and
regulations.

Page 20 of 374

 

2.3.3 TennCare CHOICES Groups

	 	 	 	As specified in Section 2.6.1.5, in order to receive covered long-term care services, a
member must be enrolled by TENNCARE into one of the CHOICES Groups (as defined in Section
1).

2.3.4 TennCare Applications

	 	 	 	The CONTRACTOR shall not cause applications for TennCare to be submitted. However, as
provided in Section 2.9.6.3, the CONTRACTOR shall facilitate members’ eligibility
determination for CHOICES enrollment.

2.3.5 Eligibility Determination and Determination of Cost Sharing

	 	 	 	The State shall have sole responsibility for determining the eligibility of an individual
for TennCare. The State shall have sole responsibility for determining the applicability of
TennCare cost sharing amounts, the collection of applicable premiums, and determination of
patient liability.

2.3.6 Eligibility for Enrollment in an MCO

	 	 	 	Except for TennCare enrollees enrolled in the Program of All-Inclusive Care for the Elderly
(PACE) and enrollees who are only receiving assistance with Medicare cost sharing, all
TennCare enrollees will be enrolled in an MCO, including TennCare Select (see definition in
Section 1 of this Agreement).

5. Section 2.4 shall be deleted in its entirety and replaced with the following:

2.4 ENROLLMENT IN AN MCO

2.4.1 General

	 	 	 	TENNCARE is solely responsible for enrollment of TennCare enrollees in an MCO.

2.4.2 Authorized Service Area

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

2.4.3 Maximum Enrollment

	 	2.4.3.1	 	The CONTRACTOR agrees to accept enrollment in the CONTRACTOR’s MCO of
up to seventy percent (70%) of the eligible population in the applicable Grand

Page 21 of 374

 

	 	 	 	Region. TENNCARE shall determine and notify the CONTRACTOR of the number of
eligibles in the applicable Grand Region and the CONTRACTOR’s maximum enrollment
limit, which shall be approximately seventy percent (70%) of the eligible
population in the applicable Grand Region.
	 
	 	2.4.3.2	 	TENNCARE shall establish an enrollment threshold for the CONTRACTOR that
will equal approximately ninety percent (90%) of the maximum enrollment limit
established in Section 2.4.3.1 above. This enrollment threshold may be adjusted
by TENNCARE at its discretion.
	 
	 	2.4.3.3	 	Once the CONTRACTOR’s enrollment threshold is met, TENNCARE may
discontinue default assignment of enrollees to the CONTRACTOR’s MCO. Enrollees
who select the CONTRACTOR or whose family members are enrolled in the
CONTRACTOR’s MCO shall continue to be enrolled in the CONTRACTOR’s MCO until the
maximum enrollment limit established in Section 2.4.3.1 above is met.
	 
	 	2.4.3.4	 	Both TENNCARE and the CONTRACTOR recognize that management of the
CONTRACTOR’s maximum enrollment limit and enrollment threshold within exact
limits may not be possible. In the event enrollment in the CONTRACTOR’s MCO
exceeds the maximum enrollment limit, TENNCARE may reduce enrollment in the
CONTRACTOR’s MCO based on a plan established by TENNCARE that provides
appropriate notice to the CONTRACTOR, allows appropriate choice of MCOs for
enrollees, and meets the objectives of the TennCare program.
	 
	 	2.4.3.5	 	The establishment of a maximum enrollment limit and/or of an enrollment
threshold
does not obligate the State to enroll a certain number of TennCare enrollees in
the CONTRACTOR’s MCO and does not create in the CONTRACTOR any rights, interests
or claims of entitlement to enrollment. The CONTRACTOR’s actual enrollment level
will be determined through the MCO selection and assignment process described in
Section 2.4.4 below.
	 
	 	2.4.3.6	 	Upon the request of TENNCARE, the CONTRACTOR shall demonstrate to the
satisfaction of TENNCARE it has the capacity to serve the number of enrollees in
the maximum enrollment limit.

2.4.4 MCO Selection and Assignment

	 	2.4.4.1	 	General
	 
	 	 	 	TENNCARE shall enroll individuals determined eligible for TennCare and eligible
for enrollment in an MCO that is available in the Grand Region in which the
enrollee resides. Enrollment in an MCO may be the result of an enrollee’s
selection of a particular MCO or assignment by TENNCARE. Enrollment in the
CONTRACTOR’s MCO is subject to the CONTRACTOR’s maximum enrollment limit and
threshold (see Section 2.4.3) and capacity to accept additional members.

Page 22 of 374

 

	 	2.4.4.2	 	Current TennCare Enrollees
	 
	 	 	 	TennCare enrollees who are known to be eligible for enrollment with the CONTRACTOR as
of the start date of operations (defined in Section 1 of this Agreement) and residing
in the Grand Region served by the CONTRACTOR shall be assigned by TENNCARE to the MCOs
serving the Grand Region in accordance with the process described in Section 2.4.4.6
below. Except as otherwise provided in Section 2.4.4, this includes enrollees currently
enrolled in another MCO, including TennCare Select.
	 
	 	2.4.4.3	 	New TennCare Enrollees
	 
	 	2.4.4.3.1	 	Except as otherwise provided in this Agreement, all non-SSI applicants shall be
required at the time of their application to select an MCO other than TennCare Select
from those MCOs available in the Grand Region where the applicant resides. If the
applicant does not select an MCO, the person will be assigned to an MCO by the State in
accordance with Section 2.4.4.6.
	 
	 	2.4.4.3.2	 	Adults eligible for TennCare as a result of being eligible for SSI benefits will be
assigned to an MCO (other than TennCare Select) by the State.
	 
	 	2.4.4.3.3	 	Children eligible for TennCare as a result of being eligible for SSI will be assigned to
TennCare Select (defined in Section 1 of this Agreement) but may opt-out of TennCare
Select and choose another MCO.
	 
	 	2.4.4.3.4	 	TennCare may allow enrollment of new TennCare enrollees in TennCare Select if there is
insufficient capacity in other MCOs.
	 
	 	2.4.4.4	 	Children in State Custody
	 
	 	 	 	TennCare enrollees who are children in the custody of the Department of Children’s
Services (DCS) will be enrolled in TennCare Select. When these enrollees exit state
custody, they remain enrolled in TennCare Select for a specified period of time and
then are disenrolled from TennCare Select. After disenrollment from TennCare Select, if
the enrollee has a family member in an MCO (other than TennCare Select) he/she will be
enrolled in that MCO. Otherwise, the enrollee will be given the opportunity to select
another MCO. If the enrollee does not select another MCO, he/she will be assigned to an
MCO (other than TennCare Select) using the default logic in the auto assignment process
(see Section 2.4.4.6 below).
	 
	 	2.4.4.5	 	Enrollment in MCO Other than the MCO Selected
	 
	 	 	 	In certain circumstances, if an enrollee requests enrollment in a particular MCO, the
enrollee may be assigned by the State to an MCO other than the one that he/she
requested. Examples of circumstances when an enrollee would not be enrolled in the
requested MCO include, but are not limited to, such factors as the enrollee does not
reside in the Grand Region covered by the requested MCO, the enrollee has other family
members already enrolled in a different MCO, the MCO is closed to new TennCare
enrollment, or the enrollee is a member of a population that is to be enrolled in a
specified MCO as defined by TENNCARE (e.g., children in the custody of the Department
of Children’s Services are enrolled in TennCare Select).

Page 23 of 374

 

	 	2.4.4.6	 	Auto Assignment
	 
	 	2.4.4.6.1	 	TENNCARE will auto assign an enrollee to an MCO, in specified circumstances, including but not limited
to, the enrollee does not request enrollment in a specified MCO, cannot be enrolled in the requested MCO, or is an
adult eligible as a result of receiving SSI benefits.
	 
	 	2.4.4.6.2	 	The current auto assignment process does not apply to children eligible for TennCare as a result of being
eligible for SSI or children in the state’s custody.
	 
	 	2.4.4.6.3	 	There are four different levels to the current auto assignment process:
	 
	 	2.4.4.6.3.1	 	If the enrollee was previously enrolled with an MCO and lost TennCare
eligibility for a period of two (2) months or less, the enrollee will be
re-enrolled with that MCO.
	 
	 	2.4.4.6.3.2	 	If the enrollee has family members in an MCO (other than TennCare Select), the
enrollee will be enrolled in that MCO.
	 
	 	2.4.4.6.3.3	 	If the enrollee is a newborn, the enrollee will be assigned to his/her mother’s
MCO.
	 
	 	2.4.4.6.3.4	 	If none of the above applies, the enrollee will be assigned using default logic that
randomly assigns enrollees to MCOs (other than TennCare Select).

	 
	 	2.4.4.6.4	 	TENNCARE may modify the auto assignment algorithm to change or add criteria
including but not limited to quality measures or cost or utilization management
performance.
	 
	 	2.4.4.7	 	Non-Discrimination
	 
	 	2.4.4.7.1	 	The CONTRACTOR shall
accept enrollees in the order in
which applications are approved and
enrollees are assigned to the
CONTRACTOR (whether by selection or
assignment).
	 
	 	2.4.4.7.2	 	The CONTRACTOR shall
accept an enrollee in the health
condition the enrollee is in at the
time of enrollment and shall not
discriminate against individuals on
the basis of health status or need
for health care services.
	 
	 	2.4.4.8	 	Family Unit
	 
	 	 	 	If an individual is determined eligible for TennCare and has another family member
already enrolled in an MCO, that individual shall be enrolled in the same MCO. This
does not apply when the individual or family member is assigned to TennCare Select. If
the newly enrolled family member opts to change MCOs during the 45-day change period
(see Section 2.4.7.2.1), all family members in the case will be transferred to the new
MCO.

Page 24 of 374

 

2.4.5 Effective Date of Enrollment

	 	2.4.5.1	 	Initial Enrollment of Current TennCare Enrollees
	 
	 	 	 	The effective date of initial enrollment in an MCO for TennCare enrollees who
are enrolled in accordance with Section 2.4.4.2 shall be the date provided on
the enrollment file from TENNCARE. In general, the effective date of enrollment
for these enrollees will be the start date of operations.
	 
	 	2.4.5.2	 	Ongoing Enrollment
	 
	 	 	 	In general, a member’s effective date of enrollment in the CONTRACTOR’s MCO will
be the member’s effective date of eligibility for TennCare. For SSI enrollees
the effective date of eligibility/enrollment is determined by the Social
Security Administration in approving SSI coverage for the individual. The
effective date of eligibility for other TennCare enrollees is the date of
application or the date of the qualifying event (e.g., the date the spend down
obligation is met for medically needy enrollees). The effective date on the
enrollment file provided by TENNCARE to the CONTRACTOR shall govern regardless
of the other provisions of this Section 2.4.5.2.
	 
	 	2.4.5.3	 	In the event the effective date of eligibility provided by TENNCARE to the
CONTRACTOR for either the initial enrollment of current TennCare enrollees or
ongoing enrollment precedes the start date of operations, the CONTRACTOR shall
treat the enrollee as a member of the CONTRACTOR’s MCO effective on the start
date of operations. Although the enrollee is not a member of the CONTRACTOR’s
MCO prior to the start date of operations, the CONTRACTOR shall be responsible
for the payment of claims incurred by the enrollee during the period of
eligibility prior to the start date of operations as specified in Section
3.7.1.2.1.
	 
	 	2.4.5.4	 	TENNCARE will be responsible for the payment of claims for long-term care
services provided to a CHOICES member during the member’s period of TennCare
eligibility prior to the implementation of CHOICES in the Grand Region covered
by this Agreement.
	 
	 	2.4.5.5	 	Enrollment Prior to Notification
	 
	 	2.4.5.5.1	 	Because individuals can be retroactively eligible for TennCare, and the effective
date of initial enrollment in an MCO is the effective date of eligibility or start
date of operations, whichever is sooner, the effective date of enrollment may
occur prior to the CONTRACTOR being notified of the person’s enrollment.
Therefore, enrollment of individuals in the CONTRACTOR’s MCO may occur without
prior notice to the CONTRACTOR or enrollee.
	 
	 	2.4.5.5.2	 	The CONTRACTOR shall not be liable for the cost of any covered services prior to
the effective date of enrollment/eligibility but shall be responsible for the costs of
covered services obtained on or after 12:01 a.m. on the effective date of
enrollment/eligibility.
	 
	 	2.4.5.5.3	 	TENNCARE shall make payments to the CONTRACTOR from the effective date of an
enrollee’s date of enrollment/eligibility. If the effective date of

Page 25 of 374

 

	 	 	 	enrollment/eligibility precedes the start date of operations, payment shall be
made in accordance with Section 3.7.1.2.1. TENNCARE will be responsible for the
payment of claims for long-term care services provided to a CHOICES member
during the member’s period of TennCare eligibility prior to the implementation
of CHOICES in the Grand Region covered by this Agreement.
	 
	 	2.4.5.5.4	 	Except for applicable TennCare cost sharing and patient liability, the CONTRACTOR
shall ensure that members are held harmless for the cost of covered services provided
as of the effective date of enrollment with the CONTRACTOR.

2.4.6 Eligibility and Enrollment Data

	 	2.4.6.1	 	The CONTRACTOR shall receive, process, and update enrollment files from
TENNCARE. Enrollment data shall be updated or uploaded to the CONTRACTOR’s
eligibility/enrollment database(s) within twenty-four (24) hours of receipt from
TENNCARE.
	 
	 	2.4.6.2	 	The CONTRACTOR shall provide an electronic eligibility file to TENNCARE as
specified and in conformance to data exchange format and method standards
outlined in Section 2.23.5.

2.4.7 Enrollment Period

	 	2.4.7.1	 	General
	 
	 	2.4.7.1.1	 	The CONTRACTOR shall be responsible for the provision and costs of all covered
physical health and behavioral health services provided to enrollees during their
period of enrollment with the CONTRACTOR. The CONTRACTOR shall be responsible for the
provision and costs of covered long-term care services provided to CHOICES members as
of the date of CHOICES implementation.
	 
	 	2.4.7.1.2	 	Enrollment shall begin at 12:0 1 a.m. on the effective date of enrollment in the
CONTRACTOR’s MCO and shall end at 12:00 midnight on the date that the enrollee is
disenrolled from the CONTRACTOR’s MCO (see Section 2.5).
	 
	 	2.4.7.1.3	 	Once enrolled in the CONTRACTOR’s MCO, the member shall remain enrolled in the
CONTRACTOR’s MCO until or unless the enrollee is disenrolled pursuant to Section 2.5 of
this Agreement.
	 
	 	2.4.7.2	 	Changing MCOs
	 
	 	2.4.7.2.1	 	45-Day Change Period
	 
	 	 	 	After becoming eligible for TennCare and enrolling in the CONTRACTOR’s MCO
(whether the result of selection by the enrollee or assignment by TENNCARE),
enrollees shall have one (1) opportunity, anytime during the forty-five (45) day
period immediately following the date of enrollment with the CONTRACTOR’s MCO or
the date TENNCARE sends the member notice of enrollment in an MCO, whichever is
later, to request to change MCOs. Children eligible for TennCare as a result of
being eligible for SSI may request to enroll in another MCO or remain with
TennCare Select.

Page 26 of 374

 

	 	2.4.7.2.2	 	Annual Choice Period
	 
	 	2.4.7.2.2.1	 	TENNCARE shall provide an opportunity for members to change MCOs
(excluding TennCare Select) every twelve (12) months. Children eligible for
TennCare as a result of being eligible for SSI may request to enroll in
another MCO or remain with TennCare Select.
	 
	 	2.4.7.2.2.2	 	Members who do not select another MCO will be deemed to have chosen to
remain with their current MCO.
	 
	 	2.4.7.2.2.3	 	Enrollees who select a new MCO shall have one (1) opportunity anytime during
the forty-five (45) day period immediately following the specified enrollment
effective date in the newly selected MCO to request to change MCOs.
	 
	 	2.4.7.2.3	 	Appeal Based on Hardship Criteria

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

2.4.8 Transfers from Other MCOs

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

Page 27 of 374

 

	 	 	 	the Grand Region; however, failure by TENNCARE to provide advance notice shall
not limit in any manner the responsibility of each MCO to accept enrollees from
failed MCOs.

2.4.9 Enrollment of Newborns

	 	2.4.9.1	 	TennCare-eligible newborns and their mothers, to the extent that the mother is
eligible for TennCare, should be enrolled in the same MCO with the exception of
newborns that are SSI eligible at birth. Newborns that are SSI eligible at birth
shall be assigned to TennCare Select but may opt out and enroll in another MCO.
	 
	 	2.4.9.2	 	A newborn may be inadvertently enrolled in an MCO different than its mother.
When such cases are identified by the CONTRACTOR, the CONTRACTOR shall immediately
report to TENNCARE, in accordance with written procedures provided by TENNCARE,
that a newborn has been incorrectly enrolled in an MCO different than its
mother.
	 
	 	2.4.9.3	 	Upon receipt of notice from the CONTRACTOR or discovery by TENNCARE that a
newborn has been incorrectly enrolled in an MCO different than its mother,
TENNCARE shall immediately:
	 
	 	2.4.9.3.1	 	Disenroll the newborn from the incorrect MCO;
	 
	 	2.4.9.3.2	 	Enroll the newborn in the same MCO as its mother with the same effective date as
when the newborn was enrolled in the incorrect MCO;
	 
	 	2.4.9.3.3	 	Recoup any payments made to the incorrect MCO for the newborn; and
	 
	 	2.4.9.3.4	 	Make payments only to the correct MCO for the period of coverage.
	 
	 	2.4.9.4	 	The MCO in which the newborn is correctly enrolled shall be responsible for the
coverage and payment of covered services provided to the newborn for the full
period of eligibility. Except as provided below, the MCO in which the newborn
was incorrectly enrolled shall have no liability for the coverage or payment of
any services during the period of incorrect MCO assignment. TENNCARE shall only
be liable for the capitation payment to the correct MCO.
	 
	 	2.4.9.5	 	There are circumstances in which a newborn’s mother may not be eligible for
participation in the TennCare program. The CONTRACTOR shall be required to
process claims received for services provided to newborns within the time frames
specified in Section 2.22.4 of this Agreement. A CONTRACTOR shall not utilize
any blanket policy which results in the automatic denial of claims for services
provided to a TennCare-eligible newborn, during any period of enrollment in the
CONTRACTOR’s MCO, because the newborn’s mother is not a member of the
CONTRACTOR’s MCO. However, it is recognized that in complying with the claims
processing time frames specified in 2.22.4 of this Agreement, a CONTRACTOR may
make payment for services provided to a TennCare-eligible newborn enrolled in
the CONTRACTOR’s MCO at the time of payment but the newborn’s eligibility may
subsequently be moved to another MCO. In such event, the MCO in which the
newborn is first enrolled (first MCO) may submit supporting documentation to the
MCO in which the newborn is moved (second MCO) and the

Page 28 of 374

 

	 	 	 	second MCO shall reimburse the first MCO within thirty (30) calendar days of
receipt of such properly documented request for reimbursement, for the amount
expended on behalf of the newborn prior to the newborn’s eligibility having been
moved to the second MCO. Such reimbursement shall be the actual amount expended
by the first MCO. The second MCO agrees that should the second MCO fail to
reimburse the first MCO the actual amount expended on behalf of the newborn
within thirty (30) calendar days of receipt of a properly documented request for
payment, TENNCARE is authorized to deduct the amount owed from any funds due the
second MCO and to reimburse the first MCO. In the event that the CONTRACTOR
fails to reimburse the first MCO the actual amount expended on behalf of the
newborn within thirty (30) calendar days of receipt of a properly documented
request for payment, TENNCARE may assess liquidated damages as specified in
Section 4.20.2. Should it become necessary for TENNCARE to intervene in such
cases, both the second MCO and the first MCO agree that TENNCARE shall be held
harmless by both MCOs for actions taken by TENNCARE to resolve the dispute.

2.4.10 Information Requirements Upon Enrollment

	 	 	As described in Section 2.17 of this Agreement, the CONTRACTOR shall provide the following
information to new members: a member handbook, a provider directory and an identification
card. In addition, the CONTRACTOR shall provide CHOICES members with CHOICES member
education materials (see Section 2.17.7).
	 
	6.	 	Section 2.5.2 shall be amended by adding a new Section 2.5.2.3 and renumbering existing
subparts accordingly, including any references thereto.

	 	2.5.2.3	 	A request by the member to change MCOs based on hardship criteria (pursuant to
TennCare rules and regulations) is approved by TENNCARE, and the member is enrolled in
another MCO;

	7.	 	Section 2.5.5 shall be amended by adding “from an MCO” to the end of the heading to read as
follows:

	 	2.5.5	 	Effective Date of Disenrollment from an MCO

	8.	 	Section 2.6 shall be deleted in its entirety and replaced with the following:
	 	 
	2.6	 	BENEFITS/SERVICE REQUIREMENTS AND LIMITS

2.6.1 CONTRACTOR Covered Benefits

	 	2.6.1.1	 	The CONTRACTOR shall cover the physical health, behavioral health and long-term
care services/benefits outlined below. Additional requirements for behavioral
health services are included in Section 2.7.2 and Attachment I.
	 
	 	2.6.1.2	 	The CONTRACTOR shall integrate the delivery of physical health, behavioral health
and long-term care services. This shall include but not be limited to the following:

Page 29 of 374

 

	 	2.6.1.2.1	 	The CONTRACTOR shall operate a member services toll-free phone line (see
Section 2.18.1) that is used by all members, regardless of whether they are calling
about physical health, behavioral health and/or long-term care services. The CONTRACTOR
shall not have a separate number for members to call regarding behavioral health and/or
long-term care services. The CONTRACTOR may either route the call to another entity or
conduct a “warm transfer” to another entity, but the CONTRACTOR shall not require an
enrollee to call a separate number regarding behavioral health and/or long-term care
services.
	 
	 	2.6.1.2.2	 	If the CONTRACTOR’s nurse triage/nurse advice line is separate from its member services
line, the CONTRACTOR shall comply with the requirements in Section 2.6.1.2.2 as applied to the
nurse triage/nurse advice line. The number for the nurse triage/nurse advice line shall be the
same for all members, regardless of whether they are calling about physical health, behavioral
health and/or long-term services, and the CONTRACTOR may either route calls to another entity
or conduct “warm transfers,” but the CONTRACTOR shall not require an enrollee to call a
separate number.
	 
	 	2.6.1.2.3	 	As required in Sections 2.9.5 and 2.9.6, the CONTRACTOR shall ensure continuity and
coordination among physical health, behavioral health, and long-term care services and ensure
collaboration among physical health, behavioral health, and long-term care providers. For
CHOICES members, the member’s care coordinator shall ensure continuity and coordination of
physical health, behavioral health, and long-term care services, and facilitate communication
and ensure collaboration among physical health, behavioral health, and long-term care
providers.
	 
	 	2.6.1.2.4	 	Each of the CONTRACTOR’s disease management programs (see Section 2.8) shall address the
needs of members who have co-morbid physical health and behavioral health conditions.
	 
	 	2.6.1.2.5	 	As required in Section 2.9.5.2.2, the CONTRACTOR shall provide MCO case management to
non-CHOICES members with co-morbid physical health and behavioral health conditions. These
members should have a single case manager that is trained to provide MCO case management to
enrollees with co-morbid physical health and behavioral health conditions. If a member with
co-morbid physical and behavioral health conditions does not have a single case manager, the
CONTRACTOR shall ensure, at a minimum, that the member’s MCO case managers collaborate and
communicate in an effective and ongoing manner. As required in Section 2.9.6.1.8 of this
Agreement, the CONTRACTOR shall ensure that upon enrollment into CHOICES, MCO case management
activities are integrated with CHOICES care coordination processes and functions, and that the
member’s assigned care coordinator has primary responsibility for coordination of all the
member’s physical health, behavioral health, and long-term care needs. The member’s care
coordinator may use resources and staff from the CONTRACTOR’s case management program,
including persons with specialized expertise in areas such as behavioral health, to supplement
but not supplant the role and responsibilities of the member’s care coordinator/care
coordination team. The CONTRACTOR shall report on its case management activities per
requirements in Section 2.30.6.1.

Page 30 of 374

 

	 	2.6.1.2.6	 	If the CONTRACTOR uses different Systems for physical
health services, behavioral health and/or long-term care services,
these systems shall be interoperable. In addition, the CONTRACTOR
shall have the capability to integrate data from the different
systems.
	 
	 	2.6.1.2.7	 	The CONTRACTOR’s administrator/project director (see
Section 2.29.1.3.1) shall be the primary contact for TENNCARE
regarding all issues, regardless of the type of service, and shall
not direct TENNCARE to other entities. The CONTRACTOR’s
administrator/project director shall coordinate with the
CONTRACTOR’s senior executive psychiatrist who oversees behavioral
health activities (see Section 2.29.1.3.4 of this Agreement) for
all behavioral health issues and the senior executive responsible
for CHOICES activities (see Section 2.29.1.3.5 of this Agreement)
for all issues pertaining to the CHOICES program.
	 
	 	2.6.1.3	 	CONTRACTOR Physical Health Benefits Chart

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Inpatient

Hospital

Services

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

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

Hospital

Services

	 	As medically necessary.
	 
	 	 
	Physician

Inpatient

Services

	 	As medically necessary.
	 
	 	 
	Physician

Outpatient

Services/Community

Health Clinic

Services/Other Clinic

Services

	 	As medically necessary.

Page 31 of 374

 

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	TENNderCare

Services

	 	Medicaid/Standard Eligible, Age 21 and older: Not
covered.
	 
	 	 
	 

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

	 	Screening, interperiodic screening, diagnostic and
follow-up treatment services as medically
necessary in accordance with federal and state
requirements. See Section 2.7.6.
	 	 
	Preventive Care

Services

	 	As described in Section 2.7.5.
	 
	 	 
	Lab and X-ray

Services

	 	As medically necessary.
	 
	 	 
	Hospice

Care

	 	As medically necessary. Shall be provided by a
Medicare-certified hospice.
	 
	 	 
	Dental Services

	 	Dental Services shall be provided by the Dental
Benefits Manager.
	 
	 	 
	 

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

	 	Medicaid/Standard Eligible, Age 21 and older:
	Services

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

	 	Medicaid/Standard Eligible, Under age 21 :
	 

	 	Preventive, diagnostic, and treatments services
(including eyeglasses) are covered as medically
necessary in accordance with TENNderCare
requirements.

Page 32 of 374

 

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Home Health

	 	Medicaid /Standard Eligible, Age 21 and older:
	Care

	 	Covered as medically necessary and in accordance
with the definition of Home Health Care at Rule
1200-13-13-.01 (for TennCare Medicaid) and Rule
1200-13-14-.01 (for TennCare Standard). Prior
authorization required for home health nurse and
home health aide services, as described in Rule
1200-13-13-.04 (for TennCare Medicaid) and
1200-13-14-.04 (for TennCare Standard).
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21:
	 

	 	Covered as medically necessary in accordance with
the definition of Home Health Care at Rule 1200-13-13-.01 (for TennCare Medicaid) and Rule
1200-13-14-.01 (for TennCare Standard). Prior
authorization required for home health nurse and
home health aide services, as described in Rule
1200-13-13-.04 (for TennCare Medicaid) and
1200-13-14-.04 (for TennCare Standard).
	 
	 	 
	Pharmacy

Services

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

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

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

Equipment (DME)

	 	As medically necessary.
	 
	 	 
	 

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

Supplies

	 	As medically necessary.
	 
	 	 
	 

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

Ground Ambulance

Transportation

	 	As medically necessary.
	 
	 	 
	Non-emergency

Medical

Transportation

(including Non-

Emergency

	 	Covered non-emergency medical transportation
(NEMT) services are necessary non-emergency
transportation services provided to convey
members to and from TennCare covered services
(see definition in Exhibit A to Attachment XI).
Non emergency transportation services

Page 33 of 374

 

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Ambulance

Transportation)

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

	 	If a member requires assistance, an escort (as defined in
TennCare rules and regulations) may accompany the member;
however, only one (1) escort is allowed per member (see
TennCare rules and regulations). Except for fixed route
and commercial carrier transport, the CONTRACTOR shall
not make separate or additional payment to a NEMT
provider for an escort. Covered NEMT services include
having an accompanying adult ride with a member if the
member is under age eighteen (18). Except for fixed route
and commercial carrier transport, the CONTRACTOR shall
not make separate or additional payment to a NEMT
provider for an adult accompanying a member under age
eighteen (18).
	 
	 	 
	 

	 	The CONTRACTOR is not responsible for providing NEMT to
HCBS, including services provided through a 1915(c)
waiver program for persons with mental
retardation and HCBS provided through the CHOICES
program. However, as specified in Section 2.11.1.8
in the event the CONTRACTOR is unable to meet the access
standard for adult day care (see Attachment III), the
CONTRACTOR shall provide and pay for the cost of
transportation for the member to the adult day care
facility until such time the CONTRACTOR has
sufficient provider capacity.
	 
	 	 
	 

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

	 	If the member is a child, transportation shall be
provided in accordance with TENNderCare requirements (see
Section 2.7.6.4.6).
	 
	 	 
	 

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

Page 34 of 374

 

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Renal Dialysis

Services

	 	As medically necessary.
	 
	 	 
	Private Duty

	 	Medicaid/Standard Eligible, Age 21 and older:
	Nursing

	 	Covered as medically necessary in accordance
with the definition of Private Duty Nursing at
Rule 1200-13-13-.01 (for TennCare Medicaid) and
Rule 1200-13-14-.01 (for TennCare Standard),
when prescribed by an attending physician for
treatment and services rendered by a Registered
Nurse (R.N.) or a licensed practical nurse
(L.P.N.) who is not an immediate relative.
Private duty nursing services are limited to
services that support the use of ventilator
equipment or other life sustaining technology
when constant nursing supervision, visual
assessment, and monitoring of both equipment and
patient are required. Prior authorization
required, as described Rule 1200-13-13-.04 (for
TennCare Medicaid) and 1200- 13-14-.04 (for
TennCare Standard).
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21:
	 

	 	Covered as medically necessary in accordance
with the definition of Private Duty Nursing at
Rule 1200-13-13-.01 (for TennCare Medicaid) and
1200-13-14-.01 (for TennCare Standard) when
prescribed by an attending physician for
treatment and services rendered by a registered
nurse (R.N.) or a licensed practical nurse
(L.P.N.), who is not an immediate relative.
Prior authorization required as described in
Rule 1200-13-13-.04 (for TennCare Medicaid) and
1200-13-14-.04 (for TennCare Standard).
	 
	 	 
	Speech

	 	Medicaid/Standard Eligible, Age 21 and older:
	Therapy

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

	 	Medicaid/Standard Eligible, Under age 21:
	 

	 	Covered as medically necessary in accordance
with TENNderCare requirements.
	 
	 	 
	Occupational

	 	Medicaid/Standard Eligible, Age 21 and older:
	Therapy

	 	Covered as medically necessary when provided by
a Licensed Occupational Therapist to restore,
improve, or stabilize impaired functions.
	 
	 	 
	 

	 	Medicaid/Standard Eligible, Under age 21:
	 

	 	Covered as medically necessary in accordance
with TENNderCare requirements.

Page 35 of 374

 

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Physical

	 	Medicaid/Standard Eligible, Age 21 and older:
	Therapy

	 	Covered as medically necessary when provided by a
Licensed Physical Therapist to restore, improve,
or stabilize impaired functions.
	 
	 	 
	 

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

Transplant

And Donor Organ

Procurement

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

	 	Bone marrow/Stem cell;
	 

	 	Cornea;
	 

	 	Heart;
	 

	 	Heart/Lung;
	 

	 	Kidney;
	 

	 	Kidney/ Pancreas;
	 

	 	Liver;
	 

	 	Lung;
	 

	 	Pancreas; and
	 

	 	Small bowel/Multi-visceral.
	 
	 	 
	 

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

Surgery

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

Services

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

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

Page 36 of 374

 

2.6.1.4 CONTRACTOR Behavioral Health Benefits Chart

	 	 	 
	SERVICE	 	BENEFIT LIMIT
	Psychiatric Inpatient

Hospital

Services (including

physician services)

	 	As medically necessary.
	 
	 	 
	24-hour Psychiatric

Residential Treatment

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

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

Health Services

(including physician

services)

	 	As medically necessary.
	 
	 	 
	Inpatient, Residential

& Outpatient

Substance Abuse

Benefits1

	 	Medicaid/Standard Eligible, Age
21 and older: Limited to ten (10) days detox,
$30,000 in medically necessary lifetime benefits unless otherwise described in
the 2008 Mental Health Parity Act as determined by TENNCARE.
	 
	 	 
	 

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

Management

	 	As medically necessary.
	 
	 	 
	Psychiatric-

Rehabilitation

Services

	 	As medically necessary.
	 
	 	 
	Behavioral Health

Crisis Services

	 	As necessary.
	 
	 	 
	Lab and X-ray

Services

	 	As medically necessary.
	 
	 	 
	Non-emergency

Medical

Transportation

(including Non-

Emergency

Ambulance

Transportation)

	 	Same as for physical health (see Section 2.6.1.3 above).

 

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

	 	2.6.1.5	 	Long-Term Care Benefits for CHOICES Members
	 
	 	2.6.1.5.1	 	In addition to physical health benefits (see Section 2.6.1.3) and behavioral health
benefits (see Section 2.6.1.4), the CONTRACTOR shall provide long-term care
services (including HCBS and nursing facility care) as described in this Section
2.6.1.5 to members who have been enrolled into CHOICES by TENNCARE, as
shown in the enrollment file furnished by TENNCARE to the CONTRACTOR, effective
upon the CHOICES Implementation Date (see Section 1).

Page 37 of 374

 

	 	2.6.1.5.2	 	TennCare enrollees will be enrolled by TENNCARE into CHOICES if the following
conditions, at a minimum, are met:

	 	2.6.1.5.2.1	 	TENNCARE or its designee determines the enrollee meets the categorical and
financial eligibility criteria for Group 1, 2 or 3;
	 
	 	2.6.1.5.2.2	 	For Groups 1 and 2, TENNCARE determines that the enrollee meets nursing facility
level of care;
	 
	 	2.6.1.5.2.3	 	For Group 2, the CONTRACTOR or, for new TennCare applicants, TENNCARE or its
designee, determines that the enrollee’s combined HCBS, private duty nursing and home
health care can be safely provided at a cost less than the cost of nursing facility
care for the member;
	 
	 	2.6.1.5.2.4	 	For Group 3, TENNCARE determines that the enrollee meets the at-risk level of
care; and
	 
	 	2.6.1.5.2.5	 	For Groups 2 and 3, if there is an enrollment target, TENNCARE determines that
the enrollment target has not been met or, for Group 2, approves the CONTRACTOR’s
request to provide HCBS as a cost effective alternative (see Section 2.6.5). Enrollees
transitioning from a nursing facility to the community will not be subject to the
enrollment target for Group 2 but must meet categorical and financial eligibility for
Group 2.

	 	2.6.1.5.3	 	For persons determined to be eligible for enrollment in Group 2 as a result of Immediate
Eligibility (as defined in Section 1 of this Agreement), the CONTRACTOR shall provide a
limited package of HCBS (personal care, attendant care, homemaker services, home-delivered
meals, PERS, adult day care, and/or any other services as specified in TennCare rules and
regulations) as identified through a needs assessment and specified in the plan of care. Upon
notice that the State has determined that the member meets categorical and financial
eligibility for TennCare CHOICES, the CONTRACTOR shall authorize additional services in
accordance with Section 2.9.6.2.5. For members residing in a community-based residential
alternative at the time of CHOICES enrollment, authorization for community-based residential
alternative services shall be retroactive to the member’s effective date of CHOICES
enrollment.
	 
	 	2.6.1.5.4	 	The following long-term care services are available to CHOICES members, per Group, when
the services have been determined medically necessary by the CONTRACTOR.

	 	 	 	 	 	 	 
	Service and Benefit Limit	 	Group 1	 	Group 2	 	Group 3
	Nursing facility care

	 	X	 	Short-term only
(up to 90 days)
	 	Short-term only
 (up
to 90 days)
	 
	 	 	 	 	 	 
	Community-based 

residential alternatives

	 	 	 	X	 	 
	 
	 	 	 	 	 	 
	Personal care visits (up
to 2 visits per day)

	 	 	 	X	 	X

Page 38 of 374

 

	 	 	 	 	 	 	 
	Service and Benefit Limit	 	Group 1	 	Group 2	 	Group 3
	Attendant care (up to 1080 hours per
calendar year)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Homemaker services (up to 3 visits
per week)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Home-delivered meals (up to 1 meal
per day)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Personal Emergency Response Systems

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Adult day care (up to 2080 hours per
calendar year)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	In-home respite care (up to 216
hours per calendar year)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	In-patient respite care (up to 9
days per calendar year)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Assistive technology (up to $900 per
calendar year)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Minor home modifications (up to
$6,000 per project; $10,000 per
calendar year; and $20,000 per
lifetime)

	 	 	 	X
	 	X
	 
	 	 	 	 	 	 
	Pest control (up to 9 units per
calendar year)

	 	 	 	X
	 	X

	 	2.6.1.5.5	 	In addition to the benefit limits described above, in no case shall the CONTRACTOR exceed
the cost neutrality cap for CHOICES Group 2 or the expenditure cap for Group 3. For CHOICES
members in Group 2, the total cost of HCBS, home health care and private duty nursing shall
not exceed a member’s cost neutrality cap (as defined in Section 1 of this Agreement). For
CHOICES members in Group 3, the total cost of HCBS, excluding minor home modifications, shall
not exceed the expenditure cap (as defined in Section 1 of this Agreement).
	 
	 	2.6.1.5.6	 	CHOICES members may, pursuant to Section 2.9.7, choose to participate in consumer
direction of HCBS and, at a minimum, hire, fire and supervise workers of eligible HCBS.
	 
	 	2.6.1.5.7	 	The CONTRACTOR shall monitor CHOICES members’ receipt and utilization of long-term care
services, identify CHOICES members who have not received long-term care services within a
thirty (30) day period of time, and notify TENNCARE regarding these members pursuant to
Section 2.30.10.5. TENNCARE will investigate to determine if the member should remain enrolled
in CHOICES.
	 
	 	2.6.1.5.8	 	The CONTRACTOR may submit to TENNCARE a request to no longer provide long-term care
services to a member due to concerns regarding the ability to safely and effectively care for
the member in the community and/or to ensure the member’s health, safety and welfare.
Acceptable reasons for this request include but are not limited to the following:

Page 39 of 374

 

	 	2.6.1.5.8.1	 	A member in Group 2 or 3 for whom the CONTRACTOR has determined that it
cannot safely and effectively meet the member’s needs at a cost that is less
than the member’ cost neutrality cap, and the member declines to transition
to a nursing facility;
	 
	 	2.6.1.5.8.2	 	A member in Group 2 or 3 who repeatedly refuses to allow a care coordinator
entrance into his/her place of residence (Section 2.9.6);
	 
	 	2.6.1.5.8.3	 	A member in Group 2 or 3 who refuses to receive critical HCBS as identified
through a needs assessment and documented in the member’s plan of care; and
	 
	 	2.6.1.5.8.4	 	A member in Group 1 who fails to pay his/her patient liability and the
CONTRACTOR is unable to find a nursing facility willing to provide services
to the member (Section 2.6.7.2).
	 
	 	2.6.1.5.8.5	 	The CONTRACTOR’s request to no longer provide long-term care services to a
member shall include documentation as specified by TENNCARE. The State shall
make any and all determinations regarding whether the CONTRACTOR may
discontinue providing long-term care services to a member, disenrollment from
CHOICES, and, as applicable, termination from TennCare.

2.6.2 TennCare Benefits Provided by TENNCARE

TennCare shall be responsible for the payment of the following
benefits:

	 	2.6.2.1	 	Dental Services 
	 
	 	 	 	Except as provided in Section 2.6.1.3 of this Agreement, dental services shall
not be provided by the CONTRACTOR but shall be provided by a dental benefits
manager (DBM) under contract with TENNCARE. Coverage of dental services is
described in TennCare rules and regulations.
	 
	 	2.6.2.2	 	Pharmacy Services
	 
	 	 	 	Except as provided in Section 2.6.1.3 of this Agreement, pharmacy services shall
not be provided by the CONTRACTOR but shall be provided by a pharmacy benefits
manager (PBM) under contract with TENNCARE. Coverage of pharmacy services is
described in TennCare rules and regulations. TENNCARE does not cover pharmacy
services for enrollees who are dually eligible for TennCare and Medicare.
	 
	 	2.6.2.3	 	ICF/MR Services and Alternatives to ICF/MR Services
	 
	 	 	 	For qualified enrollees in accordance with TennCare policies and/or TennCare
rules and regulations, TENNCARE covers the costs of long-term care institutional
services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or
alternative to an ICF/MR provided through a Home and Community Based Services
(HCBS) waiver for persons with MR.

Page 40 of 374

 

2.6.3 Medical Necessity Determination

	 	2.6.3.1	 	The CONTRACTOR may establish procedures for the determination of medical
necessity. The determination of medical necessity shall be made on a case by
case basis and in accordance with the definition of medical necessity defined in
TCA 71- 5-144 and TennCare rules and regulations. However, this requirement
shall not limit the CONTRACTOR’s ability to use medically appropriate cost
effective alternatives in accordance with Section 2.6.5.
	 
	 	2.6.3.2	 	The CONTRACTOR shall not employ, and shall not permit others acting on their
behalf to employ, utilization control guidelines or other quantitative coverage
limits, whether explicit or de facto, unless supported by an individualized
determination of medical necessity based upon the needs of each TennCare
enrollee and his/her medical history. The CONTRACTOR shall have the ability to
place tentative limits on a service; however, such tentative limits placed by
the CONTRACTOR shall be exceeded (up to the applicable benefit limits on
behavioral health and long-term care services provided in Section 2.6.1.4 and
2.6.1.5 above) when medically necessary based on a member’s individual
characteristics.
	 
	 	2.6.3.3	 	The CONTRACTOR shall not arbitrarily deny or reduce the amount, duration, or
scope of a required service solely because of the diagnosis, type of illness, or
condition.
	 
	 	2.6.3.4	 	The CONTRACTOR may deny services that are non-covered except as otherwise
required by TENNderCare or unless otherwise directed to provide by TENNCARE
and/or an administrative law judge.
	 
	 	2.6.3.5	 	All medically necessary services shall be covered for enrollees under
twenty-one (21)
years of age in accordance with TENNderCare requirements (see Section 2.7.6).

2.6.4 Second Opinions

The CONTRACTOR shall provide for a second opinion in any situation where there is a question
concerning a diagnosis or the options for surgery or other treatment of a health condition
when requested by a member, parent and/or legally appointed representative. The second
opinion shall be provided by a contracted qualified health care professional or the
CONTRACTOR shall arrange for a member to obtain one from a non-contract provider. The second
opinion shall be provided at no cost to the member.

2.6.5 Use of Cost Effective Alternative Services

	 	2.6.5.1	 	The CONTRACTOR shall be allowed to use cost effective alternative services,
whether listed as covered or non-covered or omitted in Section 2.6.1 of this
Agreement, when the use of such alternative services is medically appropriate
and is cost effective. This may include, for example, use of nursing facilities
as step down alternatives to acute care hospitalization or hotel accommodations
for persons on outpatient radiation therapy to avoid the rigors of daily
transportation. The CONTRACTOR shall comply with TennCare policies and
procedures. As provided in the applicable TennCare policies and procedures,
services not listed in the TennCare policies and procedures must be prior
approved in writing by TENNCARE.

Page 41 of 374

 

	 	2.6.5.2	 	For CHOICES members, the CONTRACTOR may choose to provide the following
as a cost effective alternative to other covered services:

	 	2.6.5.2.1	 	HCBS to CHOICES members who would otherwise receive nursing facility care. If a member meets
categorical and financial eligibility requirements for enrollment in Group 2 and also meets the
nursing facility level of care, as determined by TENNCARE, and would otherwise remain in or be
admitted to a nursing facility (as determined by the CONTRACTOR and demonstrated to the satisfaction
of TENNCARE), the CONTRACTOR may, at its discretion and upon TENNCARE written prior approval, offer
that member HCBS as a cost effective alternative to nursing facility care (see Section 2.9.6.3.13). In
this instance, TENNCARE will enroll the member receiving HCBS as a cost effective alternative to
nursing facility services in Group 2, notwithstanding any enrollment target for Group 2 that has been
reached.
	 
	 	2.6.5.2.2	 	HCBS to CHOICES members in Group 2 in excess of the benefit limits described in
Section 2.6.1.5.4 as a cost effective alternative to nursing facility care or covered home health
services.
	 
	 	2.6.5.2.3	 	HCBS to CHOICES members in Group 3 in excess of the benefit limits described in
Section 2.6.1.5.4 as a cost effective alternative to covered home health services. Members in Group 3 do not
meet nursing facility level of care and as such, HCBS in excess of benefit limits specified in Section 2.6.1.5.4
may not be offered as a cost effective alternative to nursing facility care.
	 
	 	2.6.5.2.4	 	Non-covered HCBS services to CHOICES members in Group 2 not otherwise specified in this
Agreement or in applicable TennCare policies and procedures, upon written prior approval from
TENNCARE.
	 
	 	2.6.5.2.5	 	For CHOICES members transitioning from a nursing facility to a community setting, a one-time
transition allowance, per member. The amount of the transition allowance shall not exceed two thousand
dollars ($2,000) and may be used for items such as, but not limited to, the first month’s rent and/or
utility deposits, kitchen appliances, furniture, and basic household items.
	 
	 	2.6.5.2.6	 	For CHOICES members in Groups 2 or 3, non-emergency medical transportation (NEMT) not
otherwise covered by this Agreement.
	 
	 	2.6.5.3	 	If the CONTRACTOR chooses to provide cost effective alternative services to a
CHOICES member, in no case shall the cost of HCBS, private duty nursing and home health
care for Group 2 exceed a member’s cost neutrality cap nor the total cost of HCBS,
excluding minor home modifications, for members in Group 3 exceed the expenditure cap.
The total cost of HCBS includes all HCBS (whether otherwise covered or not covered) and
other services that are offered as a cost effective alternative to nursing facility
care, HCBS, or home health, including, as applicable, the one-time transition allowance
for Group 2 and NEMT for Groups 2 and 3.

Page 42 of 374

 

2.6.6 Additional Services and Use of Incentives

	 	2.6.6.1	 	The CONTRACTOR shall not advertise any services that are not required by this
Agreement other than those covered pursuant to Section 2.6.1 of this Agreement.
	 
	 	2.6.6.2	 	The CONTRACTOR shall not offer or provide any services other than services
covered by this Agreement (see Section 2.6.1) or services provided as a cost
effective alternative (see Section 2.6.5) of this Agreement. However, the
CONTRACTOR may provide incentives that have been specifically prior approved in
writing by TENNCARE. For example, TENNCARE may approve the use of incentives
given to enrollees to encourage participation in disease management programs.

2.6.7 Cost Sharing and Patient Liability

	 	2.6.7.1	 	General
	 
	 	 	 	The CONTRACTOR and all providers and subcontractors shall not require any cost
sharing or patient liability responsibilities for covered services except to the
extent that cost sharing or patient liability responsibilities are required for
those services by TENNCARE in accordance with TennCare rules and regulations,
including but not limited to, holding enrollees liable for debt due to
insolvency of the CONTRACTOR or non-payment by the State to the CONTRACTOR.
Further, the CONTRACTOR and all providers and subcontractors shall not charge
enrollees for missed appointments.
	 
	 	2.6.7.2	 	Patient Liability
	 
	 	2.6.7.2.1	 	TENNCARE will notify the CONTRACTOR of any applicable patient liability amounts
for CHOICES members in Group 1 via the eligibility/enrollment file. The CONTRACTOR
shall delegate collection of patient liability to the nursing facility and shall pay
the facility net of the applicable patient liability amount.
	 
	 	2.6.7.2.2	 	In accordance with the involuntary discharge process, including notice and appeal
(see Section 2.12.11.3), a nursing facility may refuse to continue providing services
to a member who fails to pay his or her patient liability and for whom the nursing
facility can demonstrate to the CONTRACTOR that it has made a good faith effort to
collect payment.
	 
	 	2.6.7.2.3	 	If the CONTRACTOR is notified that a nursing facility is considering discharging a
member (see Section 2.12.11.3), the CONTRACTOR shall work to find an alternate nursing
facility willing to serve the member and document its efforts in the member’s files.
	 
	 	2.6.7.2.4	 	If the CONTRACTOR is unable to find an alternate nursing facility willing to serve
the member, the CONTRACTOR shall determine if it can safely and effectively serve the
member in the community and within the cost neutrality cap. If it can, the member shall
be offered a choice of HCBS. If the member chooses HCBS, the CONTRACTOR shall forward
all relevant information to TENNCARE for a decision regarding enrollment in Group 2
(Section 2.9.6.3).

Page 43 of 374

 

	 	2.6.7.2.5	 	If the CONTRACTOR is unable to find an alternate nursing facility willing to
serve the member and the CONTRACTOR determines that it cannot safely and effectively
serve the member in the community and within the cost neutrality cap, the member
declines to enroll in Group 2, or TENNCARE denies enrollment in Group 2, the CONTRACTOR
may, pursuant to Section 2.6.1.5.8, request to no longer provide long-term care
services to the member.
	 
	 	2.6.7.3	 	Preventive Services
	 
	 	 	 	TennCare cost sharing or patient liability responsibilities shall apply to covered
services other than the preventive services described in TennCare rules and
regulations.
	 
	 	2.6.7.4	 	Cost Sharing Schedule
	 
	 	 	 	The current TennCare cost sharing schedule is included in this Agreement as Attachment
II. The CONTRACTOR shall not waive or use any alternative cost sharing schedules,
unless required by TENNCARE.
	 
	 	2.6.7.5	 	Provider Requirements
	 
	 	2.6.7.5.1	 	Providers or collection agencies acting on the provider’s behalf may not bill enrollees
for amounts other than applicable TennCare cost sharing or patient liability amounts
for covered services, including but not limited to, services that the State or the
CONTRACTOR has not paid for, except as permitted by TennCare rules and regulations and
as described below. Providers may seek payment from an enrollee only in the following
situations.
	 
	 	2.6.7.5.1.1	 	If the services are not covered services and, prior to providing the services, the
provider informed the enrollee that the services were not covered. The provider
shall inform the enrollee of the non-covered service and have the enrollee
acknowledge the information. If the enrollee still requests the service, the
provider shall obtain such acknowledgment in writing prior to rendering the
service. Regardless of any understanding worked out between the provider and the
enrollee about private payment, once the provider bills an MCO for the service that
has been provided, the prior arrangement with the enrollee becomes null and void
without regard to any prior arrangement worked out with the enrollee.
	 
	 	2.6.7.5.1.2	 	If the enrollee’s TennCare eligibility is pending at the time services are provided
and if the provider informs the person they will not accept TennCare assignment
whether or not eligibility is established retroactively. Regardless of any
understanding worked out between the provider and the enrollee about private
payment, once the provider bills an MCO for the service the prior arrangement with
the enrollee becomes null and void without regard to any prior arrangement worked
out with the enrollee.

Page 44 of 374

 

	 	2.6.7.5.1.3	 	If the enrollee’s TennCare eligibility is pending at the time services are
provided,
however, all monies collected, except applicable TennCare cost sharing or
patient liability amounts shall be refunded when a claim is submitted to an
MCO because the provider agreed to accept TennCare assignment once
retroactive TennCare eligibility was established. (The monies collected shall
be refunded as soon as a claim is submitted and shall not be held
conditionally upon payment of the claim.)
	 
	 	2.6.7.5.1.4	 	If the services are not covered because they are in excess of an enrollee’s
benefit
limit, and the provider complies with applicable TennCare rules and regulations.
	 
	 	2.6.7.5.2	 	The CONTRACTOR shall require, as a condition of payment, that the provider accept
the amount paid by the CONTRACTOR or appropriate denial made by the CONTRACTOR (or, if
applicable, payment by the CONTRACTOR that is supplementary to the enrollee’s third
party payer) plus any applicable amount of TennCare cost sharing or patient liability
responsibilities due from the enrollee as payment in full for the service. Except in
the circumstances described above, if the CONTRACTOR is aware that a provider, or a
collection agency acting on the provider’s behalf, bills an enrollee for amounts other
than the applicable amount of TennCare cost sharing or patient liability
responsibilities due from the enrollee, the CONTRACTOR shall notify the provider and
demand that the provider and/or collection agency cease such action against the
enrollee immediately. If a provider continues to bill an enrollee after notification by
the CONTRACTOR, the CONTRACTOR shall refer the provider to the Tennessee Bureau of
Investigation.

9. Section 2.7 shall be deleted in its entirety and replaced with the following:

2.7 SPECIALIZED SERVICES

2.7.1 Emergency Services

	 	2.7.1.1	 	Emergency services (as defined in Section 1 of this Agreement) shall be available
twenty-four (24) hours a day, seven (7) days a week.
	 
	 	2.7.1.2	 	The CONTRACTOR shall review and approve or disapprove claims for emergency
services based on the definition of emergency medical condition specified in
Section 1 of this Agreement. The CONTRACTOR shall base coverage decisions for
emergency services on the severity of the symptoms at the time of presentation
and shall cover emergency services where the presenting symptoms are of
sufficient severity to constitute an emergency medical condition in the judgment
of a prudent layperson. The CONTRACTOR shall not impose restrictions on coverage
of emergency services more restrictive than those permitted by the prudent
layperson standard.
	 
	 	2.7.1.3	 	The CONTRACTOR shall provide coverage for inpatient and outpatient emergency
services, furnished by a qualified provider, regardless of whether the member
obtains the services from a contract provider, that are needed to evaluate or
stabilize an emergency medical condition that is found to exist using the
prudent layperson standard. These services shall be provided without prior
authorization in accordance with 42 CFR 438.114. The CONTRACTOR shall pay for
any emergency screening examination services conducted to determine whether an
emergency medical

Page 45 of 374

 

	 	 	 	condition exists and for all emergency services that are medically necessary
until the member is stabilized.
	 
	 	2.7.1.4	 	If an emergency screening examination leads to a clinical determination by the
examining provider that an actual emergency medical condition exists, the
CONTRACTOR shall pay for both the services involved in the screening examination
and the services required to stabilize the member. The CONTRACTOR shall be
required to pay for all emergency services which are medically necessary until
the clinical emergency is stabilized. This includes all medical and behavioral
health services that may be necessary to assure, within reasonable medical
probability, that no material deterioration of the member’s condition is likely
to result from, or occur during, discharge of the member or transfer of the
member to another facility. If there is a disagreement between the treating
facility and the CONTRACTOR concerning whether the member is stable enough for
discharge or transfer, or whether the medical benefits of an un-stabilized
transfer outweigh the risks, the judgment of the attending provider(s) actually
caring for the member at the treating facility prevails and is binding on the
CONTRACTOR. The CONTRACTOR, however, may establish arrangements with a treating
facility whereby the CONTRACTOR may send one of its own providers with
appropriate emergency room privileges to assume the attending provider’s
responsibilities to stabilize, treat, and transfer the member, provided that
such arrangement does not delay the provision of emergency services.
	 
	 	2.7.1.5	 	The CONTRACTOR shall not retroactively deny a claim for an emergency screening
examination because the condition, which appeared to be an emergency medical
condition under the prudent layperson standard, turned out to be non-emergency
in nature. If an emergency screening examination leads to a clinical
determination by the examining provider that an actual emergency medical
condition does not exist, then the determining factor for payment liability
shall be whether the member had acute symptoms of sufficient severity at the
time of presentation. In such cases, the CONTRACTOR shall review the presenting
symptoms of the member and shall pay for all services involved in the screening
examination where the presenting symptoms (including severe pain) were of
sufficient severity to have warranted emergency attention under the prudent
layperson standard regardless of final diagnosis.
	 
	 	2.7.1.6	 	When the member’s PCP or the CONTRACTOR instructs the member to seek
emergency services, the CONTRACTOR shall be responsible for payment for the
medical screening examination and for other medically necessary emergency
services, without regard to whether the member’s condition meets the prudent
layperson standard.
	 
	 	2.7.1.7	 	Once the member’s condition is stabilized, the CONTRACTOR may require prior
authorization for hospital admission or follow-up care.

2.7.2 Behavioral Health Services

	 	2.7.2.1	 	General Provisions
	 
	 	2.7.2.1.1	 	The CONTRACTOR shall provide all behavioral health services as described in this
Section, Section 2.6.1 and
Attachment I.

Page 46 of 374

 

	 	2.7.2.1.2	 	The CONTRACTOR shall provide behavioral health services in accordance with best
practice guidelines, rules and regulations, and policies and procedures issued by TDMHDD and
approved by the Bureau of TennCare, including but not limited to “Managed Care Standards for
Delivery of Behavioral Health Services”.
	 
	 	2.7.2.1.3	 	The CONTRACTOR shall ensure that all members receiving behavioral health services
from providers whose primary focus is to render behavioral health services have individualized
treatment plans. Providers included in this requirement are:
	 
	 	2.7.2.1.3.1	 	Community mental health agencies;
	 
	 	2.7.2.1.3.2	 	Case management agencies;
	 
	 	2.7.2.1.3.3	 	Psychiatric rehabilitation agencies;
	 
	 	2.7.2.1.3.4	 	Psychiatric and substance abuse residential treatment facilities; and
	 
	 	2.7.2.1.3.5	 	Psychiatric and substance abuse inpatient facilities.
	 
	 	2.7.2.1.4	 	Individualized treatment plans shall be completed within thirty (30) calendar days of the
start date of service and updated every six (6) months, or more frequently as clinically
appropriate. The treatment plans shall be developed, negotiated and agreed upon by the members
and/or their support systems in face-to-face encounters and shall be used to identify the
treatment needs necessary to meet the members’ stated goals. The duration and intensity of
treatment shall promote the recovery and resilience of members and shall be documented in the
treatment plans.
	 
	 	2.7.2.2	 	Psychiatric Inpatient Hospital Services
	 
	 	2.7.2.2.1	 	The CONTRACTOR shall ensure that all psychiatric
inpatient hospitals serving children, youth, and adults separate
members by age and render developmental age appropriate services.
	 
	 	2.7.2.2.2	 	The CONTRACTOR shall require that all psychiatric
inpatient facilities are accredited by the Joint Commission and
accept voluntary and involuntary admissions.
	 
	 	2.7.2.3	 	24-Hour Psychiatric Residential Treatment
	 
	 	2.7.2.3.1	 	The CONTRACTOR shall ensure that 24-hour psychiatric residential treatment facilities
(RTFs) serving children, youth, and adults separate members by age and render developmental
age appropriate services.
	 
	 	2.7.2.3.2	 	The CONTRACTOR shall ensure RTFs have the capacity to render short term crisis
stabilization and long-term treatment and rehabilitation.
	 
	 	2.7.2.3.3	 	The CONTRACTOR shall ensure all RTFs meet local housing codes.
	 
	 	2.7.2.3.4	 	The CONTRACTOR shall ensure all RTFs are accredited by a State-recognized accreditation
organization as required by 42 CFR 441.151.

Page 47 of 374

 

	 	2.7.2.4	 	Outpatient Mental Health Services
	 
	 	2.7.2.4.1	 	The CONTRACTOR shall ensure that outpatient mental health providers
(including providers of intensive outpatient and providers of partial hospitalization
services) serving children, youth and adults separate members by age and render
developmental age appropriate services.
	 
	 	2.7.2.4.2	 	The CONTRACTOR shall ensure outpatient mental health providers are capable
of rendering services both on and off site, as appropriate, depending on the services
being rendered. On site services include, but are not limited to intensive outpatient
services, partial hospitalization and many types of therapy. Off site services
include but are not limited to intensive in home service for children and youth and
home and community treatment for adults.
	 
	 	2.7.2.5	 	Inpatient, Residential & Outpatient Substance Abuse Services

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

Page 48 of 374

 

	 	2.7.2.6.5.1	 	Members receiving mental health case management services at the start date of
operations shall be maintained in mental health case management until such time as
the member no longer qualifies on the basis of medical necessity or refuses
treatment;
	 
	 	2.7.2.6.5.2	 	Members discharged from psychiatric inpatient hospitals and psychiatric
residential treatment facilities shall be evaluated for mental health case
management services and provided with appropriate behavioral health follow-up
services; and
	 
	 	2.7.2.6.5.3	 	The CONTRACTOR shall review the cases of members referred by PCPs or
otherwise identified to the CONTRACTOR as potentially in need of mental health case
management services and shall contact and offer such services to all members who
meet medical necessity criteria.
	 
	 	2.7.2.7	 	Psychiatric Rehabilitation Services
	 
	 	 	 	The CONTRACTOR shall provide psychiatric rehabilitation services in accordance with the
requirements in Attachment I. As described in Attachment I, the covered array of
services available under psychiatric rehabilitation are psychosocial rehabilitation,
supported employment, peer support, illness management and recovery, and supported
housing. An individual may receive one or more of these services and may receive
different services from different providers.
	 
	 	2.7.2.8	 	Behavioral Health Crisis Services
	 
	 	2.7.2.8.1	 	Entry into the Behavioral Health Crisis Services System
	 
	 	2.7.2.8.1.1	 	The State shall maintain a statewide toll-free telephone number for entry into the
behavioral health crisis system. This line shall be for any individual in the
general population for the purposes of providing immediate phone intervention by
trained crisis specialists and dispatch of mobile crisis teams.
	 
	 	2.7.2.8.1.2	 	The CONTRACTOR shall ensure that the crisis telephone line is linked to an
appropriate crisis service team staffed by qualified crisis service providers in
order to provide crisis intervention services to members.
	 
	 	2.7.2.8.1.3	 	As required in Section 2.11.5.3, the CONTRACTOR shall contract with specified
crisis service teams for both adults and children as directed by the State.
	 
	 	2.7.2.8.1.4	 	The CONTRACTOR shall require the crisis service teams to provide telephone
and walk-in triage screening services, telephone and face-to-face crisis
intervention/assessment services, and follow-up telephone or face-to-face
assessments to ensure the safety of the member until the member’s treatment begins
and/or the crisis is alleviated and/or stabilized.
	 
	 	2.7.2.8.1.5	 	Prior to admission to a psychiatric inpatient hospital on an involuntary basis, the
CONTRACTOR shall ensure that the member has been evaluated by a crisis team. In
addition, the CONTRACTOR shall ensure that Tennessee’s statutory requirement for a
face-to-face evaluation by a mandatory pre-screening agent (MPA), is conducted to
assess eligibility for emergency involuntary admission to

Page 49 of 374

 

	 	 	 	an RMHI (Regional Mental Health Institute) and determine whether all available less
drastic alternatives services and supports are unsuitable.

	 	2.7.2.8.2	 	Behavioral Health Crisis Respite and Crisis Stabilization Services
	 
	 	2.7.2.8.2.1	 	The CONTRACTOR shall ensure access to behavioral health crisis respite and
crisis stabilization services.
	 
	 	2.7.2.8.2.2	 	Behavioral health crisis respite services provide immediate shelter to members
with emotional/behavioral problems who are in need of emergency respite. The
CONTRACTOR shall ensure that behavioral health crisis respite services are provided
in a CONTRACTOR approved community location.
	 
	 	2.7.2.8.2.3	 	The CONTRACTOR shall ensure behavioral health crisis stabilization services
are rendered at sites licensed by the State. These services are more intensive than
regular behavioral health crisis services in that they require more secure
environments, highly trained staff, and typically have longer stays.
	 
	 	2.7.2.8.3	 	The CONTRACTOR shall monitor behavioral health crisis services and report information to
TENNCARE on a quarterly basis as described in Section 2.30.4.4.
	 
	 	2.7.2.9	 	Clinically Related Group (CRG) and Target Population Group (TPG) Assessments
	 
	 	2.7.2.9.1	 	The CONTRACTOR shall provide CRG/TPG assessments in response to requests from members or
legally appointed representatives or, in the case of minors, the members’ parents or legally
appointed representatives, behavioral health providers, PCPs, or the State.
	 
	 	2.7.2.9.2	 	The CONTRACTOR shall complete CRG/TPG assessments within fourteen (14) calendar days of
the requests. The CONTRACTOR shall not require prior authorization in order for a member to
receive a CRG/TPG assessment.
	 
	 	2.7.2.9.3	 	The CONTRACTOR shall ensure that its contract providers are trained and that there is
sufficient capacity to perform CRG/TPG assessments. The CONTRACTOR shall require providers to
use the CRG/TPG assessment form(s) as appropriate, prescribed by and in accordance with the
policies of the state. The CRG/TPG assessments shall be subject to review and prior written
approval by the State.
	 
	 	2.7.2.9.4	 	The CONTRACTOR shall identify persons in need of CRG/TPG assessments. The CONTRACTOR
shall use the CRG/TPG assessments to identify persons who are SPMI or SED for reporting and
tracking purposes, in accordance with the definitions contained in Section 1.
	 
	 	2.7.2.9.5	 	The CONTRACTOR shall ensure that providers who perform CRG/TPG assessments have been
trained and authorized by the State to perform CRG/TPG assessments. Certified trainers shall
be responsible for providing rater training within their agencies.
	 
	 	2.7.2.9.6	 	The CONTRACTOR shall reject all CRG/TPG assessments completed by unapproved raters. The
CONTRACTOR shall report on rejected assessments as required in Section 2.30.4.6.

Page 50 of 374

 

	 	2.7.2.9.7	 	The CONTRACTOR shall conduct audits of CRG/TPG assessments for accuracy and
conformity to state policies and procedures. The CONTRACTOR shall audit all providers
conducting these assessments on at least an annual basis. The methodology for these
audits and the results of these audits shall be reported as required in Sections
2.30.4.7 and 2.30.4.8.
	 
	 	2.7.2.10	 	Judicial Services
	 
	 	2.7.2.10.1	 	The CONTRACTOR shall provide covered court ordered behavioral health services to its
members pursuant to court order(s). The CONTRACTOR shall furnish these services in the same
manner as services furnished to other members.
	 
	 	2.7.2.10.2	 	The CONTRACTOR shall provide for behavioral health services to its members in
accordance with state law. Specific laws employed include the following:
	 
	 	2.7.2.10.2.1	 	Psychiatric treatment for persons found by the court to require judicial
psychiatric hospitalization (TCA 33-6 part 4 and part 5). The CONTRACTOR may apply
medical necessity criteria to the situation after seventy-two (72) hours of
emergency services, unless there is a court order prohibiting release;
	 
	 	2.7.2.10.2.2	 	Judicial review of discharge for persons hospitalized by a circuit, criminal or
juvenile court (TCA 33-6-708);
	 
	 	2.7.2.10.2.3	 	Access to and provision of mandatory outpatient psychiatric treatment and
services to persons who are discharged from psychiatric hospitals after being
hospitalized (TCA 33-6, Part 6);
	 
	 	2.7.2.10.2.4	 	Inpatient psychiatric examination for up to forty-eight (48) hours for persons
whom the court has ordered to be detained for examination but who have been
unwilling to be evaluated for hospital admission (TCA 33-3-607);
	 
	 	2.7.2.10.2.5	 	Voluntary psychiatric hospitalization for persons when determined to be
medically necessary, subject to the availability of suitable accommodations (TCA
33-6, Part 2); and
	 
	 	2.7.2.10.2.6	 	Voluntary psychiatric hospitalization for persons with a severe impairment when
determined to be medically necessary but who do not meet the criteria for emergency
involuntary hospitalization, subject to the availability of suitable accommodations
(TCA 33-6, Part 3).
	 
	 	2.7.2.11	 	Mandatory Outpatient Treatment
	 
	 	2.7.2.11.1	 	The CONTRACTOR shall provide mandatory outpatient treatment for individuals found not
guilty by reason of insanity following a thirty (30) to sixty (60) calendar day inpatient
evaluation. Treatment can be terminated only by the court pursuant to TCA 33-7-303(b).
	 
	 	2.7.2.11.2	 	The State will assume responsibility for all forensic services other than the mandatory
outpatient treatment service identified in Section 2.7.2.11.1 (TCA 33-7- 30 1(a), 33-7-301(b),
33-7-303(a) and 33-7-303(c)).

Page 51 of 374

 

2.7.3 Self-Direction of Health Care Tasks

The CONTRACTOR shall, as specified in TennCare rules and regulations, offer CHOICES members
the option to direct and supervise a paid personal aide in the performance of health care
tasks.

2.7.4 Health Education and Outreach

	 	2.7.4.1	 	The CONTRACTOR shall develop programs and participate in activities to enhance
the general health and well-being of members. Health education and outreach
programs and activities may include the following:
	 
	 	2.7.4.1.1	 	General physical, behavioral health and long-term care education classes;
	 
	 	2.7.4.1.2	 	Mental illness awareness programs and education campaigns with special emphasis on
events such as National Mental Health Month and National Depression Screening Day;
	 
	 	2.7.4.1.3	 	Smoking cessation programs with targeted outreach for adolescents and pregnant
women;
	 
	 	2.7.4.1.4	 	Nutrition counseling;
	 
	 	2.7.4.1.5	 	Early intervention and risk reduction strategies to avoid complications of
disability and chronic illness;
	 
	 	2.7.4.1.6	 	Prevention and treatment of substance abuse;
	 
	 	2.7.4.1.7	 	Self care training, including
self-examination;
	 
	 	2.7.4.1.8	 	Need for clear understanding of how to take medications and the importance of
coordinating all medications;
	 
	 	2.7.4.1.9	 	Understanding the difference between emergent, urgent and routine health
conditions;
	 
	 	2.7.4.1.10	 	Education for members on the significance of their role in their overall health
and welfare and available resources;
	 
	 	2.7.4.1.11	 	Education for caregivers on the significance of their role in the overall health
and welfare of the member and available resources;
	 
	 	2.7.4.1.12	 	Education for members and caregivers about identification and reporting of
suspected abuse and neglect;
	 
	 	2.7.4.1.13	 	Telephone calls, mailings and home visits to current members for the sole purpose
of educating current members about services offered by or available through the
CONTRACTOR’s MCO; and

Page 52 of 374

 

	 	2.7.4.1.14	 	General activities that benefit the entire community (e.g., health
fairs and school activity sponsorships).
	 
	 	2.7.4.2	 	The CONTRACTOR shall ensure that all health education and outreach activities are
prior approved in writing by TENNCARE (see Section 2.17.1).

2.7.5 Preventive Services

	 	2.7.5.1	 	The CONTRACTOR shall provide preventive services which include, but are not
limited to, initial and periodic evaluations, family planning services, prenatal
care, laboratory services and immunizations in accordance with TennCare rules
and regulations. These services shall be exempt from TennCare cost sharing
responsibilities described in Section 2.6.7 of this Agreement (see TennCare
rules and regulations for service codes).
	 
	 	2.7.5.2	 	Prenatal Care
	 
	 	2.7.5.2.1	 	The CONTRACTOR shall provide or arrange for the provision of medically necessary
prenatal care to members beginning on the date of their enrollment in the CONTRACTOR’s
MCO. This requirement includes pregnant women who are presumptively eligible for
TennCare, enrollees who become pregnant, as well as enrollees who are pregnant on the
effective date of enrollment in the CONTRACTOR’s MCO. The requirement to provide or
arrange for the provision of medically necessary prenatal care shall include assistance
in making a timely appointment for a woman who is presumptively eligible and shall be
provided as soon as the CONTRACTOR becomes aware of the enrollment. For a woman in her
second or third trimester, the appointment shall occur as required in Section 2.11.4.2.
In the event a member enrolling in the CONTRACTOR’s MCO is receiving medically
necessary prenatal care services the day before enrollment, the CONTRACTOR shall comply
with the requirements in Sections 2.9.2.2 and 2.9.2.3 regarding prior authorization of
prenatal care.
	 
	 	2.7.5.2.2	 	Failure of the CONTRACTOR to respond to a member’s request for prenatal care by
failing to identify a prenatal care provider to honor a request from a member,
including a presumptively eligible member, (or from an PCP or patient advocate acting
on behalf of a member) for a prenatal care appointment shall be considered a material
breach of this Agreement.
	 
	 	2.7.5.2.3	 	The CONTRACTOR shall notify all contract providers that any unreasonable delay in
providing care to a pregnant member seeking prenatal care shall be considered a
material breach of the provider’s agreement with the CONTRACTOR. Unreasonable delay in
care for pregnant members shall mean failure of the prenatal care provider to meet the
accessibility requirements required in Section 2.11.4 of this Agreement.

2.7.6 TENNderCare

	 	2.7.6.1	 	General Provisions
	 
	 	2.7.6.1.1	 	The CONTRACTOR shall provide TENNderCare services to members under age twenty-one
(21) in accordance with TennCare and federal requirements including TennCare rules and
regulations, TennCare policies and procedures, 42 USC

Page 53 of 374

 

	 	 	 	1396a(a)(43), 1396d(a) and (r), 42 CFR Part 441, Subpart B, the Omnibus Budget
Reconciliation Act of 1989, and the State Medicaid Manual. TENNderCare services means
early and periodic screening, diagnosis and treatment of members under age twenty-one
(21) to ascertain children’s individual (or individualized/or on an individual basis)
physical and mental defects, and providing treatment to correct or ameliorate, or
prevent from worsening defects and physical and mental illnesses and conditions
discovered by the screening services, regardless of whether the required service is a
covered benefit as described in Section 2.6.1.
	 
	 	2.7.6.1.2	 	The CONTRACTOR shall use the name “TENNderCare” in describing or
naming the State’s EPSDT program or services. This requirement is applicable
for all policies, procedures and other material, regardless of the format or
media. No other names or labels shall be used.
	 
	 	2.7.6.1.3	 	The CONTRACTOR shall have written policies and procedures for the
TENNderCare program that include coordinating services with child-serving
agencies and providers, providing all medically necessary TENNderCare
services to all eligible members under the age of twenty-one (21) regardless
of whether the service is included in the Medicaid State Plan, and conducting
outreach and education. The CONTRACTOR shall ensure the availability and
accessibility of required health care resources and shall help members and
their parents or legally appointed representatives use these resources
effectively.
	 
	 	2.7.6.1.4	 	The CONTRACTOR shall be responsible for and comply with all
provisions related to screening, vision, dental, and hearing services
(including making arrangements for necessary follow-up if all components of a
screen cannot be completed in a single visit).
	 
	 	2.7.6.1.5	 	The CONTRACTOR shall:
	 
	 	2.7.6.1.5.1	 	Require that providers provide TENNderCare services;
	 
	 	2.7.6.1.5.2	 	Require that providers make appropriate referrals and document said referrals in
the member’s medical record;
	 
	 	2.7.6.1.5.3	 	Educate contract providers about proper coding and encourage them to submit the
appropriate diagnosis codes identified by TENNCARE in conjunction with evaluation and
management procedure codes for TENNderCare services;
	 
	 	2.7.6.1.5.4	 	Educate contract providers about how to submit claims with appropriate codes and
modifiers as described in standardized billing requirements (e.g., CPT, HCPCS, etc.)
and require that they adjust billing methodology according to described components of
said procedure codes/modifiers; and
	 
	 	2.7.6.1.5.5	 	Monitor provider compliance with required TENNderCare activities including
compliance with proper coding.
	 
	 	2.7.6.1.6	 	The CONTRACTOR shall require that its contract providers notify the CONTRACTOR in the
event a screening reveals the need for other health care services and the provider is unable
to make an appropriate referral for those services. Upon notification of the inability to make
an appropriate referral, the

Page 54 of 374

 

	 	 	 	CONTRACTOR shall secure an appropriate referral and contact the member to offer
scheduling assistance and transportation for members lacking access to transportation.
In the event the failed referral is for dental services, the CONTRACTOR shall
coordinate with the DBM to arrange for services.
	 
	 	2.7.6.1.7	 	The CONTRACTOR shall not require prior
authorization for periodic and interperiodic screens
conducted by PCPs. The CONTRACTOR shall provide all
medically necessary covered services regardless of
whether the need for such services was identified by a
provider who had received prior authorization from the
CONTRACTOR or from a contract provider.
	 
	 	2.7.6.1.8	 	The CONTRACTOR shall have a tracking system
to monitor each TENNderCare eligible member’s receipt
of the required screening, diagnosis, and treatment
services. The tracking system shall have the ability
to generate immediate reports on each member’s
TENNderCare status, reflecting all encounters reported
more than sixty (60) days prior to the date of the
report.
	 
	 	2.7.6.1.9	 	In the event that a member under sixteen
(16) years of age is seeking behavioral health
TENNderCare services and the member’s parent(s), or
legally appointed representative is unable to
accompany the member to the examination, the
CONTRACTOR shall require that its providers either
contact the member’s parent(s), or legally appointed
representative to discuss the findings and inform the
family of any other necessary health care, diagnostic
services, treatment or other measures recommended for
the member or notify the MCO to contact the parent(s),
or legally appointed representative with the results.
	 
	 	2.7.6.2	 	Member Education and Outreach
	 
	 	2.7.6.2.1	 	The CONTRACTOR shall be responsible for outreach activities and for informing members
who are under the age of twenty-one (21), or their parent or legally appointed representative,
of the availability of TENNderCare services. All TENNderCare member materials shall be
submitted to TENNCARE for written approval prior to distribution in accordance with Section
2.17.1 and shall be made available in accordance with the requirements specified in Section
2.17.2.
	 
	 	2.7.6.2.2	 	The CONTRACTOR shall have a minimum of six (6) “outreach contacts” per member per
calendar year in which it provides information about TENNderCare to members. The minimum
“outreach contacts” include: one (1) member handbook as described in Section 2.17.4, four (4)
quarterly member newsletters as described in Section 2.17.5, and one (1) reminder notice issued
before a screening is due. The reminder notice shall include an offer of transportation and
scheduling assistance.
	 
	 	2.7.6.2.2.1	 	If the CONTRACTOR’s TENNderCare screening rate is below ninety percent
(90%), as determined in the most recent CMS 416 report, the CONTRACTOR shall
conduct New Member Calls for all new members under the age of twenty- one (21) to
inform them of TENNderCare services including assistance with appointment
scheduling and transportation to appointments.
	 
	 	2.7.6.2.2.2	 	The CONTRACTOR shall have the ability to conduct EPSDT outreach in
formats appropriate to members who are blind, deaf, illiterate or have Limited
English Proficiency. At least one of the 6 outreach attempts identified above shall

Page 55 of 374

 

	 	 	 	advise members regarding how to request and/or access such assistance and/or
information. The CONTRACTOR shall collaborate with agencies that have established
procedures for working with special populations in order to develop effective
outreach materials.
	 
	 	2.7.6.2.3	 	The CONTRACTOR shall have a mechanism for systematically notifying families when
TENNderCare screens are due.
	 
	 	2.7.6.2.4	 	As part of its TENNderCare policies and procedures, the CONTRACTOR shall have a written
process for following up with members who do not get their screenings timely. This process for
follow up shall include provisions for documenting all outreach attempts and maintaining
records of efforts made to reach out to members who have missed screening appointments or who
have failed to receive regular check-ups. The CONTRACTOR shall make at least one (1) effort
per quarter in excess of the six (6) “outreach contacts” to get the member in for a screening.
The efforts, whether written or oral, shall be different each quarter. The CONTRACTOR is
prohibited from simply sending the same letter four (4) times.
	 
	 	2.7.6.2.5	 	The CONTRACTOR shall have a process for determining if a member who is eligible for
TENNderCare has used no services within a year and shall make two (2) reasonable attempts to
re-notify such members about TENNderCare. The attempts must be different in format or message.
One (1) of these attempts can be a referral to DOH for a screen. (These two (2) attempts are
in addition to the one (1) attempt per quarter mentioned in Section 2.7.6.2.4 above.)
	 
	 	2.7.6.2.6	 	The CONTRACTOR shall require that providers have a process for documenting services
declined by a parent or legally appointed representative or mature competent child, specifying
the particular service was declined. This process shall meet all requirements outlined in
Section 5320.2.A of the State Medicaid Manual.
	 
	 	2.7.6.2.7	 	The CONTRACTOR shall make and document a minimum of two (2) reasonable attempts to find a
member with one (1) of the two (2) attempts being made within thirty (30) days of receipt of
mail returned as undeliverable and the second being made within ninety (90) days of receipt of
mail returned as undeliverable. At least one (1) of these attempts shall be by phone.
	 
	 	2.7.6.2.8	 	The CONTRACTOR shall make available to members and families accurate lists of names and
phone numbers of contract providers who are currently accepting TennCare members as described
in Section 2.17.8 of this Agreement.
	 
	 	2.7.6.2.9	 	The CONTRACTOR shall target specific informing activities to pregnant women and families
with newborns. Provided that the CONTRACTOR is aware of the pregnancy, the CONTRACTOR shall
inform all pregnant women prior to the estimated delivery date about the availability of
TENNderCare services for their children. The CONTRACTOR shall offer TENNderCare services for
the child when it is born.
	 
	 	2.7.6.2.10	 	The CONTRACTOR shall provide member education and outreach in community settings.
Outreach events shall be conducted in the Grand Region covered by this Agreement in accordance
with the following specifications:

Page 56 of 374

 

	 	2.7.6.2.10.1	 	Outreach events shall number a minimum of one hundred fifty (150) per year
with no less than twenty-five (25) per region, per quarter.
	 
	 	2.7.6.2.10.1.1	 	At least thirty percent (30%) shall be conducted in rural areas. Results of the
CONTRACTOR’s 416 report and HEDIS report, as well as county demographics, shall be utilized in
determining counties for targeted activities and in developing strategies for specific
populations.
	 
	 	2.7.6.2.10.2	 	The CONTRACTOR shall contact a minimum of twenty-five (25) state agencies
or community-based organizations per quarter, to either educate them on services
available through the CONTRACTOR or to develop outreach and educational
initiatives. All of the agencies engaged shall be those who serve TennCare
enrollees. Collaborative activities should include those designed to reach
enrollees with limited English proficiency, low literacy levels, behavioral health
and special health care needs or who are pregnant.
	 
	 	2.7.6.3	 	Screening
	 
	 	2.7.6.3.1	 	The CONTRACTOR shall provide periodic comprehensive child health assessments meaning, “regularly
scheduled examinations and evaluations of the general physical and mental health, growth, development, and
nutritional status of infants, children, and youth.”
	 
	 	2.7.6.3.2	 	At a minimum, these screens shall include periodic and interperiodic screens and be provided at
intervals which meet reasonable standards of medical, behavioral and dental practice, as determined by the
State after consultation with recognized medical and dental organizations involved in child health care.
The State has determined that “reasonable standards of medical and dental practice” are those standards set
forth in the American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care for
medical practice and American Academy of Pediatric Dentistry (AAPD) guidelines for dental practice. Tools
used for screening shall be consistent with the screening guidelines recommended by the State which are
available on the TennCare web site. These include, but are not limited to recommended screening guidelines
for developmental/behavioral surveillance and screening, hearing screenings, and vision screenings.
	 
	 	2.7.6.3.3	 	The screens shall include, but not be limited to:
	 
	 	2.7.6.3.3.1	 	Comprehensive health and developmental history (including assessment of
physical and mental health development and dietary practices);
	 
	 	2.7.6.3.3.2	 	Comprehensive unclothed physical examination, including measurements (the
child’s growth shall be compared against that considered normal for the child’s age
and gender);
	 
	 	2.7.6.3.3.3	 	Appropriate immunizations scheduled according to the most current Advisory
Committee on Immunization Practices (ACIP) schedule according to age and health
history;

Page 57 of 374

 

	 	2.7.6.3.3.4	 	Appropriate vision and hearing testing provided at intervals which meet
reasonable standards of medical practice and at other intervals as medically
necessary to determine the existence of suspected illness or condition;
	 
	 	2.7.6.3.3.5	 	Appropriate laboratory tests (including lead toxicity screening appropriate for
age and risk factors). All children are considered at risk and shall be screened
for lead poisoning. All children shall receive a screening blood lead test at
twelve (12) and twenty-four (24) months of age. Children between the ages of
thirty-six (36) months and seventy-two (72) months of age shall receive a screening
blood lead test if they have not been previously screened for lead poisoning. A
blood lead test shall be used when screening Medicaid-eligible children. A blood
lead test equal to or greater than ten (10) ug/dL obtained by capillary specimen
(finger stick) shall be confirmed by using a venous blood sample; and
	 
	 	2.7.6.3.3.6	 	Health education which includes anticipatory guidance based on the findings of
all screening. Health education should include counseling to both members and
members’ parents or to the legally appointed representative to assist in
understanding what to expect in terms of the child’s development and to provide
information about the benefits of healthy lifestyles and practices as well as
accident and disease prevention.
	 
	 	2.7.6.3.4	 	The CONTRACTOR shall
encourage providers to refer
children to dentists for periodic
dental screens beginning no later
than three (3) years of age and
earlier as needed (as early as
six (6) to twelve (12) months in
accordance with the American
Academy of Pediatric Dentistry
(AAPD) guidelines) and as
otherwise appropriate.
	 
	 	2.7.6.3.5	 	The CONTRACTOR shall
establish a procedure for PCPs or
other providers completing
TENNderCare screenings to refer
TENNderCare eligible members
requiring behavioral health
services to appropriate
providers.
	 
	 	2.7.6.4	 	Services
	 
	 	2.7.6.4.1	 	Should screenings indicate a need, the CONTRACTOR shall provide all necessary health
care, diagnostic services, treatment, and other measures described in 42 USC 1396d(a) (Section
1905(a) of the Social Security Act) to correct or ameliorate or prevent from worsening defects
and physical and mental illnesses and conditions discovered by the screening services, whether
or not such services are covered under the Medicaid State plan (see Section 2.7.6.4.8). This
includes, but is not limited to, the services detailed below.
	 
	 	2.7.6.4.2	 	The CONTRACTOR shall provide treatment for defects in vision and hearing, including
eyeglasses and hearing aids.
	 
	 	2.7.6.4.3	 	The CONTRACTOR shall coordinate with the DBM to ensure that TENNderCare eligible members
receive dental care services furnished by direct referral to a dentist, at as early an age as
necessary, and at intervals which meet reasonable standards of dental practice as determined
by the State and at other intervals as medically necessary to determine the existence of a
suspected illness or condition.
	 
	 	2.7.6.4.4	 	The CONTRACTOR shall not require prior authorization or written PCP referral in order for
a member to obtain a mental health or substance abuse assessment, whether

Page 58 of 374

 

	 	 	 	the assessment is requested as follow-up to a TENNderCare screening or an interperiodic
screening. This requirement shall not preclude the CONTRACTOR from requiring
notification for a referral for an assessment. Furthermore, the CONTRACTOR shall
establish a procedure for PCPs, or other providers, completing TENNderCare screenings,
to refer members under the age of twenty-one (21) for a mental health or substance
abuse assessment.
	 
	 	2.7.6.4.5	 	For services not covered by Section 1905(a) of the Social Security Act, but found to be
needed as a result of conditions disclosed during screening and diagnosis, the CONTRACTOR
shall provide referral assistance as required by 42 CFR 441.61, including referral to
providers and State health agencies.
	 
	 	2.7.6.4.6	 	Transportation Services
	 
	 	2.7.6.4.6.1	 	The CONTRACTOR shall provide transportation assistance for a child and for the
child’s escort or accompanying adult, including related travel expenses, cost of meals,
and lodging en route to and from TennCare covered services. The requirement to provide
the cost of meals shall not be interpreted to mean that a member (or the child’s escort
or accompanying adult) can request meals while in transport to and from care.
Reimbursement for meals and lodging shall only be provided when transportation for a
TennCare covered service cannot be completed in one (1) day and would require an
overnight stay.
	 
	 	2.7.6.4.6.2	 	The CONTRACTOR shall offer transportation and scheduling assistance to all
members under age twenty-one (21) who do not have access to transportation in order to
access covered services. This may be accomplished through various means of
communication to members, including but not limited to, member handbooks, TENNderCare
outreach notifications, etc.
	 
	 	2.7.6.4.7	 	Services for Elevated Blood Lead Levels
	 
	 	2.7.6.4.7.1	 	The CONTRACTOR shall provide follow up for elevated blood lead levels in
accordance with the State Medicaid Manual, Part 5. The Manual currently says that
children with blood lead levels equal to or greater than ten (10) ug/dL should be
followed according to CDC guidelines. These guidelines include follow up blood tests
and investigations to determine the source of lead, when indicated.
	 
	 	2.7.6.4.7.2	 	The CONTRACTOR shall provide for any follow up service within the scope of the
federal Medicaid statute, including diagnostic or treatment services determined to be
medically necessary when elevated blood lead levels are identified in children. Such
services would include both MCO case management services and a one (1) time
investigation to determine the source of lead.
	 
	 	2.7.6.4.7.3	 	The CONTRACTOR is responsible for the primary environmental lead
investigation—commonly called a “lead inspection”—for children when elevated blood
levels suggest a need for such an investigation.
	 
	 	2.7.6.4.7.4	 	If the lead inspection does not reveal the presence of lead paint in the home,
there may be a need for other testing, such as risk assessments involving water and
soil sampling or inspections of sites other than the primary residence if the child
spends a substantial amount of time in
another location. The

Page 59 of 374

 

	 	 	 	CONTRACTOR is not responsible for either the risk assessments or the lead inspection at the
secondary site. However, the CONTRACTOR shall contact the DOH when these services are indicated
as this agency is responsible for these services.
	 
	 	2.7.6.4.7.5	 	CONTRACTOR reimbursement for the primary environmental investigations is
limited to the items specified in Part 5 of the State Medicaid Manual. These items
include the health professional’s time and activities during the on-site
investigation of the child’s primary residence. They do not include testing of
environmental substances such as water, paint, or soil.
	 
	 	2.7.6.4.8	 	Services Chart
	 
	 	 	 	Pursuant to federal and state requirements, TennCare enrollees under the age of 21 are
eligible for all services listed in Section 1905(a) of the Social Security Act. These
services, and the entity responsible for providing them to TennCare enrollees under the
age of 21, are listed below. Notwithstanding any other provision of this Agreement, the
CONTRACTOR shall provide all services for which “MCO” is identified as the responsible
entity to members under the age of 21. All services, other than TENNderCare screens and
interperiodic screens, must be medically necessary in order to be covered by the
CONTRACTOR. The CONTRACTOR shall provide all medically necessary TENNderCare covered
services regardless of whether or not the need for such services was identified by a
provider whose services had received prior authorization from the CONTRACTOR or by a
contract provider.

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

services (other than
services in an
institution for mental
diseases)

	 	MCO	 	 
	 
	 	 	 	 
	
(2)(A)   Outpatient
hospital services

	 	MCO	 	 
	 
	 	 	 	 
	
(2)(B)   Rural health
clinic services (RHCs)

	 	MCO
	 	MCOs are not
required to contract
with RHCs if the
services are
available through
other contract
providers.
	 
	 	 	 	 
	
(2)(C)   Federally-qualified
health center services
(FQHCs)

	 	MCO
	 	MCOs are not
required to contract
with FQHCs if they
can demonstrate
adequate provider
capacity without
them.
	 
	 	 	 	 
	
(3)         Other laboratory and X-ray services

	 	MCO	 	 
	 
	 	 	 	 
	
(4)(A)   Nursing facility
services for individuals
age 21 and older

	 	 	 	Not applicable for

TENNderCare

Page 60 of 374

 

	 	 	 	 	 
	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity in	 	 
	1905(a)	 	Tennessee	 	Comments
	
(4)(B)   EPSDT services

	 	MCO for physical health
and behavioral health
services; DBM for dental
services except as
described in Section
2.6.1.3; 
 PBM for
pharmacy services as
described except as in
Section 2.6.1.3	 	 
	 
	 	 	 	 
	
(4)(C)   Family planning services
and supplies

	 	MCO;

PBM for pharmacy
services except as
described in Section
2.6.1.3	 	 
	 
	 	 	 	 
	
(5)(A)   Physicians’ services
furnished by a physician,
whether furnished in the
office, the patient’s home, a
hospital, or a nursing facility

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

	 	DBM except as described
in Section 2.6.1.3	 	 
	 
	 	 	 	 
	
(6)        Medical care, or any
other type of remedial care
recognized under state law,
furnished by licensed
practitioners within the scope
of their practice as defined by
state law

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

services

	 	MCO	 	 
	 
	 	 	 	 
	
(8)        Private duty nursing 

services

	 	MCO	 	 
	 
	 	 	 	 
	
(9)        Clinic services

	 	MCO	 	 
	 
	 	 	 	 
	
(10)      Dental services

	 	DBM except as described
in Section 2.6.1.3	 	 
	 
	 	 	 	 
	
(11)      Physical therapy and
related services

	 	MCO	 	 
	 
	 	 	 	 
	
(12)      Prescribed drugs,
dentures, and prosthetic
devices, and eyeglasses

	 	MCO;
 PBM for pharmacy
services except as
described in Section
2.6.1.3;
 DBM for
dentures	 	 
	 
	 	 	 	 
	
(13)     Other diagnostic,
screening, preventive, and
rehabilitative

	 	MCO for physical health
and behavioral health
services;
 DBM for dental
services
	 	The following are
considered
practitioners of
the healing arts in

Page 61 of 374

 

	 	 	 	 	 
	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity in	 	 
	1905(a)	 	Tennessee	 	Comments
	
services, including any
medical or remedial
services recommended
by a physician or other
licensed practitioner of
the healing arts within
the scope of their
practice under state
law, for the maximum
reduction of physical
or mental disability
and restoration of an
individual to the best
possible functional
level 

	 	except as described in
Section
2.6.1.3;

PBM for pharmacy services
except as described in
Section
2.6.1.3
	 	Tennessee law:1
•      Alcohol and drug
abuse counselor

•      Athletic trainer

•      Audiologist

•      Certified
acupuncturist

•      Certified master
social worker

•      Certified nurse
practitioner
 •      Certified professional counselor

•      Certified psychological assistant

	 

	 	 	 	 •      Chiropractic physician

	 

	 	 	 	 •      Chiropractic therapy assistant

	 

	 	 	 	 •      Clinical pastoral therapist

	 

	 	 	 	 •      Dentist

	 

	 	 	 	 •      Dental assistant

	 

	 	 	 	 •      Dental hygienist

	 

	 	 	 	 •      Dietitian/nutritionist

	 

	 	 	 	 •      Dispensing optician

	 

	 	 	 	 •      Electrologist

	 

	 	 	 	 •      Emergency medical personnel

	 

	 	 	 	 •      First responder

	 

	 	 	 	 •      Hearing instrument specialist

	 

	 	 	 	 •      Laboratory personnel

	 

	 	 	 	 •      Licensed clinical perfusionist

	 

	 	 	 	 •      Licensed clinical social worker

	 

	 	 	 	 •      Licensed practical nurse

	 

	 	 	 	 •      Licensed professional

 

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

Page 62 of 374

 

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

•      Marital and family therapist, certified

	 
	 	 	 	 •      Marital and family therapist, licensed

	 
	 	 	 	 •      Massage therapist

	 
	 	 	 	 •      Medical doctor

	 
	 	 	 	 •      Medical doctor (special training)

	 
	 	 	 	 •      Midwives and nurse midwives

	 

	 	 	 	 •      Nurse aide

	 
	 	 	 	 •      Occupational therapist

	 
	 	 	 	 •      Occupational therapy assistant

	 
	 	 	 	 •      Optometrist

	 
	 	 	 	 •      Osteopathic physician

	 
	 	 	 	 •      Pharmacist

	 
	 	 	 	 •      Physical therapist

	 
	 	 	 	 •      Physical therapist assistant

	 
	 	 	 	 •      Physician assistant

	 
	 	 	 	 •      Podiatrist

	 
	 	 	 	 •      Psychological examiner

	 
	 	 	 	 •      Psychologist

	 
	 	 	 	 •      Registered nurse

	 
	 	 	 	 •      Registered certified reflexologist

	 
	 	 	 	 •      Respiratory care assistant

	 
	 	 	 	 •      Respiratory care technician

	 
	 	 	 	 •      Respiratory care therapist

	 
	 	 	 	 
	 
	 	 	 	 •      Senior psychological examiner

	 
	 	 	 	
•      Speech pathologist

	 
	 	 	 	 •      Speech pathology aide

	 
	 	 	 	 •      X-ray op in chiropractic physician’s office

Page 63 of 374

 

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

	 	 	 	 •      X-ray op in MD office

	 

	 	 	 	 •      X-ray op in osteopathic office

	 

	 	 	 	 •      X-ray op in podiatrist’s office

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

	 	 	 	Not applicable for

TENNderCare
	 
	 	 	 	 
	
(15)      Services in an 

intermediate care facility 

for the mentally retarded

	 	TENNCARE	 	 
	 
	 	 	 	 
	
(16)      Inpatient psychiatric 

services for individuals 

under age 21

	 	MCO	 	 
	 
	 	 	 	 
	
(17)       Services furnished by a 

nurse-midwife

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

	 	MCO	 	 
	 
	 	 	 	 
	
(19)      Case management services 

	 	MCO	 	 
	 
	 	 	 	 
	
(20)      Respiratory care services

	 	MCO	 	 
	 
	 	 	 	 
	
(21)      Services furnished by a 

certified pediatric nurse 

practitioner or certified 

family nurse practitioner

	 	MCO
	 	The MCOs are not
required to
contract with PNPs
or CFNPs if the
services are
available through
other contract
providers.
	 
	 	 	 	 
	
(22)      Home and community care
for functionally disabled
elderly individuals

	 	 	 	Not applicable for

TENNderCare
	 
	 	 	 	 
	
(23)      Community supported 

living arrangements services

	 	 	 	Not applicable for

TENNderCare
	 
	 	 	 	 
	
(24)      Personal care services

	 	MCO	 	 

Page 64 of 374

 

	 	 	 	 	 
	Services Listed in Social	 	 	 	 
	Security Act Section	 	Responsible Entity in	 	 
	1905(a)	 	Tennessee	 	Comments
	
(25)      Primary care case
management services

	 	 	 	Not applicable
	 
	 	 	 	 
	
(26)      Services furnished
under a PACE program 

	 	 	 	Not applicable for

TENNderCare
	 
	 	 	 	 
	
(27)      Any other medical care, and any other type
of remedial care
recognized under state
law.

	 	MCO for physical and
behavioral health
services; DBM for dental
services except as
described in Section
2.6.1.3;
PBM for
pharmacy services except
as described in Section
2.6.1.3
	 	See Item (13)

	 	2.7.6.4.8.1	 	Note 1: “Targeted case management services,” which are listed under Section 191
5(g)(1), are not TENNderCare services except to the extent that the definition in
Section 1915(g)(2) is used with Item (19) above.
	 
	 	2.7.6.4.8.2	 	Note 2: “Psychiatric residential treatment facility” is not listed in Social
Security Act Section 1905(a). It is, however, defined in 42 CFR 483.352 as “a facility
other than a hospital, that provides psychiatric services, as described in subpart D of
part 441 of this chapter, to individuals under age twenty-one (21), in an inpatient
setting.”
	 
	 	2.7.6.4.8.3	 	Note 3: “Rehabilitative” services are differentiated from “habilitative”
services in federal law. “Rehabilitative” services, which are TENNderCare services, are
defined in 42 CFR 440.130(d) as services designed “for maximum reduction of physical or
mental disability and restoration of a recipient to his best possible functional
level.” “Habilitative” services, which are not TENNderCare services, are defined in
Section 1915(c)(5) as services designed “to assist individuals in acquiring, retaining,
and improving the self-help, socialization, and adaptive skills necessary to reside
successfully in home and community based settings.”
	 
	 	2.7.6.4.8.4	 	Note 4: Certain services are covered under a Home and Community Based waiver but
are not TENNderCare services because they are not listed in the Social Security Act
Section 1905(a). These services include habilitation, prevocational, supported
employment services, homemaker services and respite services. (See Section 1915(c)(4).)
	 
	 	2.7.6.4.8.5	 	Note 5: Certain services are not coverable even under a Home and Community Based
waiver and are not TENNderCare services. These services include room and board, and
special education and related services which are otherwise available through a Local
Education Agency. (See Section 191 5(c)(5).)

Page 65 of 374

 

	 	2.7.6.5	 	Children with Special Health Care Needs
	 
	 	 	 	Children with special health care needs are those children who are in the
custody of DCS. As provided in Section 2.4.4.4, TennCare enrollees who are in
the custody of DCS will be enrolled in TennCare Select.

2.7.7 Advance Directives

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

2.7.8 Sterilizations, Hysterectomies and Abortions

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

Page 66 of 374

 

	 	2.7.8.2	 	Sterilizations
	 
	 	 	 	Sterilization shall mean any medical procedure, treatment or operation done for the
purpose of rendering an individual permanently incapable of reproducing. The CONTRACTOR
shall cover sterilizations only if the following requirements are met:
	 
	 	2.7.8.2.1	 	At least thirty (30) calendar days, but not more than one hundred eighty (180) calendar
days, have passed between the date of informed consent and the date of the sterilization,
except in the case of premature delivery or emergency abdominal surgery. A member may consent
to be sterilized at the time of a premature delivery or emergency abdominal surgery if at
least seventy-two (72) hours have passed since the member gave informed consent for the
sterilization. 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;
	 
	 	2.7.8.2.2	 	The member is at least twenty-one (21) years old at the time consent is obtained;
	 
	 	2.7.8.2.3	 	The member is mentally competent;
	 
	 	2.7.8.2.4	 	The member is not institutionalized (i.e., not involuntarily confined or detained under a
civil or criminal status in a correctional or rehabilitative facility or confined in a mental hospital
or other facility for the care and treatment of mental illness, whether voluntarily or involuntarily
committed); and
	 
	 	2.7.8.2.5	 	The member has voluntarily given informed consent on the approved “STERILIZATION CONSENT
FORM” which is available on TENNCARE’s web site. The form shall be available in English and Spanish,
and the CONTRACTOR shall provide assistance in completing the form when an alternative form of
communication is necessary.
	 
	 	2.7.8.3	 	Hysterectomies
	 
	 	2.7.8.3.1	 	Hysterectomy shall mean a medical procedure or operation for the purpose of removing the
uterus. The CONTRACTOR shall cover hysterectomies only if the following requirements are met:
	 
	 	2.7.8.3.1.1	 	The hysterectomy is medically necessary;
	 
	 	2.7.8.3.1.2	 	The member or her authorized representative, if any, has been informed orally
and in writing that the hysterectomy will render the member permanently incapable
of reproducing; and
	 
	 	2.7.8.3.1.3	 	The member or her authorized representative, if any, has signed and dated an
“ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form which is available on the Bureau
of TennCare’s web site, prior to the hysterectomy. Informed consent shall be
obtained regardless of diagnosis or age in accordance with federal requirements.
The form shall be available in English and Spanish, and assistance shall be
provided in completing the form when an alternative form of communication is
necessary. Refer to “ACKNOWLEDGMENT OF HYSTERECTOMY INFORMATION” form and
instructions for additional guidance and exceptions.

Page 67 of 374

 

	 	2.7.8.3.2	 	The CONTRACTOR shall not cover hysterectomies under the following
circumstances:
	 
	 	2.7.8.3.2.1	 	If it is performed solely for the purpose of rendering an individual permanently
incapable of reproducing;
	 
	 	2.7.8.3.2.2	 	If there is more than one purpose for performing the hysterectomy, but the
primary purpose is to render the individual permanently incapable of
reproducing; or
	 
	 	2.7.8.3.2.3	 	It is performed for the purpose of cancer prophylaxis.
	 
	 	2.7.8.4	 	Abortions
	 
	 	2.7.8.4.1	 	The CONTRACTOR shall cover abortions and services associated with the abortion
procedure only if the pregnancy is the result of an act of rape or incest; or in the
case where a woman suffers from a physical disorder, physical injury, or physical
illness, including a life-endangering physical condition caused by or arising from the
pregnancy itself, that would, as certified by a physician, place the woman in danger of
death unless an abortion is performed.
	 
	 	2.7.8.4.2	 	The CONTRACTOR shall ensure that a “CERTIFICATION OF MEDICAL NECESSITY FOR
ABORTION” form, which is available on TENNCARE’s web site, is completed. The form shall
be available in English and Spanish, and assistance shall be provided in completing the
form when an alternative form of communication is necessary.

10. Section 2.8 shall be deleted in its entirety and replaced with the following:

2.8 DISEASE MANAGEMENT

2.8.1 General

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

Page 68 of 374

 

	 	2.8.1.1.8	 	Major depression; and
	 
	 	2.8.1.1.9	 	Schizophrenia.
	 
	 	2.8.1.2	 	Each DM program shall utilize evidence-based clinical practice guidelines (hereafter
referred to as the guidelines) that have been formally adopted by the CONTRACTOR’s
Quality Management/Quality Improvement (QM/QI) committee or other clinical committee
and patient empowerment strategies to support the provider-patient relationship and the
plan of care. For the conditions listed in 2.8.1.1.1 through 2.8.1.1.9, the guidelines
shall include a requirement to conduct a mental health and substance abuse screening.
The DM programs for bipolar disorder, major depression, and schizophrenia shall include
the use of the evidence-based practice for co-occurring disorders.
	 
	 	2.8.1.3	 	The DM programs shall emphasize the prevention of exacerbation and complications
of the conditions as evidenced by decreases in emergency room utilization and inpatient
hospitalization and/or improvements in condition-specific health status indicators.
	 
	 	2.8.1.4	 	The CONTRACTOR shall develop and maintain DM program policies and
procedures, which shall include program descriptions. These policies and procedures
shall include, for each of the conditions listed above, the following:
	 
	 	2.8.1.4.1	 	The definition of the target population;
	 
	 	2.8.1.4.2	 	Member identification strategies, which shall not exclude CHOICES members, including dual
eligible CHOICES members;
	 
	 	2.8.1.4.3	 	The guidelines;
	 
	 	2.8.1.4.4	 	Written description of the stratification levels for each of the conditions, including
member criteria and associated interventions;
	 
	 	2.8.1.4.5	 	Program content;
	 
	 	2.8.1.4.6	 	Targeted methods for informing and educating members which may include, but shall not be
limited to mailing educational materials;
	 
	 	2.8.1.4.7	 	Methods for informing and educating providers; and
	 
	 	2.8.1.4.8	 	Program evaluation.
	 
	 	2.8.1.5	 	As part of its DM program policies and procedures, the CONTRACTOR shall also
address how the DM programs will coordinate with MCO case management activities, in
particular for members who would benefit from both.
	 
	 	2.8.1.6	 	The CONTRACTOR’s DM and care coordination policies and procedures shall
address how the CONTRACTOR shall ensure that upon enrollment into CHOICES, disease
management activities are integrated with CHOICES care coordination processes and
functions, and that the member’s assigned care coordinator has primary responsibility
for coordination of all the member’s physical health,

Page 69 of 374

 

	 	 	 	behavioral health, and long-term care services, including appropriate management of
conditions specified in 2.8.1.1. If a CHOICES member has one or more of the conditions
specified in Section 2.8.1.1, the member’s care coordinator may use the CONTRACTOR’s
applicable DM tools and resources, including staff with specialized training, to help
manage the member’s condition and shall integrate the use of these DM tools and
resources with care coordination. DM staff shall supplement but not supplant the role
and responsibilities of the member’s care coordinator/care coordination team. The
CONTRACTOR’s policies and procedures shall also include at a minimum how the CONTRACTOR
will address the following for CHOICES members:
	 
	 	2.8.1.6.1	 	Notify the member’s care coordinator of the member’s participation in a DM program;
	 
	 	2.8.1.6.2	 	Provide to the member’s care coordinator information about the member collected through the DM program;
	 
	 	2.8.1.6.3	 	Provide to the care coordinator any educational materials given to the member through the DM program;
	 
	 	2.8.1.6.4	 	Ensure that the care coordinator reviews the information noted in Section 2.8.1.6.3 above verbally with the
member and with the member’s paid and/or unpaid caregiver and coordinates any necessary follow-up that may be needed
regarding the DM program such as scheduling screenings or appointments;
	 
	 	2.8.1.6.5	 	Ensure that the care coordinator integrates into the member’s plan of care aspects of the DM program that would
help to better manage the member’s condition; and
	 
	 	2.8.1.6.6	 	Ensure that the member’s care coordinator shall be responsible for coordinating with the member’s providers
regarding the development and implementation of an individualized treatment plan which shall be integrated into the
member’s plan of care and which shall include monitoring the member’s condition, helping to ensure compliance with
treatment protocols, and to the extent appropriate, lifestyle changes which will help to better ensure management of the
member’s condition (see Section 2.9.6 of this Agreement).
	 
	 	2.8.1.7	 	The CONTRACTOR shall implement DM programs specific to CHOICES members
in accordance with the following schedule:
	 
	 	2.8.1.7.1	 	After the second calendar quarter following CHOICES implementation in the Grand Region
covered by this Agreement, the CONTRACTOR shall implement DM programs for CHOICES members for
four of the six disease management conditions listed in Sections 2.8.1.1.2, 2.8.1.1.3,
2.8.1.1.5, 2.8.1.1.6, 2.8.1.1.8, and 2.8.8).
	 
	 	2.8.1.7.2	 	After the fourth calendar quarter following CHOICES implementation in the Grand Region
covered by this Agreement, the CONTRACTOR shall implement DM programs for CHOICES members for
the two DM conditions listed in Sections 2.8.1.1.2, 2.8.1.1.3, 2.8.1.1.5, 2.8.1.1.6,
2.8.1.1.8, and 2.8.8 for which the CONTRACTOR has not developed a DM program for CHOICES
members.

Page 70 of 374

 

	 	2.8.1.7.3	 	After the sixth calendar quarter following CHOICES implementation in
the Grand Region covered by this Agreement, the CONTRACTOR shall implement DM
programs for CHOICES members for the three DM conditions listed in Sections
2.8.1.1.4, 2.8.1.1.7, and 2.8.1.1.9, for a total of nine (9) DM programs for
CHOICES members.

2.8.2 Member Identification Strategies

	 	2.8.2.1	 	The CONTRACTOR shall have a systematic method of identifying and enrolling
eligible members in each DM program, including CHOICES members, through the same
processes used for identification of non-CHOICES members and the CHOICES care
coordination process..
	 
	 	2.8.2.2	 	The CONTRACTOR shall operate its disease management programs using an “opt
out” methodology, meaning that disease management services shall be provided to
eligible members unless they specifically ask to be excluded.

2.8.3 Stratification

As part of the DM programs, the CONTRACTOR shall classify eligible members into
stratification levels according to condition severity or other clinical or member-provided
information which, for members enrolled in the CHOICES program shall also include
stratification by the type of setting in which long-term care services are delivered, i.e.,
nursing facility, community-based residential alternative, or home-based. The DM programs
shall tailor the program content and education activities for each stratification level. For
CHOICES members, this shall include targeted interventions based on the setting in which the
member resides.

2.8.4 Program Content

Each DM program shall include the development of treatment plans, as described in NCQA
Disease Management program content, that serve as the outline for all of the activities and
interventions in the program. At a minimum the activities and interventions associated with
the treatment plan shall address condition monitoring, patient adherence to the treatment
plan, consideration of other co-morbidities, and condition-related lifestyle issues. For
CHOICES members, appropriate elements of the treatment plan shall be individualized and
integrated into the member’s plan of care to facilitate better management of the member’s
condition.

2.8.5 Informing and Educating Members

The DM programs shall educate members and/or their caregivers regarding their particular
condition(s) and needs. This information shall be provided upon enrollment in the DM
program. The DM programs shall educate members to increase their understanding of their
condition(s), the factors that impact their health status (e.g., diet and nutrition,
lifestyle, exercise, medication compliance), and to empower members to be more effective in
self-care and management of their health so they:

	 	2.8.5.1	 	Are proactive and effective partners in their care;
	 
	 	2.8.5.2	 	Understand the appropriate use of resources needed for their care;

Page 71 of 374

 

	 	2.8.5.3	 	Identify precipitating factors and appropriate responses before they require more
acute intervention; and
	 
	 	2.8.5.4	 	Are compliant and cooperative with the recommended treatment plan.

2.8.6 Informing and Educating Providers

As part of the DM programs, the CONTRACTOR shall educate providers regarding the guidelines
and shall distribute the guidelines to providers who are likely to treat enrollees with the
DM conditions. This includes, but is not limited to, PCPs and specialists involved in
treating that particular condition. The CONTRACTOR shall also provide each PCP with a list
of their patients enrolled in each DM program upon the member’s initial enrollment and at
least annually thereafter. The CONTRACTOR shall provide specific information to the provider
concerning how the program(s) works. The DM’s provider education shall be designed to
increase the providers’ adherence to the guidelines in order to improve the members’
conditions.

2.8.7 Program Evaluation (Satisfaction and Effectiveness)

	 	2.8.7.1	 	The CONTRACTOR shall evaluate member satisfaction with the DM services (as
described by NCQA) by systematically analyzing feedback from members and
analyzing member complaints and inquiries at least annually. The feedback on
satisfaction shall be specific to DM programs.
	 
	 	2.8.7.1.1	 	A written summary, of member satisfaction with the DM program, shall be included
in the annual DM report.
	 
	 	2.8.7.2	 	The CONTRACTOR shall establish measurable benchmarks and goals for each DM
program and shall evaluate the programs using these benchmarks and goals. These
benchmarks and goals shall be specific to each condition but should include:
	 
	 	2.8.7.2.1	 	Performance measured against at least two important clinical aspects of the
guidelines associated with each DM program;
	 
	 	2.8.7.2.2	 	The rate of emergency department utilization, inpatient hospitalization, and
nursing facility admission;
	 
	 	2.8.7.2.3	 	Neonatal Intensive Care Unit (NICU) days for births associated with members
enrolled in the maternity care management program;
	 
	 	2.8.7.2.4	 	Appropriate HEDIS measures;
	 
	 	2.8.7.2.5	 	The passive participation rates (as defined by NCQA) and the number of individuals
participating in each level of each of the DM programs;
	 
	 	2.8.7.2.6	 	Cost savings;
	 
	 	2.8.7.2.7	 	Member adherence to treatment plans; and
	 
	 	2.8.7.2.8	 	Provider adherence to the guidelines.

Page 72 of 374

 

	 	2.8.7.3	 	For CHOICES members, measures of member satisfaction and effectiveness shall be
reported by the type of setting in which long-term care services are delivered
in order to facilitate comparison across long-term care service delivery
settings.
	 
	 	2.8.7.4	 	The CONTRACTOR shall report on DM activities as required in Section 2.30.5.

2.8.8 Obesity Disease Management

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

11. Section 2.9 shall be deleted in its entirety and replaced with the following:

2.9 SERVICE COORDINATION

2.9.1 General

	 	2.9.1.1	 	The CONTRACTOR shall be responsible for the management, coordination, and
continuity of care for all its TennCare members and shall develop and maintain
policies and procedures to address this responsibility. For CHOICES members,
these policies and procedures shall specify the role of the care
coordinator/care coordination team in conducting these functions (see Section
2.9.6).
	 
	 	2.9.1.2	 	The CONTRACTOR shall:
	 
	 	2.9.1.2.1	 	Coordinate care among PCPs, specialists, behavioral health providers, and
long-term
care providers;
	 
	 	2.9.1.2.2	 	Perform reasonable preventive health case management services, have mechanisms to
assess the quality and appropriateness of services furnished, and provide appropriate
referral and scheduling assistance;
	 
	 	2.9.1.2.3	 	Monitor members with ongoing medical or behavioral health conditions;
	 
	 	2.9.1.2.4	 	Provide care coordination to CHOICES members (see Section 2.9.6);
	 
	 	2.9.1.2.5	 	Identify members using emergency department services inappropriately to assist in
scheduling follow-up care with PCPs and/or appropriate specialists to improve
continuity of care and establish a medical home;
	 
	 	2.9.1.2.6	 	Maintain and operate a formalized hospital and/or institutional discharge planning
program;

Page 73 of 374

 

	 	2.9.1.2.7	 	Coordinate hospital and/or institutional discharge planning that
includes post- discharge care, as appropriate;
	 
	 	2.9.1.2.8	 	Maintain an internal tracking system that identifies the current preventive
services screening status and pending preventive services screening due dates for each
member; and
	 
	 	2.9.1.2.9	 	Authorize services provided by non-contract providers, as required in this
Agreement (see, e.g., Section 2.13).

2.9.2 Transition of New Members

	 	2.9.2.1	 	In the event an enrollee entering the CONTRACTOR’s MCO, either as a new
TennCare enrollee or transferring from another MCO, is receiving medically
necessary covered services in addition to or other than prenatal services (see
below for enrollees receiving only prenatal services) the day before enrollment,
the CONTRACTOR shall be responsible for the costs of continuation of such
medically necessary services, without any form of prior approval and without
regard to whether such services are being provided by contract or non-contract
providers. Except as specified in this Section 2.9.2 or in Sections 2.9.3 or
2.9.6, this requirement shall not apply to long-term care services.
	 
	 	2.9.2.1.1	 	For medically necessary covered services, other than long-term care services,
being
provided by a non-contract provider, the CONTRACTOR shall provide continuation
of such services for up to ninety (90) calendar days or until the member may be
reasonably transferred without disruption to a contract provider, whichever is
less. The CONTRACTOR may require prior authorization for continuation of
services beyond thirty (30) calendar days; however, the CONTRACTOR is prohibited
from denying authorization solely on the basis that the provider is a
non-contract provider.
	 
	 	2.9.2.1.2	 	For medically necessary covered services, other than long-term care services,
being provided by a contract provider, the CONTRACTOR shall provide continuation of
such services from that provider but may require prior authorization for continuation
of such services from that provider beyond thirty (30) calendar days. The CONTRACTOR
may initiate a provider change only as otherwise specified in this Agreement.
	 
	 	2.9.2.1.3	 	For medically necessary covered long-term care services for CHOICES members who
are new to both TennCare and CHOICES, the CONTRACTOR shall provide long-term care
services as specified in Sections 2.9.6.2.4 and 2.9.6.2.5.
	 
	 	2.9.2.1.4	 	For covered long-term care services for CHOICES members who are transferring from
another MCO, the CONTRACTOR shall be responsible for continuing to provide covered
long-term care services, including both HCBS authorized by the transferring MCO and
nursing facility services, without regard to whether such services are being provided
by contract or non-contract providers.
	 
	 	2.9.2.1.4.1	 	For a member in CHOICES Group 2 or 3, the CONTRACTOR shall continue
HCBS authorized by the transferring MCO for a minimum of thirty (30) days
after the member’s enrollment and thereafter shall not reduce these services
unless a care coordinator has conducted a comprehensive needs assessment and

Page 74 of 374

 

	 	 	 	developed a plan of care, and the CONTRACTOR has authorized and initiated HCBS in
accordance with the member’s new plan of care. If a member in CHOICES Group 2 or 3
is receiving short-term nursing facility care, the CONTRACTOR shall continue to
provide nursing facility services to the member in accordance with the level of
nursing facility services (Level I or Level II) approved by TENNCARE (see Section
2.14.1.12). For a member in Group 1, the CONTRACTOR shall provide nursing facility
services to the member in accordance with the level of nursing facility services
(Level I or Level II) approved by TENNCARE (see Section 2.14.1.12); however, the
member may be transitioned to the community in accordance with Section 2.9.6.8 of
this Agreement.
	 
	 	2.9.2.1.4.2	 	For a member in CHOICES Group 2 or 3, within thirty (30) days of notice of the
member’s enrollment with the CONTRACTOR, a care coordinator shall conduct a
face-to-face visit (see Section 2.9.6.2.5), including a comprehensive needs assessment
(see Section 2.9.6.5), and develop a plan of care (see Section 2.9.6.6), and the
CONTRACTOR shall authorize and initiate HCBS in accordance with the new plan of care
(see Section 2.9.6.2.5). If a member in Group 2 or 3 is receiving short-term nursing
facility care on the date of enrollment with the CONTRACTOR, a care coordinator shall
complete a face-to-face visit prior to the expiration date of the level of nursing
facility services approved by TENNCARE, but no later than thirty (30) days after
enrollment to determine appropriate needs assessment and care planning activities (see
Section 2.9.6.2.5 for members who will be discharged from the nursing facility and
remain in Group 2 or 3 and Section 2.9.6.2.4 for members who will remain in the nursing
facility and be enrolled in Group 1). If the expiration date for the level of nursing
facility services approved by TENNCARE occurs prior to thirty (30) days after
enrollment, and the CONTRACTOR is unable to conduct the face-to-face visit prior to the
expiration date, the CONTRACTOR shall be responsible for facilitating discharge to the
community or enrollment in Group 1, whichever is appropriate.
	 
	 	2.9.2.1.4.3	 	If at any time before conducting a comprehensive needs assessment for a member
in CHOICES Group 2 or 3 the CONTRACTOR becomes aware of an increase in the member’s
needs, a care coordinator shall immediately conduct a comprehensive needs assessment
and update the member’s plan of care, and the CONTRACTOR shall initiate the change in
services within ten (10) days of becoming aware of the increase in the member’s needs.
	 
	 	2.9.2.1.4.4	 	For a member in CHOICES Group 1 who, at the time of enrollment with the
CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, a care
coordinator shall conduct a face-to-face in-facility visit within thirty (30) days of
the member’s enrollment with the CONTRACTOR and conduct a needs assessment as
determined necessary by the CONTRACTOR (see Section 2.9.6.5). For a member in CHOICES
Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in a nursing
facility for ninety (90) days or more, a care coordinator shall conduct a face-to-face
in-facility visit within sixty (60) days of the member’s enrollment with the CONTRACTOR
and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section
2.9.6.5).

Page 75 of 374

 

	 	2.9.2.1.4.5	 	The CONTRACTOR shall facilitate a seamless transition to new services and/or
providers, as applicable, in the plan of care developed by the CONTRACTOR without
any disruption in services.
	 
	 	2.9.2.1.4.6	 	The CONTRACTOR shall not:
	 
	 	2.9.2.1.4.6.1	 	Transition nursing facility residents or residents of community-based residential
alternatives to another facility unless (1) the member or his/her representative
specifically requests to transition, which shall be documented in the member’s
file, (2) the member or his/her representative provides written consent to
transition based on quality or other concerns raised by the CONTRACTOR, which shall
not include the nursing facility’s rate of reimbursement; or (3) the facility where
the member is residing is not a contract provider; if the community-based
residential facility where the member is currently residing is not a contract
provider, the CONTRACTOR shall provide continuation of services in such facility
for at least thirty (30) days, which shall be extended as necessary to ensure
continuity of care pending the facility’s contracting with the CONTRACTOR or the
member’s transition to a contract facility; if the member is transitioned to a
contract facility, the CONTRACTOR shall facilitate a seamless transition to the new
facility; if the nursing facility where the member is currently residing is a
non-contract provider, the CONTRACTOR shall (a) authorize continuation of the
services pending enrollment of the facility as a contract provider (except a
facility excluded for a 2-year period when the facility has withdrawn from Medicaid
participation); (b) authorize continuation of the services pending facilitation of
the member’s transition to a contract facility, subject to the member’s agreement
with such transition; or (c) may continue to reimburse services from the
non-contract nursing facility in accordance with TennCare rules and regulations;
	 
	 	2.9.2.1.4.6.2	 	Transition Group 1 members to HCBS unless the member chooses to receive
HCBS as an alternative to nursing facility care and is enrolled in CHOICES Group 2
(see Section 2.9.6.8 for requirements regarding nursing facility to community
transition);
	 
	 	2.9.2.1.4.6.3	 	Admit a member in CHOICES Group 2 to a nursing facility unless (1) the
member requires a short-term nursing facility care stay; (2) the member chooses to
transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR
determines that it cannot safely and effectively meet the needs of the member and
within the member’s cost neutrality cap, and the member agrees to transition to a
nursing facility and enroll in Group 1;
	 
	 	2.9.2.1.4.6.4	 	Admit a member enrolled in CHOICES Group 3 to a nursing facility unless: (1) the
member meets nursing facility level of care and is expected to require nursing facility
services for ninety (90) days or less; or (2) the member meets nursing facility level of care,
is expected to require nursing facility services for more than ninety (90) days and chooses to
transition to a nursing facility and enroll in Group 1; or
	 
	 	2.9.2.1.4.6.5	 	Transition members in Group 2 or 3 to another HCBS provider for continuing
services unless the current HCBS provider is not a contract provider; if the
current HCBS provider is not a contract provider, the CONTRACTOR shall

Page 76 of 374

 

	 	 	 	provide continuation of HCBS from that provider for at least thirty (30) days,
which shall be extended as necessary to ensure continuity of care pending the
provider’s contracting with the CONTRACTOR or the member’s transition to a contract
provider; if the member is transitioned to a contract provider, the CONTRACTOR
shall facilitate a seamless transition to the new provider.
	 
	 	2.9.2.1.5	 	For CHOICES members who are transferring to the CONTRACTOR’s MCO serving the Grand Region
covered by this Agreement from a Grand Region where CHOICES has not yet been implemented, the
CONTRACTOR shall be responsible for continuing to provide covered long-term care services,
including both HCBS in the member’s approved HCBS E/D waiver plan of care and nursing facility
services.
	 
	 	2.9.2.1.5.1	 	For CHOICES members in Group 2, the CONTRACTOR shall be responsible for
continuing to provide HCBS in accordance with the member’s approved HCBS E/D waiver
plan of care for a minimum of thirty (30) calendar days after enrollment; thereafter
the CONTRACTOR shall not reduce the member’s HCBS unless a care coordinator has
conducted a comprehensive needs assessment and developed a plan of care, and the
CONTRACTOR has authorized and initiated HCBS in accordance with the member’s new plan
of care. If a member in CHOICES Group 2 is receiving short-term nursing facility care,
the CONTRACTOR shall continue to provide nursing facility services to the member in
accordance with the level of nursing facility services (Level I or Level II) approved
by TENNCARE (see Section 2.14.1.12). For a member in Group 1, the CONTRACTOR shall
provide nursing facility services to the member in accordance with the level of nursing
facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12);
however, the member may be transitioned to the community in accordance with Section
2.9.6.8 of this Agreement.
	 
	 	2.9.2.1.5.2	 	For a member in CHOICES Group 2, within thirty (30) days of notice of the
member’s enrollment, a care coordinator shall conduct a face-to-face visit (see Section
2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5), and
develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize and
initiate HCBS in accordance with the new plan of care (see Section 2.9.6.2.5). If the
member is receiving short-term nursing facility care on the date of enrollment with the
CONTRACTOR, a care coordinator shall complete a face-to-face visit prior to the
expiration date of the level of nursing facility services approved by TENNCARE, and
within no more than thirty (30) days of the member’s enrollment, to determine
appropriate needs assessment and care planning activities (see Section 2.9.6.2.5 for
members who will be discharged for the nursing facility and remain in Group 2 and
Section 2.9.6.2.4 for members who will remain in the nursing facility and be enrolled
in Group 1). If the expiration date for the level of nursing facility services approved
by TENNCARE occurs prior to thirty (30) days after enrollment, and the CONTRACTOR is
unable to conduct the face-to-face visit prior to the expiration date, the CONTRACTOR
shall be responsible for facilitating discharge to the community or enrollment in Group
1, whichever is appropriate.
	 
	 	2.9.2.1.5.3	 	If at any time before conducting the comprehensive needs assessment for a member
in CHOICES Group 2 the CONTRACTOR becomes aware of an increase in the member’s needs, a
care coordinator shall immediately conduct a comprehensive needs assessment and update
the member’s plan of

Page 77 of 374

 

	 	 	 	care, and the CONTRACTOR shall initiate the change in services within ten (10) days of becoming
aware of the change in the member’s needs.
	 
	 	2.9.2.1.5.4	 	For a member in CHOICES Group 1 who, at the time of enrollment with the
CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, a
care coordinator shall conduct a face-to-face in-facility visit within thirty (30)
days of the member’s enrollment with the CONTRACTOR and conduct a needs assessment
as determined necessary by the CONTRACTOR (see Section 2.9.6.5). For a member in
CHOICES Group 1 who, at the time of enrollment with the CONTRACTOR, has resided in
a nursing facility for ninety (90) days or more, a care coordinator shall conduct a
face-to-face in-facility visit within sixty (60) days of the member’s enrollment
with the CONTRACTOR and conduct a needs assessment as determined necessary by the
CONTRACTOR (see Section 2.9.6.5).
	 
	 	2.9.2.1.5.5	 	The CONTRACTOR shall facilitate a seamless transition to new services and/or
providers, as applicable, in the plan of care developed by the CONTRACTOR without
any disruption in services.
	 
	 	2.9.2.1.5.6	 	The CONTRACTOR shall not:
	 
	 	2.9.2.1.5.6.1	 	Transition nursing facility residents or residents of community-based residential
alternatives to another facility unless (1) the member or his/her representative
specifically requests to transition, which shall be documented in the member’s
file, (2) the member or his/her representative provides written consent to
transition based on quality or other concerns raised by the CONTRACTOR, which shall
not include the nursing facility’s rate of reimbursement; or (c) the facility where
the member is residing is not a contract provider; if the community-based
residential facility where the member is currently residing is not a contract
provider, the CONTRACTOR shall provide continuation of services in such facility
for at least thirty (30) days, which shall be extended as necessary to ensure
continuity of care pending the facility’s contracting with the CONTRACTOR or the
member’s transition to a contract facility; if the member is transitioned to a
contract facility, the CONTRACTOR shall facilitate a seamless transition to the new
facility; if the nursing facility where the member is currently residing is a
non-contract provider, the CONTRACTOR shall (a) authorize continuation of the
services pending enrollment of the facility as a contract provider (except a
facility excluded for a 2-year period when the facility has withdrawn from Medicaid
participation); (b) authorize continuation of the services pending facilitation of
the member’s transition to a contract facility, subject to the member’s agreement
with such transition; or (c) may continue to reimburse services from the
non-contract nursing facility in accordance with TennCare rules and regulations;
	 
	 	2.9.2.1.5.6.2	 	Transition Group 1 members to HCBS unless the member chooses to receive
HCBS as an alternative to nursing facility care and is enrolled in CHOICES Group 2
(see Section 2.9.6.8 for requirements regarding nursing facility to community
transition);

Page 78 of 374

 

	 	2.9.2.1.5.6.3	 	Admit a member in CHOICES Group 2 to a nursing facility unless (1) the
member requires a short-term nursing facility care stay; (2) the member chooses to
transition to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR
determines that it cannot safely and effectively meet the needs of the member and
within the member’s cost neutrality cap and the member agrees to transition to a
nursing facility and enroll in Group 1; or
	 
	 	2.9.2.1.5.6.4	 	Transition members in Group 2 to another HCBS provider for continuing services unless
the current HCBS provider is not a contract provider; if the current HCBS provider is not a
contract provider, the CONTRACTOR shall provide continuation of HCBS from that provider for at
least thirty (30) days, which shall be extended as necessary to ensure continuity of care
pending the provider’s contracting with the CONTRACTOR or the member’s transition to a
contract provider; if the member is transitioned to a contract provider, the CONTRACTOR shall
facilitate a seamless transition to the new provider.
	 
	 	2.9.2.2	 	In the event an enrollee entering the CONTRACTOR’s MCO, either as a new
TennCare enrollee or transferring from another MCO, is in her first trimester of
pregnancy and is receiving medically necessary covered prenatal care services the day
before enrollment, the CONTRACTOR shall be responsible for the costs of continuation of
such medically necessary prenatal care services, including prenatal care, delivery, and
post-natal care, without any form of prior approval and without regard to whether such
services are being provided by a contract or non-contract provider.
	 
	 	2.9.2.2.1	 	If the member is receiving services from a non-contract provider, the
CONTRACTOR shall be responsible for the costs of continuation of medically necessary
covered prenatal services, without any form of prior approval, until such time as the
CONTRACTOR can reasonably transfer the member to a contract provider without impeding
service delivery that might be harmful to the member’s health.
	 
	 	2.9.2.2.2	 	If the member is receiving services from a contract provider, the CONTRACTOR shall be
responsible for the costs of continuation of medically necessary covered prenatal services
from that provider, without any form of prior approval, through the postpartum period.
	 
	 	2.9.2.3	 	In the event an enrollee entering the CONTRACTOR’s MCO, either as a new
TennCare enrollee or transferring from another MCO, is in her second or third trimester
of pregnancy and is receiving medically necessary covered prenatal care services the
day before enrollment, the CONTRACTOR shall be responsible for providing continued
access to the prenatal care provider (whether contract or noncontract provider) through
the postpartum period, without any form of prior approval.
	 
	 	2.9.2.4	 	If a member enrolls in the CONTRACTOR’s MCO from another MCO, the
CONTRACTOR shall immediately contact the member’s previous MCO and request the transfer
of “transition of care data” as specified by TENNCARE. If the CONTRACTOR is contacted
by another MCO requesting “transition of care data” for a member who has transferred
from the CONTRACTOR to the requesting MCO (as verified by the CONTRACTOR), the
CONTRACTOR shall provide such data in the timeframe and format specified by TENNCARE.

Page 79 of 374

 

	 	2.9.2.5	 	If the CONTRACTOR becomes aware that a CHOICES member will be transferring
to another MCO, the CONTRACTOR (including, but not limited to the member’s care
coordinator) shall work with the other MCO in facilitating a seamless transition
for that member. If a member in Group 2 or 3 is transferring to a Grand Region
where CHOICES has not been implemented, the care coordinator shall provide the
local Area Agency on Aging and Disability (AAAD) with the member’s plan of care
and other information specified by TENNCARE within the timeframe and in the
format specified by TENNCARE and shall work with the AAAD to facilitate a
seamless transition for that member.
	 
	 	2.9.2.6	 	The CONTRACTOR shall ensure that any member entering the CONTRACTOR’s
MCO is held harmless by the provider for the costs of medically necessary
covered services except for applicable TennCare cost sharing and patient
liability amounts (see Section 2.6.7 of this Agreement).
	 
	 	2.9.2.7	 	The CONTRACTOR shall develop and maintain policies and procedures regarding
the transition of new members.

2.9.3 Transition of Members Receiving Long-Term Care Services at the Time of CHOICES Implementation

	 	2.9.3.1	 	For each member who is enrolling in CHOICES as of the date of CHOICES
implementation in the Grand Region covered by this Agreement, as identified by
TENNCARE (herein referred to as “transitioning CHOICES members”), the CONTRACTOR
shall assign a care coordinator prior to the first face-to-face visit. If the
face-to-face visit will not occur within ten (10) days after the implementation
of CHOICES, the CONTRACTOR shall send the member written notification within ten
(10) calendar days of implementation that explains how the member can reach the
care coordination unit for assistance with concerns or questions pending the
assignment of a specific care coordinator.
	 
	 	2.9.3.2	 	For each transitioning CHOICES member, the CONTRACTOR shall be responsible
for the costs of continuing to provide covered long-term care services
previously authorized by TENNCARE or its designee, including, as applicable,
HCBS in the member’s approved HCBS E/D waiver plan of care and nursing facility
services without regard to whether such services are being provided by contract
or noncontract providers.
	 
	 	2.9.3.3	 	For members in Group 2 the CONTRACTOR shall continue HCBS in the member’s
approved HCBS E/D waiver plan of care except case management for a minimum of
thirty (30) days after the member’s enrollment and thereafter shall not reduce
HCBS unless the member’s care coordinator has conducted a comprehensive needs
assessment and developed a plan of care and the CONTRACTOR has authorized and
initiated HCBS in accordance with the member’s new plan of care. If a member in
CHOICES Group 2 is receiving short-term nursing facility care, the CONTRACTOR
shall continue to provide nursing facility services to the member in accordance
with the level of nursing facility services (Level I or Level II) approved by
TENNCARE (see Section 2.14.1.12).

Page 80 of 374

 

	 	2.9.3.4	 	For a member in CHOICES Group 2, within ninety (90) days of CHOICES
implementation, the member’s care coordinator shall conduct a face-to-face visit (see
Section 2.9.6.2.5), including a comprehensive needs assessment (see Section 2.9.6.5),
and develop a plan of care (see Section 2.9.6.6), and the CONTRACTOR shall authorize
and initiate HCBS in accordance with the new plan of care. If a member in Group 2 is
receiving short-term nursing facility care on the date of enrollment with the
CONTRACTOR the member’s care coordinator shall complete a face-to-face visit prior to
the expiration date of the level of nursing services approved by TENNCARE, but no more
than ninety (90) days after CHOICES implementation, to determine appropriate needs
assessment and care planning activities (see Section 2.9.6.2.5 for members who will be
discharged from the nursing facility and remain in Group 2 or 3 and Section 2.9.6.2.4
for members who will remain in the nursing facility and be enrolled in Group 1). If the
expiration date for the level of nursing facility services approved by TENNCARE occurs
prior to ninety (90) days after CHOICES implementation, and the CONTRACTOR is unable to
conduct the face-to- face visit prior to the expiration date, the CONTRACTOR shall be
responsible for facilitating discharge to the community or enrollment in Group 1,
whichever is appropriate.
	 
	 	2.9.3.5	 	If at any time before conducting a comprehensive needs assessment for a member in
CHOICES Group 2 the CONTRACTOR becomes aware of an increase in the member’s needs, the
member’s care coordinator shall immediately conduct a comprehensive needs assessment
and update the member’s plan of care, and the CONTRACTOR shall initiate the change in
services within ten (10) days of becoming aware of the change in the member’s needs.
	 
	 	2.9.3.6	 	The CONTRACTOR shall provide nursing facility services to a member in Group 1
in accordance with the level of nursing facility services (Level I or Level II)
approved by TENNCARE (see Section 2.14.1.12); however, the member may be transitioned
to the community in accordance with Section 2.9.6.8 of this Agreement.
	 
	 	2.9.3.7	 	For a member in CHOICES Group 1 who, at the time of enrollment with the
CONTRACTOR, has resided in a nursing facility for less than ninety (90) days, the
member’s care coordinator shall conduct a face-to-face in-facility visit within ninety
(90) days of the implementation of CHOICES and conduct a needs assessment as determined
necessary by the CONTRACTOR (see Section 2.9.6.5.1). For a member in CHOICES Group 1
who, at the time of implementation of CHOICES, has resided in a nursing facility for
ninety (90) days or more, the member’s care coordinator shall conduct a face-to-face
in-facility visit within six (6) months of the member’s enrollment with the CONTRACTOR
and conduct a needs assessment as determined necessary by the CONTRACTOR (see Section
2.9.6.5.1).
	 
	 	2.9.3.8	 	The CONTRACTOR shall facilitate a seamless transition to new services and/or
providers, as applicable, in the plan of care developed by the CONTRACTOR without any
disruption in services.
	 
	 	2.9.3.9	 	The CONTRACTOR shall not:
	 
	 	2.9.3.9.1	 	Transition nursing facility residents or residents of community-based residential
alternatives to another facility unless (1) the member or his/her representative
specifically requests to transition, which shall be documented in the member’s file,

Page 81 of 374

 

	 	 	 	(2) the member or his/her representative provides written consent to transition
based on quality or other concerns raised by the CONTRACTOR, which shall not
include the nursing facility’s rate of reimbursement; or (3) the facility where
the member is residing is not a contract provider; if the community-based
residential facility where the member is currently residing is not a contract
provider, the CONTRACTOR shall provide continuation of services in such facility
for at least thirty (30) days, which shall be extended as necessary to ensure
continuity of care pending the facility’s contracting with the CONTRACTOR or the
member’s transition to a contract facility; if the member is transitioned to a
contract facility, the CONTRACTOR shall facilitate a seamless transition to the
new facility; if the nursing facility where the member is currently residing is
a non-contract provider, the CONTRACTOR shall (a) authorize continuation of the
services pending enrollment of the facility as a contract provider (except a
facility excluded for a 2-year period when the facility has withdrawn from
Medicaid participation); (b) authorize continuation of the services pending
facilitation of the member’s transition to a contract facility, subject to the
member’s agreement with such transition; or (c) may continue to reimburse
services from the non-contract nursing facility in accordance with TennCare
rules and regulations;
	 
	 	2.9.3.9.2	 	Transition Group 1 members to HCBS unless the member chooses to receive HCBS as an
alternative to nursing facility care and is enrolled in CHOICES Group
2 (see Section 2.9.6.8 for requirements regarding nursing facility to community transition);
	 
	 	2.9.3.9.3	 	Admit a member in CHOICES Group 2 to a nursing facility unless (1) the member
requires a short-term nursing facility care stay; (2) the member chooses to transition
to a nursing facility and enroll in Group 1; or (3) the CONTRACTOR determines that it
cannot safely and effectively meet the needs of the member and within the member’s cost
neutrality cap, and the member agrees to transition to a nursing facility and enroll in
Group 1; or
	 
	 	2.9.3.9.4	 	Transition members in Group 2 or 3 to another HCBS provider for continuing
services unless the current HCBS provider is not a contract provider; if the current
HCBS provider is not a contract provider, the CONTRACTOR shall provide continuation of
HCBS from that provider for at least thirty (30) days, which shall be extended as
necessary to ensure continuity of care pending the provider’s contracting with the
CONTRACTOR or the member’s transition to a contract provider; if the member is
transitioned to a contract provider, the CONTRACTOR shall facilitate a seamless
transition to the new provider.

2.9.4 Transition of Care

	 	2.9.4.1	 	The CONTRACTOR shall actively assist members with chronic or acute medical or
behavioral health conditions, members who are receiving long-term care services,
and members who are pregnant in transitioning to another provider when a
provider currently treating their chronic or acute medical or behavioral health
condition, currently providing their long-term care services, or currently
providing prenatal services has terminated participation with the CONTRACTOR.
For CHOICES members, this assistance shall be provided by the member’s care
coordinator/care coordination team.

Page 82 of 374

 

	 	2.9.4.1.1	 	Except as provided below regarding members who are in their second or third trimester of
pregnancy, the CONTRACTOR shall provide continuation of such provider for up to ninety (90) calendar days
or until the member may be reasonably transferred to another provider without disruption of care,
whichever is less.
	 
	 	2.9.4.1.2	 	For members in their second or third trimester of pregnancy, the CONTRACTOR shall allow
continued access to the member’s prenatal care provider and any provider currently treating the member’s
chronic or acute medical or behavioral health condition or currently providing long-term care services,
through the postpartum period.
	 
	 	2.9.4.2	 	The CONTRACTOR shall actively assist members in transitioning to another provider
when there are changes in providers. The CONTRACTOR shall have transition policies
that, at a minimum, include the following:
	 
	 	2.9.4.2.1	 	A schedule which ensures transfer does not create a lapse in service;
	 
	 	2.9.4.2.2	 	For CHOICES members in Groups 2 and 3, the requirement for a HCBS provider that is no longer willing or able to
provide services to a member to cooperate with the member’s care coordinator to facilitate a seamless transition to another
HCBS provider (see Section 2.12.12.1) and to continue to provide services to the member until the member has been transitioned
to another HCBS provider, as determined by the CONTRACTOR, or as otherwise directed by the CONTRACTOR (see Section 2.12.12.2);
	 
	 	2.9.4.2.3	 	A mechanism for timely information exchange (including transfer of the member record);
	 
	 	2.9.4.2.4	 	A mechanism for assuring confidentiality;
	 
	 	2.9.4.2.5	 	A mechanism for allowing a member to request and be granted a change of provider;
	 
	 	2.9.4.2.6	 	An appropriate schedule for transitioning members from one (1) provider to another when there is medical necessity
for ongoing care.
	 
	 	2.9.4.2.7	 	Specific transition language on the following special populations:
	 
	 	2.9.4.2.7.1	 	Children who are SED;
	 
	 	2.9.4.2.7.2	 	Adults who are SPMI;
	 
	 	2.9.4.2.7.3	 	Persons who have addictive disorders;
	 
	 	2.9.4.2.7.4	 	Persons who have co-occurring disorders of both mental health and substance
abuse disorders; and
	 
	 	2.9.4.2.7.5	 	Persons with behavioral health conditions who also have a developmental
disorder (dually diagnosed). These members shall be allowed to remain with their
providers of the services listed below for the minimum time frames set out below as
long as the services continue to be medically necessary. The CONTRACTOR may shorten
these transition time frames only when the provider of services is no

Page 83 of 374

 

	 	 	 	longer available to serve the member or when a change in providers is agreed
to in writing by the member.
	 
	 	2.9.4.2.7.5.1	 	Mental health case management: three (3) months;
	 
	 	2.9.4.2.7.5.2	 	Psychiatrist: three (3) months;
	 
	 	2.9.4.2.7.5.3	 	Outpatient behavioral health therapy: three (3) months;
	 
	 	2.9.4.2.7.5.4	 	Psychosocial rehabilitation and supported employment: three (3) months; and
	 
	 	2.9.4.2.7.5.5	 	Psychiatric inpatient or residential treatment and supported housing: six (6)
months.

2.9.5 MCO Case Management

	 	2.9.5.1	 	The CONTRACTOR shall maintain an MCO case management program that
includes the following components:
	 
	 	2.9.5.1.1	 	A systematic approach to identify eligible members;
	 
	 	2.9.5.1.2	 	Assessment of member needs;
	 
	 	2.9.5.1.3	 	Development of an individualized plan of care;
	 
	 	2.9.5.1.4	 	Implementation of the plan of care, including coordination of care that actively
links the member to providers and support services; and
	 
	 	2.9.5.1.5	 	Program Evaluation (Satisfaction and Effectiveness).
	 
	 	2.9.5.2	 	The CONTRACTOR shall provide MCO case management to members who are at
high risk or have unique, chronic, or complex needs. This shall include but not
be limited to members with co-occurring mental illness and substance abuse
and/or co- morbid physical health and behavioral health conditions.
	 
	 	2.9.5.3	 	The CONTRACTOR has the option of allowing members to be enrolled in both
MCO case management and a disease management program.
	 
	 	2.9.5.4	 	The CONTRACTOR shall ensure that, upon a member’s enrollment in CHOICES,
MCO case management activities are integrated with CHOICES care coordination
processes and functions, and that the member’s assigned care coordinator has
primary responsibility for coordination of all the member’s physical health,
behavioral health, and long-term care needs. The care coordinator may use
resources and staff from the CONTRACTOR’s MCO case management program, including
persons with specialized expertise in areas such as behavioral health, to
supplement but not supplant the role and responsibilities of the member’s care
coordinator/care coordination team.
	 
	 	2.9.5.5	 	Eligible members shall be offered MCO case management services. However,
member participation shall be voluntary.

Page 84 of 374

 

	 	2.9.5.6	 	The CONTRACTOR shall develop a process to inform members and providers about
the availability of MCO case management and to inform the member’s PCP and/or
appropriate specialist when a member has been assigned to the MCO case management
program.
	 
	 	2.9.5.7	 	The CONTRACTOR shall use utilization data, including pharmacy data provided by
 TENNCARE or its PBM (see Section 2.9.10), to identify members for MCO case management
services as appropriate. In particular, the CONTRACTOR shall track utilization data to
determine when a member has exceeded the ED threshold (see Section 2.14.1.13).

Page 85 of 374

 

	 	2.9.6.1	 	General
	 
	 	2.9.6.1.1	 	The CONTRACTOR shall provide care coordination to all persons enrolled in TennCare
CHOICES in accordance with this Agreement and to other TennCare members only in order to
determine the member’s eligibility for and facilitate the member’s enrollment in TennCare
CHOICES. Except for the initial process for current members that is necessary to determine the
member’s eligibility for and facilitate the member’s enrollment in TennCare CHOICES, care
coordination shall not be available to non-CHOICES members.
	 
	 	2.9.6.1.2	 	The CONTRACTOR shall provide care coordination in a comprehensive, holistic,
person-centered manner.
	 
	 	2.9.6.1.3	 	The CONTRACTOR shall use care coordination as the continuous process of:
(1) assessing a member’s physical, behavioral, functional, and psychosocial needs;
(2) identifying the physical health, behavioral health and long-term care services
and other social support services and assistance (e.g., housing or income assistance)
that are necessary to meet identified needs; (3) ensuring timely access to and
provision, coordination and monitoring of physical health, behavioral health, and
long-term care services needed to help the member maintain or improve his or her
physical or behavioral health status or functional abilities and maximize independence;
and (4) facilitating access to other social support services and assistance needed in
order to ensure the member’s health, safety and welfare, and as applicable, to delay or
prevent the need for more expensive institutional placement.
	 
	 	2.9.6.1.4	 	Long-term care services identified through care coordination and provided by the
CONTRACTOR shall build upon and not supplant a member’s existing support system, including but
not limited to informal supports provided by family and other caregivers, services that may be
available at no cost to the member through other entities, and services that are reimbursable
through other public or private funding sources, such as Medicare or long-term care insurance.
	 
	 	2.9.6.1.5	 	The CONTRACTOR shall develop and implement policies and procedures for care coordination
that comply with the requirements of this Agreement.
	 
	 	2.9.6.1.6	 	The CONTRACTOR’s failure to meet requirements, including timelines, for care coordination
set forth in this Agreement, except for good cause, constitutes noncompliance with this
Agreement. Such failure shall not affect any determination of eligibility for CHOICES
enrollment, which shall be based only on whether the member meets CHOICES eligibility and
enrollment criteria, as defined pursuant to the Section 1115 TennCare Demonstration Waiver,
federal and state laws and regulations, this Agreement, and TennCare policies and protocols.
Nor shall such failure affect any determination of coverage for CHOICES benefits which shall
be based only on the covered benefits for the applicable CHOICES group in which the member is
enrolled as defined pursuant to the Section 1115 TennCare Demonstration Waiver, federal and
state laws and regulations, this Agreement, and TennCare policies and protocols; and in
accordance with requirements pertaining to medical necessity.

Page 86 of 374

 

	 	2.9.6.1.7	 	The CONTRACTOR shall ensure that its care coordination program complies
with 42 CFR 438.208.
	 
	 	2.9.6.1.8	 	The CONTRACTOR shall ensure that, upon enrollment into CHOICES, MCO case
management and/or disease management activities are integrated with CHOICES care
coordination processes and functions, and that the member’s assigned care
coordinator has primary responsibility for coordination of all the member’s physical
health, behavioral health, and long-term care needs, including appropriate
management of conditions specified in 2.8.1.1. The care coordinator may use
resources and staff from the CONTRACTOR’s case management and disease management
programs, including persons with specialized expertise in areas such as behavioral
health, to supplement but not supplant the role and responsibilities of the care
coordinator/care coordination team.
	 
	 	2.9.6.2	 	Intake Process for Members New to Both TennCare and CHOICES
	 
	 	2.9.6.2.1	 	The CONTRACTOR shall refer all inquiries regarding CHOICES enrollment by or on behalf of
individuals who are not enrolled with the CONTRACTOR to TENNCARE or its designee. The form and format
for such referrals shall be developed in collaboration with the CONTRACTOR and TENNCARE or its
designee.
	 
	 	2.9.6.2.2	 	TENNCARE or its designee will assist individuals who are not enrolled in TennCare with
TennCare eligibility and CHOICES enrollment.
	 
	 	2.9.6.2.3	 	Functions of the Single Point of Entry (SPOE)
	 
	 	2.9.6.2.3.1	 	For persons wishing to apply for CHOICES, TENNCARE or its designee may
employ a screening process, using the tool and protocols specified by TENNCARE, to
assist with intake for persons new to both TennCare and CHOICES. Such screening
process shall assess: (1) whether the applicant appears to meet categorical and
financial eligibility criteria for CHOICES; (2) whether the applicant appears to
meet nursing facility level of care; and (3) for applicants seeking access to HCBS
through enrollment in CHOICES Group 2, whether it appears that the applicant’s
needs can be safely and effectively met in the community and at a cost that does
not exceed nursing facility care.
	 
	 	2.9.6.2.3.2	 	For persons identified by TENNCARE or its designee as meeting the screening
criteria, or for whom TENNCARE or its designee opts not to use a screening process,
TENNCARE or its designee will conduct a face-to-face intake visit with the
applicant. As part of this intake visit TENNCARE or its designee will, using the
tools and protocols specified by TENNCARE, conduct a level of care and needs
assessment; assess the member’s existing natural support system, including but not
limited to informal supports provided by family and other caregivers, services that
may be available at no cost to the member through other entities, and services that
are reimbursable through other public or private funding sources, such as Medicare
or long-term care insurance; and identify the long-term care services and home
health and/or private duty nursing services that may be needed by the applicant
upon enrollment into CHOICES that would build upon and not supplant a member’s
existing natural support system.

Page 87 of 374

 

	 	2.9.6.2.3.3	 	TENNCARE or its designee shall conduct the intake visit, including
the level of care and needs assessment, in the applicant’s place of residence,
except under extenuating circumstances (such as the member’s hospitalization),
which shall be documented in writing.
	 
	 	2.9.6.2.3.4	 	As part of the intake visit, TENNCARE or its designee shall: (1) provide general
CHOICES education and information, as specified by TENNCARE, and assist in answering
any questions the applicant may have; (2) provide information about estate recovery;
(3) provide choice counseling and facilitate the selection of an MCO by the applicant
or his/her representative; (4) provide information regarding freedom of choice of
nursing facility versus HCBS, both verbally and in writing, and obtain a Freedom of
Choice form signed by the applicant or his/her representative; (5) for applicants who
want to receive NF services (a) provide detailed information and signed acknowledgement
of understanding regarding a CHOICES member’s responsibility with respect to payment of
patient liability amounts, including, as applicable, the potential consequences for
non-payment of patient liability which may include loss of the member’s current nursing
facility provider, disenrollment from CHOICES, and to the extent the member’s
eligibility is dependent on receipt of long-term care services, possible loss of
eligibility for TennCare; and (b) provide information regarding the completion of all
PASRR requirements prior to nursing facility admission; (6) for applicants who are
seeking HCBS: (a) conduct a risk assessment using a tool and protocol specified by
TENNCARE and develop, as applicable, a risk agreement that shall be signed by the
applicant or his/her representative and which shall include identified risks to the
applicant, the consequences of such risks, strategies to mitigate the identified risks,
and the applicant’s decision regarding his/her acceptance of risk; (b) make a
determination regarding whether the applicant’s needs can be safely and effectively met
in the community and at a cost that does not exceed nursing facility care, including
explanation to the applicant regarding the individual cost neutrality cap, and
notification to and signed acknowledgement of understanding by the applicant or his/her
representative that a change in a member’s needs or circumstances that would result in
the cost neutrality cap being exceeded or that would result in the MCO’s inability to
safely and effectively meet a member’s needs in the community and within the cost
neutrality cap may result in the member’s disenrollment from CHOICES Group 2, in which
case, the care coordinator will assist with transition to a more appropriate care
delivery setting; and (c) provide information regarding consumer direction and obtain
signed documentation of the applicant’s interest in participating in consumer
direction; and (7) provide information regarding next steps in the process including
the need for approval by TENNCARE to enroll in CHOICES and the functions of the
CONTRACTOR, including that the CONTRACTOR will develop and approve a plan of care.
	 
	 	2.9.6.2.3.5	 	The listing of HCBS and home health and/or private duty nursing services the
member may need shall be used by TENNCARE or its designee to determine whether services
can be provided within the member’s cost neutrality cap and may be further refined
based on the CONTRACTOR’s comprehensive needs assessment and plan of care development
processes.

Page 88 of 374

 

	 	2.9.6.2.3.6	 	The State will be responsible for determining TennCare categorical
and financial eligibility and level of care and enrolling eligible TennCare
members into CHOICES.
	 
	 	2.9.6.2.3.7	 	TENNCARE will notify the CONTRACTOR via the 834 eligibility file when a person
has been enrolled in CHOICES and the member’s CHOICES Group. For members in CHOICES
Group 2, TENNCARE will notify the CONTRACTOR of the member’s cost neutrality cap (see
definition in Section 1 and see Section 2.6.1.5.2.3). For members in CHOICES Group 1,
TENNCARE will notify the CONTRACTOR of applicable patient liability amounts (see
Section 2.6.7.2).
	 
	 	2.9.6.2.3.8	 	TENNCARE or its designee will make available to the CONTRACTOR the documentation
from the intake visit, including but not limited to the member’s level of care and
needs assessment, the assessment of the member’s existing natural support system, the
member’s risk assessment and signed risk agreement (for members in CHOICES Group 2),
and the services identified by TENNCARE or its designee.
	 
	 	2.9.6.2.4	 	Functions of the CONTRACTOR for Members in CHOICES Group 1
	 
	 	2.9.6.2.4.1	 	For members enrolled in CHOICES Group 1, who are, upon CHOICES enrollment, receiving nursing
facility services, the CONTRACTOR shall immediately authorize such services in accordance with the level of
nursing facility services (Level I or Level II) approved by TENNCARE (see Section 2.14.1.12). Authorization
for such services shall be from the current provider as of the effective date of CHOICES enrollment. The
CONTRACTOR shall not move members enrolled in CHOICES Group 1 who are, upon CHOICES enrollment, receiving
nursing facility services, to another facility unless: (1) the member or his/her representative specifically
requests to move, which shall be documented in the member’s file; (2) the member or his/her representative
provides written consent to move based on quality or other concerns raised by the CONTRACTOR, which shall not
include the nursing facility‘s rate of reimbursement; or (3) the facility where the member is residing is not
a contract provider. If the nursing facility is a non-contract provider, the CONTRACTOR shall (a) authorize
continuation of the services pending enrollment of the facility as a contract provider (except a facility
excluded for a 2-year period when the facility has withdrawn from Medicaid participation); (b) authorize
continuation of the services pending facilitation of the member’s transition to a contract facility, subject
to the member’s agreement with such transition; or (c) may continue to reimburse services from the
non-contract nursing facility in accordance with TennCare rules and regulations.
	 
	 	2.9.6.2.4.2	 	For members in CHOICES Group 1 who are receiving services in a nursing
facility at the time of enrollment in CHOICES and have received such services for
ninety (90) days or more, the CONTRACTOR shall, within sixty (60) calendar days of
notice of the member’s enrollment in CHOICES, conduct a face-to-face visit with the
member and perform any additional needs assessment deemed necessary by the
CONTRACTOR (see Section 2.9.6.5.1). The care coordinator shall review the plan of
care developed by the nursing facility and may supplement the plan of care as
necessary and appropriate (see Section 2.9.6.6.1).

Page 89 of 374

 

	 	2.9.6.2.4.3	 	The care coordinator shall, for members in CHOICES Group 1 who are
receiving services in a nursing facility at the time of enrollment in CHOICES and
are new admissions to a nursing facility, having resided in the nursing facility
for less than ninety (90) days, within thirty (30) calendar days of notice of the
member’s enrollment in CHOICES conduct a face-to-face visit with the member and
perform any additional needs assessment deemed necessary by the CONTRACTOR (see
Section 2.9.6.5.1). The care coordinator shall review the plan of care developed by
the nursing facility and may supplement the plan of care as necessary and
appropriate (see in Section 2.9.6.6.1).
	 
	 	2.9.6.2.4.4	 	For members in CHOICES Group 1 who are waiting for placement in a nursing
facility, within ten (10) calendar days of notice of the member’s enrollment in CHOICES
(1) the member’s care coordinator shall conduct a face-to-face visit with the member,
which shall include (a) member education regarding choice of contract nursing facility
providers, subject to the provider’s availability and willingness to timely delivery
services, and obtain signed confirmation of the member’s choice of nursing facility;
and (b) performing any additional needs assessment deemed necessary by the CONTRACTOR
(see Section 2.9.6.5.1); and (2) the CONTRACTOR shall authorize and initiate nursing
facility services. Upon admission to a nursing facility, the care coordinator shall
participate as appropriate in the nursing facility’s care planning process (see Section
2.9.6.6.1.2) and may supplement the plan of care as necessary (see Section 2.9.6.6. 1.
1).
	 
	 	2.9.6.2.4.5	 	The CONTRACTOR shall not divert or transition members in Group 1 to HCBS unless
the member chooses to receive HCBS as an alternative to nursing facility and is
enrolled in Group 2 or 3.
	 
	 	2.9.6.2.4.6	 	The CONTRACTOR shall ensure that all PASRR requirements are met prior to a
member’s admission to a nursing facility.
	 
	 	2.9.6.2.4.7	 	For purposes of the CHOICES program, service authorization for nursing facility
services shall be for the level of nursing facility services (Level I or Level II)
approved by TENNCARE (see Section 2.14.1.12) and shall include the duration of nursing
facilities services to be provided; the requested start date; and other relevant
information as prescribed by TENNCARE. The CONTRACTOR shall be responsible for
confirming the nursing facility’s capacity and commitment to initiate services as
authorized on or before the requested start date, and if the nursing facility is unable
to initiate services as authorized on or before the requested start date, for arranging
an alternative nursing facility that is able to initiate services as authorized on or
before the requested start date in accordance with Section 2.9.6.2.4.8.
	 
	 	2.9.6.2.4.8	 	If the CONTRACTOR is unable to place a member in the nursing facility
requested by the member, the care coordinator shall meet with the member and
his/her representative to discuss the reasons why the member cannot be placed with
the requested nursing facility and the available options and identify an
alternative nursing facility.

Page 90 of 374

 

	 	2.9.6.2.4.9	 	If the CONTRACTOR is unable to initiate any nursing facility service(s) in
accordance with the timeframes specified in Section 2.9.6.2.4.1, the CONTRACTOR
shall issue written notice to the member, documenting that the service will be
delayed, the reasons for the delay, and the date the service will start, and shall
make good faith efforts to ensure that services are provided as soon as practical.
	 
	 	2.9.6.2.4.10	 	For CHOICES members approved by TENNCARE for Level II (or skilled) nursing
facility services, the CONTRACTOR shall be responsible for monitoring the member’s
continued need for Medicaid reimbursed skilled and/or rehabilitation services, promptly
notifying TENNCARE when Level II nursing facility services are no longer medically
necessary, and for the submission of information needed by TENNCARE to reevaluate the
member’s level of care for nursing facility services (see also Section 2.14.1.12.2).
	 
	 	2.9.6.2.5	 	Functions of the CONTRACTOR for Members in CHOICES Groups 2 and 3
	 
	 	2.9.6.2.5.1	 	For members enrolled in CHOICES Group 2 who are, upon CHOICES enrollment,
receiving community-based residential alternative services, the CONTRACTOR shall,
immediately upon notice of the member’s enrollment in CHOICES, authorize such services
from the current provider as of the effective date of CHOICES enrollment. In the case
of those members enrolled in CHOICES Group 2 on the basis of Immediate Eligibility,
community-based residential alternative services shall be authorized immediately upon
notice of the member’s categorical and financial eligibility for TennCare CHOICES as of
the effective date of CHOICES enrollment. The CONTRACTOR shall not transition members
enrolled in CHOICES Group 2 who are, upon CHOICES enrollment, receiving services in a
community-based residential alternative setting to another facility unless: (1) the
member or his/her representative specifically requests to move, which shall be
documented in the member’s file; (2) the member or his/her representative provides
written consent to move based on quality or other concerns raised by the CONTRACTOR; or
(3) the facility where the member is residing is not a contract provider; if the
facility is a non-contract provider, the CONTRACTOR shall authorize medically necessary
services from the noncontract provider for at least thirty (30) days which shall be
extended as necessary to ensure continuity of care pending the facility’s enrollment
with the CONTRACTOR or the member’s transition to a contract provider
	 
	 	2.9.6.2.5.2	 	For members in CHOICES Group 2 who upon CHOICES enrollment are receiving
services in a community-based residential alternative setting, within ten (10) calendar
days of notice of the member’s enrollment in CHOICES the care coordinator shall conduct
a face-to-face visit with the member, perform a comprehensive needs assessment (see
Section 2.9.6.5), develop a plan of care (see Section 2.9.6.6), and authorize and
initiate additional HCBS specified in the plan of care (i.e., assistive technology),
except in the case of members enrolled on the basis of Immediate Eligibility. If a
member residing in a community-based residential alternative setting is enrolled on the
basis of Immediate Eligibility, the CONTRACTOR shall, upon notice that the State has
determined that the member meets categorical and financial eligibility for TennCare
CHOICES, immediately authorize community-based residential services and shall authorize
and initiate additional HCBS specified in the member’s plan of care (i.e., assistive

Page 91 of 374

 

	 	 	 	technology) within five (5) days of notice; authorization for community-based
residential alternative services shall be retroactive to the member’s effective
date of CHOICES enrollment.
	 
	 	2.9.6.2.5.3	 	The care coordinator shall, for all other CHOICES members in Groups 2 and 3
not specified in 2.9.6.2.5.1 — 2.9.6.2.5.2 above, within ten (10) calendar days of
notice of the member’s enrollment in CHOICES, conduct a face-to-face visit with the
member, perform a comprehensive needs assessment (see Section 2.9.6.5), develop a
plan of care (see Section 2.9.6.6), and authorize and initiate HCBS, except in the
case of members enrolled on the basis of Immediate Eligibility in which case only
the limited package of HCBS shall be authorized and initiated. Members enrolled on
the basis of Immediate Eligibility shall have access only to a limited package of
HCBS (see Section 2.6.1.5.3) pending determination of categorical and financial
eligibility for TennCare CHOICES; however all needed services shall be listed in
the plan of care, and the CONTRACTOR shall immediately revise the service
authorizations as necessary upon notice that the State has determined that the
member meets categorical and financial eligibility for TennCare CHOICES and
initiate services within five (5) days of notice.
	 
	 	2.9.6.2.5.4	 	At the discretion of the CONTRACTOR, authorization of home health or private
duty nursing services may be completed by the care coordinator or through the
CONTRACTOR’s established UM processes but shall be in accordance with Section 2.9.2.1
of this Agreement, which requires the CONTRACTOR to continue providing medically
necessary home health or private duty nursing services the member was receiving upon
TennCare enrollment.
	 
	 	2.9.6.2.5.5	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to a nursing
facility unless: (1) the member requires a short-term nursing facility care stay; (2)
the member chooses to transition to a nursing facility and enroll in Group 1; or (3)
the CONTRACTOR determines that it cannot safely and effectively meet the needs of the
member and at a cost that is less than the member’s cost neutrality cap and the member
agrees to transition to a nursing facility and enroll in Group 1.
	 
	 	2.9.6.2.5.6	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to a nursing
facility unless: (1) the member meets nursing facility level of care and is expected to
require nursing facility services for ninety (90) days or less; or (2) the member meets
nursing facility level of care, is expected to require nursing facility services for
more than ninety (90) days and chooses to transition to a nursing facility and enroll
in Group 1.
	 
	 	2.9.6.2.5.7	 	In preparation for the face-to-face visit, the care coordinator shall review
in-depth the information from the SPOE’s intake process (see Section 2.9.6.2.3), and
the care coordinator shall consider that information, including the services identified
by TENNCARE or its designee, when developing the member’s plan of care.
	 
	 	2.9.6.2.5.8	 	As part of the face-to-face visit for members in CHOICES Group 2, the care
coordinator shall review, and revise as necessary, the member’s risk assessment and
risk agreement and have the member or his/her representative sign any revised risk
agreement.

Page 92 of 374

 

	 	2.9.6.2.5.9	 	As part of the face-to-face visit, the care coordinator shall provide member
education regarding choice of contract providers for HCBS, subject to the
provider’s availability and willingness to timely deliver services, and obtain
signed confirmation of the member’s choice of contract providers.
	 
	 	2.9.6.2.5.10	 	For purposes of the CHOICES program, service authorizations shall include the
amount, frequency, and duration of each service to be provided and the schedule at
which such care is needed, as applicable; the requested start date; and other
relevant information as prescribed by TENNCARE. The CONTRACTOR shall be responsible
for confirming the provider’s capacity and commitment to initiate services as
authorized on or before the requested start date, and if the provider is unable to
initiate services as authorized on or before the requested start date, for
arranging an alternative provider who is able to initiate services as authorized on
or before the requested start date.
	 
	 	2.9.6.2.5.11	 	The member’s care coordinator/care coordination team shall provide at least
verbal notification to the member prior to initiation of HCBS identified in the
plan of care regarding any change in providers selected by the member for each
HCBS, including the reason such change has been made.
	 
	 	2.9.6.2.5.12	 	If the CONTRACTOR is unable to initiate any HCBS in accordance with the
timeframes specified herein, the CONTRACTOR shall issue written notice to the
member, documenting the service(s) that will be delayed, the reasons for the delay,
and the date the service(s) will start, and shall make good faith efforts to ensure
that services are provided as soon as practical.
	 
	 	2.9.6.2.5.13	 	TENNCARE may establish, pursuant to policies and protocols for management
of waiting lists, alternative timeframes for completion of specified intake
functions and activities when there is a waiting list, which may include at the
time of CHOICES implementation.

	 	2.9.6.3	 	CHOICES Intake Process for the CONTRACTOR’s Current Members
	 
	 	2.9.6.3.1	 	The CONTRACTOR shall develop and implement policies and procedures for ongoing identification of members who
may be eligible for CHOICES. The CONTRACTOR shall use the following, at a minimum, to identify members who may be
eligible for CHOICES:
	 
	 	2.9.6.3.1.1	 	Referral from member’s PCP, specialist or other provider or other referral source;
	 
	 	2.9.6.3.1.2	 	Self-referral by member or referral by member’s family or guardian;
	 
	 	2.9.6.3.1.3	 	Referral from CONTRACTOR’s staff including but not limited to DM, MCO
case management, and UM staff;
	 
	 	2.9.6.3.1.4	 	Notification of hospital admission (see Section 2.12.9.38); and
	 
	 	2.9.6.3.1.5	 	Upon notice from TENNCARE but no more than one hundred eighty (180) days
following implementation of CHOICES in the Grand Region covered by this Agreement,
periodic review (at least quarterly) of:

Page 93 of 374

 

	 	2.9.6.3.1.5.1	 	Claims or encounter data;
	 
	 	2.9.6.3.1.5.2	 	Hospital admission or discharge data;
	 
	 	2.9.6.3.1.5.3	 	Pharmacy data; and
	 
	 	2.9.6.3.1.5.4	 	Data collected through the DM and/or UM processes.
	 
	 	2.9.6.3.1.5.5	 	The CONTRACTOR may define in its policies and procedures, other steps that
will be taken to better assess if the members identified through means other than
referral or notice of hospital admission will likely qualify for CHOICES, and may
target its screening and intake efforts to a more targeted list of persons that are
most likely to need and to qualify for CHOICES services.
	 
	 	2.9.6.3.2	 	As part of its identification process for members who may be eligible for CHOICES, the
CONTRACTOR may initiate a telephone screening process, using the tool and protocols specified by
TENNCARE. Such screening process shall: (1) verify the member’s current eligibility category based
on information provided by TENNCARE in the 834 eligibility file; for persons seeking access to HCBS
through enrollment in CHOICES Groups 2 or 3, identify whether the member meets categorical
eligibility requirements for enrollment in such group based on his/her current eligibility category,
and if not, for persons seeking to enroll in CHOICES Group 2, whether the member appears to meet
categorical and financial eligibility criteria for the Institutional (i.e., CHOICES 217-Like HCBS)
category); (2) determine whether the member appears to meet level of care eligibility for CHOICES;
and (3) for members seeking access to HCBS through enrollment in CHOICES Group 2, determine whether
it appears that the member’s needs can be safely and effectively met in the community and at a cost
that does not exceed nursing facility care. Such telephone screening shall be conducted at the time
of the initial call by the CONTRACTOR unless the member requests that the screening be conducted at
another time, which shall be documented in writing in the CHOICES intake record.
	 
	 	2.9.6.3.3	 	For CHOICES referrals by or on behalf of a potential CHOICES member, regardless of
referral source, if the CONTRACTOR opts to use a telephone screening process, the CONTRACTOR shall
make every effort to conduct such screening process at the time of referral, unless the person
making the referral is not able or not authorized by the member to assist with the screening
process, in which case the CONTRACTOR shall complete the telephone screening process as
expeditiously as possible.
	 
	 	2.9.6.3.3.1	 	Documentation of at least three (3) attempts to contact the member by phone
(which shall include at least one (1) attempt to contact the member at the number
most recently reported by the member and at least one (1) attempt to contact the
member at the number provided in the referral, if different), followed by a letter
sent to the member’s most recently reported address that provides information about
CHOICES and how to obtain a screening for CHOICES, shall constitute sufficient
effort by the CONTRACTOR to assist a member who has been referred for CHOICES,
regardless of referral source.
	 
	 	2.9.6.3.4	 	For persons identified through notification of hospital admission, the CONTRACTOR shall
work with the discharge planner to determine whether long-

Page 94 of 374

 

	 	 	 	term care services may be needed upon discharge, and if so, shall complete all
applicable screening and/or intake processes immediately to facilitate timely
transition to the most integrated and cost effective long-term care delivery setting
appropriate for the member’s needs.
	 
	 	2.9.6.3.5	 	For identification by the CONTRACTOR of a member who may be eligible for CHOICES by means
other than referral or notice of hospital admission, if the CONTRACTOR opts to use a telephone
screening process, the CONTRACTOR shall complete the telephone screening process as
expeditiously as possible.
	 
	 	2.9.6.3.5.1	 	Documentation of at least one (1) attempt to contact the member by phone at the
number most recently reported by the member, followed by a letter sent to the member’s
most recently reported address that provides information about CHOICES and how to
obtain a screening for CHOICES shall constitute sufficient effort by the CONTRACTOR to
assist a member that has been identified by the CONTRACTOR by means other than
referral.
	 
	 	2.9.6.3.6	 	If the CONTRACTOR uses a telephone screening process, the CONTRACTOR shall document all
screenings conducted by telephone and their disposition, with a written record.
	 
	 	2.9.6.3.7	 	If the member does not meet the telephone screening criteria, the CONTRACTOR shall notify
the member verbally and in writing: (1) that he/she does not appear to meet the criteria for
enrollment in CHOICES; (2) that he/she has the right to continue with the CHOICES intake
process and, if determined not eligible, to receive notice of such denial, including the
member’s due process right to appeal; and (3) how, if the member wishes to proceed with the
CHOICES intake process, the member can submit a written request to proceed with the CHOICES
intake process to the CONTRACTOR. In the event that a member does submit such written request,
the CONTRACTOR shall conduct a face-to-face intake visit, including level of care assessment
and needs assessment, within five (5) business days of receipt of the member’s written
request.
	 
	 	2.9.6.3.8	 	If, through the screening process described above, or upon other identification by the
CONTRACTOR of a member who appears to be eligible for CHOICES for whom the CONTRACTOR opts not
to use such screening process, the care coordinator shall conduct a face-to-face intake visit
with the member that includes a level of care assessment and a needs assessment (see Section
2.9.6.5) using tool(s) prior approved by TENNCARE and in accordance with the protocols
specified by TENNCARE. The CONTRACTOR shall complete the telephone screening process and the
face-to-face intake visit with the member within six (6) business days of receipt of the
referral.
	 
	 	2.9.6.3.8.1	 	For members in a nursing facility or seeking nursing facility services, the care
coordinator shall perform any additional needs assessment deemed necessary by the
CONTRACTOR (see Section 2.9.6.5.1).
	 
	 	2.9.6.3.8.2	 	For members seeking HCBS, the care coordinator shall, using the tools and
protocols specified by TENNCARE, assess the member’s existing natural support system,
including but not limited to informal supports provided by family and other caregivers,
services that may be available at no cost to the member through other entities, and
services that are reimbursable through other public or
private funding sources, such as Medicare or long-term care insurance; and identify
the long-term care services and home health and/or private duty nursing

Page 95 of 374

 

	 	 	 	services that may be needed by the member upon enrollment into CHOICES that would
build upon and not supplant a member’s existing natural support system.
	 
	 	2.9.6.3.9	 	As part of the face-to-face intake visit, the care coordinator/care coordination team
shall: (1) provide general CHOICES education and information, as specified by TENNCARE, to the
member and assist in answering questions the member may have; (2) provide information about
estate recovery; (3) provide assistance, as necessary, in facilitating gathering of
categorical/financial documentation needed by DHS; (4) provide information regarding freedom
of choice of nursing facility versus HCBS, both verbally and in writing, and obtain a Freedom
of Choice form signed by the member or his/her representative; (5) for members who want to
receive nursing facility services, (a) provide detailed information and signed acknowledgement
of understanding regarding a CHOICES member’s responsibility with respect to payment of
patient liability amounts, including the potential consequences for nonpayment of patient
liability which may include loss of the member’s current nursing facility provider,
disenrollment from CHOICES, and to the extent the member’s eligibility is dependent on receipt
of long-term care services, possible loss of eligibility for TennCare; and (b) provide
information regarding the completion of all PASRR requirements prior to nursing facility
admission; (6) for members who are seeking HCBS, the care coordinator, shall: (a) conduct a
risk assessment using a tool and protocol specified by TENNCARE and shall develop, as
applicable, a risk agreement that shall be signed by the member or his/her representative and
which shall include identified risks to the member, the consequences of such risks, strategies
to mitigate the identified risks, and the member’s decision regarding his/her acceptance of
risk; (b) make a determination regarding whether the person’s needs can be safely and
effectively met in the community and at a cost that does not exceed nursing facility care,
including explanation to the member regarding the individual cost neutrality cap, and
notification to and signed acknowledgement of understanding by the member or his/her
representative that a change in needs or circumstances that would result in the cost
neutrality cap being exceeded or that would result in the CONTRACTOR’s inability to safely and
effectively meet the member’s needs in the community and within the cost neutrality cap may
result in the member’s disenrollment from CHOICES Group 2, in which case, the member’s care
coordinator will assist with transition to a more appropriate care delivery setting; and (c)
provide information regarding consumer direction and obtain written confirmation of the
member’s decision regarding participation in consumer direction; and (7) for all members,
provide information regarding choice of contract providers, subject to the provider’s
availability and willingness to timely deliver services, and obtain signed documentation of
the member’s choice of contract providers.
	 
	 	2.9.6.3.10	 	For CHOICES referrals by or on behalf of a potential CHOICES member, regardless of
referral source, the care coordinator shall conduct the face-to-face intake visit and shall
develop a plan of care, as appropriate (see Section 2.9.6.6), within six (6) business days of
receipt of such referral, unless a later date is requested by the member, which shall be
documented in writing in the CHOICES intake record.
	 
	 	2.9.6.3.11	 	For members identified by the CONTRACTOR as potentially eligible for CHOICES by means
other than referral, the care coordinator shall conduct the face-to-face intake visit and
shall develop a plan of care, as appropriate (see Section 2.9.6.6),

Page 96 of 374

 

	 	 	 	within thirty (30) days of identification of the member as potentially eligible for
CHOICES. For persons identified through notification of hospital admission, the
CONTRACTOR shall coordinate with the hospital discharge planner to determine whether
long-term care services may be needed upon discharge, and if so, complete all
applicable screening and/or intake processes immediately to facilitate timely
transition to the most integrated and cost effective long-term care delivery setting
appropriate for the member’s needs.
	 
	 	2.9.6.3.12	 	Once completed, the CONTRACTOR shall submit the level of care and, for members
requesting HCBS, documentation, as specified by TENNCARE, to verify that the member’s needs
can be safely and effectively met in the community and within the cost neutrality cap to
TENNCARE within one (1) business day.
	 
	 	2.9.6.3.13	 	If the member is seeking access to HCBS through enrollment in CHOICES Group 2 and the
enrollment target for CHOICES Group 2 has been reached, the CONTRACTOR shall notify TENNCARE,
at the time of submission of the level of care and needs assessment and plan of care, as
appropriate, whether the person shall be placed on a waiting list for CHOICES Group 2. If the
CONTRACTOR wishes to enroll the person in CHOICES Group 2 as a cost effective alternative
(CEA) to nursing facility care that would otherwise be provided, the CONTRACTOR shall submit
to TENNCARE the following:
	 
	 	2.9.6.3.13.1	 	A written summary of the CONTRACTOR’s CEA determination, including and
explanation of the member’s circumstances which warrant the immediate provision of
nursing facility services unless HCBS are immediately available.
	 
	 	2.9.6.3.13.2	 	TENNCARE may request additional information as needed to confirm the
CONTRACTOR’s CEA determination and/or provider capacity to meet the member’s needs,
and shall, only upon receipt of satisfactory documentation, enroll the member in
CHOICES.
	 
	 	2.9.6.3.14	 	The CONTRACTOR shall be responsible for (1) advising members who appear to meet the
nursing facility level of care that are seeking access to HCBS through enrollment in CHOICES
Group 2 when an enrollment target has been (or will soon be) reached; (2) advising such
persons that they may choose to receive nursing facility services if HCBS are not immediately
available; (3) determining whether the person wants nursing facility services if HCBS are not
immediately available; and (4) at the CONTRACTOR’s sole discretion, making a determination
regarding whether enrollment in Group 2 constitutes a CEA because the immediate provision of
nursing facility services will otherwise be required.
	 
	 	2.9.6.3.15	 	The State will be responsible for determining TennCare categorical and financial
eligibility and level of care and enrolling eligible TennCare members into CHOICES.
	 
	 	2.9.6.3.16	 	TENNCARE will notify the CONTRACTOR via the 834 eligibility file when a person has been
enrolled in CHOICES and, if the member is enrolled in CHOICES, the member’s CHOICES Group. For
members in CHOICES Group 2, TENNCARE will notify the CONTRACTOR of the member’s cost
neutrality cap (see definition in Section 1 and see Section 2.6.1.5.2.3). For members in
CHOICES Group 1, TENNCARE will notify the CONTRACTOR of applicable patient liability amounts
(see Section 2.6.7.2).

Page 97 of 374

 

	 	2.9.6.3.17	 	The CONTRACTOR shall, within five (5) calendar days of notice of the member’s
enrollment in CHOICES, authorize and initiate long-term care services.
	 
	 	2.9.6.3.17.1	 	For purposes of the CHOICES program, service authorizations shall include the
amount, frequency, and duration of each service to be provided, and the schedule at
which such care is needed, as applicable; and other relevant information as
prescribed by TENNCARE. The CONTRACTOR is responsible for confirming the provider’s
capacity and commitment to initiate services as authorized on or before the requested
start date, and if the provider is unable to initiate services as authorized on or
before the requested start date, shall select an alternative provider who is able to
initiate services as authorized on or before the requested start date.
	 
	 	2.9.6.3.17.2	 	The CONTRACTOR shall provide at least verbal notice to the member prior to
initiation of HCBS identified in the plan of care regarding any change in providers
selected by the member for each HCBS; including the reason such change has been made.
If the CONTRACTOR is unable to place a member in the nursing facility or
community-based residential alternative setting requested by the member, the care
coordinator shall meet with the member and his/her representative to discuss the
reasons why the member cannot be placed with the requested facility and the available
options and identify an alternative facility.
	 
	 	2.9.6.3.17.3	 	If the CONTRACTOR is unable to initiate any long-term care service within the
timeframes specified in this Agreement, the CONTRACTOR shall issue written notice to
the member, documenting the service(s) that will be delayed, the reasons for the
delay and the date the service(s) will start, and shall make good faith efforts to
ensure that services are provided as soon as practical.
	 
	 	2.9.6.3.17.4	 	For members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES
enrollment, receiving nursing facility or community-based residential alternative
services from a contract provider, the CONTRACTOR shall authorize such services from
the current provider as of the effective date of CHOICES enrollment. The CONTRACTOR
shall not move members enrolled in CHOICES Groups 1 or 2 who are, upon CHOICES
enrollment, receiving services in a nursing facility or community-based residential
alternative setting to another facility unless: (1) the member or his/her
representative specifically requests to move, which shall be documented in the
member’s file; (2) the member or his/her representative provides written consent to
move based on quality or other concerns raised by the CONTRACTOR, which shall not
include the nursing facility’s rate of reimbursement; or (3) the facility where the
member is residing is not a contract provider; if the community-based residential
facility where the member is currently residing is not a contract provider, the
CONTRACTOR shall provide continuation of services in such facility for at least
thirty (30) days, which shall be extended as necessary to ensure continuity of care
pending the facility’s contracting with the CONTRACTOR or the member’s transition to
a contract facility; if the member is transitioned to a contract facility, the
CONTRACTOR shall facilitate a seamless transition to the new facility; if the nursing
facility where the member is currently residing is a non-contract provider, the
CONTRACTOR shall (a) authorize continuation of the services pending enrollment of the
facility as a contract provider (except a

Page 98 of 374

 

	 	 	 	facility excluded for a 2-year period when the facility has withdrawn from Medicaid
participation); (b) authorize continuation of the services pending facilitation of
the member’s transition to a contract facility, subject to the member’s agreement
with such transition; or (c) may continue to reimburse services from the
non-contract nursing facility in accordance with TennCare rules and regulations.
	 
	 	2.9.6.3.17.5	 	For members receiving nursing facility services, the care coordinator shall
participate as appropriate in the nursing facility’s care planning process (see
Section 2.9.6.5.1) and may supplement the plan of care as necessary (see Section
2.9.6.6.1).
	 
	 	2.9.6.3.17.6	 	The CONTRACTOR shall not divert or transition members in CHOICES Group
1 to HCBS unless the member chooses to receive HCBS as an alternative to nursing
facility and is enrolled in Group 2 or 3.
	 
	 	2.9.6.3.17.7	 	The CONTRACTOR shall ensure that all PASRR requirements are met prior to a
member’s admission to a nursing facility.
	 
	 	2.9.6.3.17.8	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 2 to
a nursing facility unless: (1) the member requires a short-term nursing facility
care stay; (2) the member chooses to transition to a nursing facility and enroll in
Group 1; or (3) the CONTRACTOR determines that it cannot safely and effectively
meet the needs of the member and at a cost that is less than the member’s cost
neutrality cap and the member agrees to transition to a nursing facility and enroll
in Group 1.
	 
	 	2.9.6.3.17.9	 	The CONTRACTOR shall not admit a member enrolled in CHOICES Group 3 to
a nursing facility unless: (1) the member meets nursing facility level of care and
is expected to require nursing facility services for ninety (90) days or less; or
(2) the member meets nursing facility level of care, is expected to require nursing
facility services for more than ninety (90) days and chooses to transition to a
nursing facility and enroll in Group 1.
	 
	 	2.9.6.3.18	 	TENNCARE may establish, pursuant to policies and protocols for management of waiting
lists, alternative timeframes for completion of specified intake functions and activities for
persons when there is a waiting list, which may include at the time of CHOICES implementation.
	 
	 	2.9.6.4	 	Care Coordination upon Enrollment in CHOICES
	 
	 	2.9.6.4.1	 	Upon notice of a member’s enrollment in CHOICES, the CONTRACTOR shall assume
responsibility for all care coordination functions and activities described herein (assessment
and care planning activities for members currently enrolled with the CONTRACTOR shall begin
prior to CHOICES enrollment; see Section 2.9.6.3).
	 
	 	2.9.6.4.2	 	The CONTRACTOR shall be responsible for all aspects of care coordination and all
requirements pertaining thereto, including but not limited to requirements set forth in the
Section 1115 TennCare Demonstration Waiver, federal and state laws and regulations, this
Agreement, and TENNCARE policies and protocols.

Page 99 of 374

 

	 	2.9.6.4.3	 	The CONTRACTOR shall assign to each member a specific care coordinator who
shall have primary responsibility for performance of care coordination activities as
specified in this Agreement, and who shall be the member’s point of contact for
coordination of all physical health, behavioral health, and long-term care services.
	 
	 	2.9.6.4.3.1	 	For CHOICES members, who are, upon CHOICES enrollment, receiving services in a
nursing facility or a community-based residential alternative setting, the CONTRACTOR
shall assign a specific care coordinator prior to the first face-to-face visit required
in this Agreement. If the first face-to-face visit will not occur within the first ten
(10) days of the member’s enrollment in CHOICES, the CONTRACTOR shall send the member
written notification within ten (10) calendar days of the member’s enrollment that
explains how the member can reach the care coordination unit for assistance with
concerns or questions pending the assignment of a specific care coordinator.
	 
	 	2.9.6.4.3.2	 	For CHOICES members who, upon enrollment in CHOICES, are not receiving services
in a nursing facility or a community-based residential alternative setting, the
CONTRACTOR shall assign a specific care coordinator and shall advise the member of the
name of his/her care coordinator and provide contact information prior to the
initiation of services (see Section 2.9.6.2.4.4 and 2.9.6.2.5.3), but no more than ten
(10) calendar days following CHOICES enrollment.
	 
	 	2.9.6.4.4	 	The CONTRACTOR may utilize a care coordination team approach to performing care
coordination activities prescribed in Section 2.9.6. For each CHOICES member, the CONTRACTOR’s
care coordination team shall consist of the member’s care coordinator and specific other
persons with relevant expertise and experience appropriate to address the needs of CHOICES
members. Care coordination teams shall be discrete entities within the CONTRACTOR’s
organizational structure dedicated to fulfilling CHOICES care coordination functions. The
CONTRACTOR shall establish policies and procedures that specify, at a minimum: the composition
of care coordination teams; the tasks that will be performed directly by the care coordinator;
measures taken to ensure that the care coordinator remains the member’s primary point of
contact for the CHOICES program and related issues; escalation procedures to elevate issues to
the care coordinator in a timely manner; and measures taken to ensure that if a member needs
to reach his/her care coordinator specifically, calls that require immediate attention by a
care coordinator are handled by a care coordinator and calls that do not require immediate
attention are returned by the member’s care coordinator the next business day.

Page 100 of 374

 

	 	2.9.6.5	 	Needs Assessment

	 	2.9.6.5.1	 	For Members in CHOICES Group 1
	 
	 	2.9.6.5.1.1	 	As part of the face-to-face intake visit for current members or face-to-face visit
with new members in CHOICES Group 1, as applicable, a care coordinator shall
conduct any needs assessment deemed necessary by the CONTRACTOR, using a tool prior
approved by TENNCARE and in accordance with protocols specified by TENNCARE. The
care coordinator shall assess the member’s potential for and interest in transition
to the community and ensure coordination of the member’s physical health,
behavioral health, and long-term care needs. This assessment may include
identification of targeted strategies related to improving health, functional, or
quality of life outcomes (e.g., related to disease management or pharmacy
management) or to increasing and/or maintaining functional abilities, including
services covered by the CONTRACTOR that are beyond the scope of the nursing
facility services benefit.
	 
	 	2.9.6.5.1.2	 	Needs reassessments shall be conducted as the care coordinator deems necessary.
	 
	 	2.9.6.5.2	 	For Members in CHOICES Groups 2 and 3
	 
	 	2.9.6.5.2.1	 	The care coordinator shall conduct a comprehensive needs assessment using a
tool prior approved by TENNCARE and in accordance with protocols specified by
TENNCARE as part of its face-to-face visit with new members in CHOICES Groups 2 and
3 (see Section 2.9.6.2.5) and as part of its face-to-face intake visit for current
members applying for CHOICES Groups 2 and 3.
	 
	 	2.9.6.5.2.2	 	At a minimum, for members in CHOICES Group 2 and 3, the comprehensive
needs assessment shall assess: (1) the member’s physical, behavioral, functional,
and psychosocial needs, including an evaluation of the member’s financial health as
it relates to the member’s ability to maintain a safe and healthy living
environment; (2) the member’s natural supports, including care being provided by
family members and/or other caregivers, and long-term care services the member is
currently receiving (regardless of payor), and whether there is any anticipated
change in the member’s need for such care or services or the availability of such
care or services from the current caregiver or payor; and (3) the physical health,
behavioral health, and long-term care services and other social support services
and assistance (e.g., housing or income assistance) that are needed, as applicable,
to ensure the member’s health safety and welfare in the community and to delay or
prevent the need for institutional placement.
	 
	 	2.9.6.5.2.3	 	The comprehensive needs assessment shall be conducted at least annually and as
the care coordinator deems necessary.
	 
	 	2.9.6.5.2.4	 	For CHOICES Group 2 and 3 members, the CONTRACTOR shall visit the
member face-to-face within five (5) business days of becoming aware that the member
has a significant change in needs or circumstances as defined in Section
2.9.6.9.2.1.16 The care coordinator shall assess the member’s needs, conduct a
comprehensive needs assessment and update the member’s plan of care as deemed
necessary based on the member’s circumstances.

Page 101 of 374

 

	 	2.9.6.6	 	Plan of Care

	 	2.9.6.6.1	 	For Members in CHOICES Group 1
	 
	 	2.9.6.6.1.1	 	For members in CHOICES Group 1, the member’s care coordinator/care
coordination team may: (1) rely on the plan of care developed by the nursing
facility for service delivery instead of developing a plan of care for the member;
and (2) supplement the plan of care as necessary with the development and
implementation of targeted strategies to improve health, functional, or quality of
life outcomes (e.g., related to disease management or pharmacy management) or to
increase and/or maintain functional abilities. A copy of any supplements to the
nursing facility plan of care, and updates to such supplements, shall be maintained
by the CONTRACTOR in the member’s file.
	 
	 	2.9.6.6.1.2	 	The member’s care coordinator shall participate as appropriate in the nursing
facility’s care planning process and advocate for the member.
	 
	 	2.9.6.6.1.3	 	The member’s care coordinator/care coordination team shall be responsible for
coordination of the member’s physical health, behavioral health, and long-term care
needs, which shall include coordination with the nursing facility as necessary to
facilitate access to physical health and/or behavioral health services needed by
the member and to help ensure the proper management of the member’s acute and/or
chronic physical health or behavioral health conditions, including services covered
by the CONTRACTOR that are beyond the scope of the nursing facility services
benefit.
	 
	 	2.9.6.6.2	 	For Members in CHOICES Groups 2 and 3
	 
	 	2.9.6.6.2.1	 	For members in CHOICES Groups 2 and 3, the care coordinator shall coordinate
and facilitate a care planning team that includes, at a minimum, the member and the
member’s care coordinator. As appropriate, the care coordinator shall include or
seek input from other individuals such as the member’s representative or other
persons authorized by the member to assist with needs assessment and care planning
activities.
	 
	 	2.9.6.6.2.2	 	The CONTRACTOR shall ensure that care coordinators consult with the
member’s PCP, specialists, behavioral health providers, other providers, and
interdisciplinary team experts, as needed when developing the plan of care.
	 
	 	2.9.6.6.2.3	 	The care coordinator shall verify that the decisions made by the care planning
team are documented in a written, comprehensive plan of care.
	 
	 	2.9.6.6.2.4	 	The plan of care developed for CHOICES members in Groups 2 and 3 prior to
initiation of HCBS shall at a minimum include: (1) pertinent demographic
information regarding the member including the name and contact information of any
representative and a list of other persons authorized by the member to have access
to health care (including long-term care) related information and to assist with
assessment, planning, and/or implementation of health care (including longterm
care) related services and supports; (2) care, including specific tasks and
functions, that will be performed by family members and other caregivers; (3) home
health, private duty nursing, and long-term care services the member will

Page 102 of 374

 

	 	 	 	receive from other payor sources including the payor of such services; (4) home
health and private duty nursing that will be authorized by the CONTRACTOR, except
in the case of persons enrolled on the basis of Immediate Eligibility who shall
have access to services beyond the limited package of HCBS (see Section 2.6.1.5.3)
only upon determination of categorical and financial eligibility for TennCare; (5)
HCBS that will be authorized by the CONTRACTOR, including the amount, frequency,
duration, and scope (tasks and functions to be performed) of each service to be
provided, and the schedule at which such care is needed, as applicable; members
enrolled on the basis of Immediate Eligibility shall have access only to a limited
package of HCBS (see Section 2.6.1.5.3) pending determination of categorical and
financial eligibility for TennCare CHOICES however all identified needed services
shall be listed in the plan of care; (6) a detailed back-up plan for situations
when regularly scheduled HCBS providers are unavailable or do not arrive as
scheduled; the back-up plan may include paid and unpaid supports and shall include
the names and telephone numbers of persons and agencies to contact and the services
provided by listed contacts; the CONTRACTOR shall assess the adequacy of the
back-up plan; and (7) for CHOICES Group 2 members, the projected TennCare monthly
and annual cost of home health and private duty nursing identified in (4) above,
and the projected monthly and annual cost of HCBS specified in (5) above, and for
CHOICES Group 3 members, the projected total cost of HCBS specified in (5) above,
excluding the cost of minor home modifications.

	 	2.9.6.6.2.5	 	Within thirty (30) calendar days of notice of enrollment in CHOICES, for
members in CHOICES Groups 2 and 3 the plan of care shall include, at a minimum, the
following additional elements:
	 
	 	2.9.6.6.2.5.1	 	Description of the member’s current physical and behavioral health conditions
and functional status (i.e., areas of functional deficit), and the member’s
physical, behavioral and functional needs;
	 
	 	2.9.6.6.2.5.2	 	Description of the member’s physical environment and any modifications
necessary to ensure the member’s health and safety;
	 
	 	2.9.6.6.2.5.3	 	Description of medical equipment used or needed by the member (if applicable);
	 
	 	2.9.6.6.2.5.4	 	Description of any special communication needs including interpreters or special
devices;
	 
	 	2.9.6.6.2.5.5	 	A description of the member’s psychosocial needs, including any housing or
financial assistance needs which could impact the member’s ability to maintain a
safe and healthy living environment;
	 
	 	2.9.6.6.2.5.6	 	Goals, objectives and desired health, functional, and quality of life outcomes for
the member;
	 
	 	2.9.6.6.2.5.7	 	Description of other services that will be provided to the member, including (1)
covered physical and behavioral health services that will be provided by the
CONTRACTOR to help the member maintain or improve his or her physical or behavioral
health status or functional abilities and maximize independence; (2) other social
support services and assistance needed in order to ensure the

Page 103 of 374

 

	 	 	 	member’s health, safety and welfare, and as applicable, to delay or prevent the
need for more expensive institutional placement; and (3) any non-covered services
including services provided by other community resources, including plans to link
the member to financial assistance programs including but not limited to housing,
utilities and food as needed;
	 
	 	2.9.6.6.2.5.8	 	Relevant information from the member’s individualized treatment plan for any
member receiving behavioral health services (see Section 2.7.2.1.4 of this
Agreement) that is needed by a long-term care provider, caregiver or the care
coordinator to ensure appropriate delivery of services or coordination of services;
	 
	 	2.9.6.6.2.5.9	 	Relevant information regarding the member’s physical health condition(s),
including treatment and medication regimen, that is needed by a long-term care
provider, caregiver or the care coordinator to ensure appropriate delivery of
services or coordination of care;
	 
	 	2.9.6.6.2.5.10	 	Frequency of planned care coordinator contacts needed, which shall include
consideration of the member’s individualized needs and circumstances, and which shall at
minimum meet required contacts as specified in Section 2.9.6.9.4 (unplanned care coordinator
contacts shall be provided as needed);
	 
	 	2.9.6.6.2.5.11	 	Additional information for members who elect consumer direction of HCBS, including
but not limited to whether the member requires a representative to participate in consumer
direction and the specific services that will be consumer directed;
	 
	 	2.9.6.6.2.5.12	 	If the member chooses to self-direct any health care tasks, the type of tasks that
will be self-directed;
	 
	 	2.9.6.6.2.5.13	 	Any steps the member and/or representative should take in the event of an emergency
that differ from the standard emergency protocol;
	 
	 	2.9.6.6.2.5.14	 	A disaster preparedness plan specific to the member; and
	 
	 	2.9.6.6.2.5.15	 	The member’s TennCare eligibility end date.
	 
	 	2.9.6.6.2.6	 	The member’s care coordinator/care coordination team shall ensure that the
member reviews, signs and dates the plan of care as well as any updates.
	 
	 	2.9.6.6.2.6.1	 	The CONTRACTOR shall develop policies and procedures that describe the
measures taken by the CONTRACTOR to address instances when a member refuses to sign
the plan of care. The policies and procedures shall include a specific escalation
process (ultimately to TENNCARE) that includes a review of the reasons for the
member’s refusal as well as actions taken to resolve any disagreements with the
plan of care and shall involve the consumer advocate in helping to facilitate
resolution.
	 
	 	2.9.6.6.2.6.2	 	When the refusal to sign is due to a member’s request for additional services,
including requests for a different type or an increased amount, frequency, scope,
and/or duration of services than what is included in the plan of care, the
CONTRACTOR shall, in the case of a new plan of care, authorize and initiate

Page 104 of 374

 

	 	 	 	services in accordance with the plan of care; and, in the case of an annual or
revised plan of care, ensure continuation of at least the level of services in
place at the time the annual or revised plan of care was developed until a
resolution is reached, which may include resolution of a timely filed appeal, if
applicable. The CONTRACTOR shall not use the member’s acceptance of services as a
waiver of the member’s right to dispute the plan of care or as cause to stop the
resolution process.
	 
	 	2.9.6.6.2.6.3	 	When the refusal to sign is due to the inclusion of services that the member does
not want to receive, either in totality or in the amount, frequency, scope or
duration of services in the plan of care, the care coordinator shall modify the
risk agreement to note this issue, the associated risks, and the measures to
mitigate the risks. The risk agreement shall be signed and dated by the member or
his/her representative and the care coordinator. In the event the care coordinator
determines that the member’s needs cannot be safely and effectively met in the
community without receiving these services, the CONTRACTOR may request that it no
longer provide long-term care services to the member (see Section 2.6.1.5.8).
	 
	 	2.9.6.6.2.7	 	The member’s care coordinator/care coordination team shall provide a copy of
the member’s completed plan of care, including any updates, to the member, the
member’s representative, as applicable, and the member’s community residential
alternative provider, as applicable. The member’s care coordinator/care
coordination team shall provide copies to other providers authorized to deliver
care to the member upon request, and shall ensure that such providers who do not
receive a copy of the plan of care are informed in writing of all relevant
information needed to ensure the provision of quality care for the member and to
help ensure the member’s health, safety, and welfare, including but not limited to
the tasks and functions to be performed.
	 
	 	2.9.6.6.2.8	 	Within five (5) business days of completing a reassessment of a member’s needs,
the member’s care coordinator/care coordination team shall update the member’s plan
of care as appropriate, and the CONTRACTOR shall authorize and initiate HCBS in the
updated plan of care. The CONTRACTOR shall comply with requirements for service
authorization in Section 2.9.6.2.5.10, change of provider in Section 2.9.6.2.5.11,
and notice of service delay in Section 2.9.6.2.5.12.
	 
	 	2.9.6.6.2.9	 	The member’s care coordinator shall inform each member of his/her eligibility
end date and educate members regarding the importance of maintaining TennCare
CHOICES eligibility, that eligibility must be redetermined at least once a year,
and that members will be contacted by TENNCARE or its designee near the date a
redetermination is needed to assist them with the process, e.g., collecting
appropriate documentation and completing the necessary forms.

	 	2.9.6.7	 	Nursing Facility Diversion

	 	2.9.6.7.1	 	The CONTRACTOR shall develop and implement a nursing facility diversion process that
complies with the requirements in this Section 2.9.6.7 and is prior approved in writing by
TENNCARE. The diversion process shall not prohibit or delay a member’s access to nursing
facility services when these services are medically necessary and requested by the member.

Page 105 of 374

 

	 	2.9.6.7.2	 	At a minimum the CONTRACTOR’s diversion process shall target the following groups for
diversion activities:
	 
	 	2.9.6.7.2.1	 	Members in CHOICES Group 1 who are waiting for placement in a nursing
facility;
	 
	 	2.9.6.7.2.2	 	CHOICES members residing in their own homes who have a negative change in
circumstances and/or deterioration in health or functional status and who request
nursing facility services;
	 
	 	2.9.6.7.2.3	 	CHOICES members residing in adult care homes or other community-based
residential alternative settings who have a negative change in circumstances and/or
deterioration in health or functional status and who request nursing facility
services;
	 
	 	2.9.6.7.2.4	 	CHOICES and non-CHOICES members admitted to an inpatient hospital or
inpatient rehabilitation who are not residents of a nursing facility; and
	 
	 	2.9.6.7.2.5	 	CHOICES and non-CHOICES members who are placed short-term in a nursing
facility regardless of payer source.
	 
	 	2.9.6.7.3	 	The CONTRACTOR’s nursing facility diversion process shall be tailored to meet the
needs of each group identified in Section 2.9.6.7.2 above.
	 
	 	2.9.6.7.4	 	The CONTRACTOR’s nursing facility diversion process shall include a detailed
description of how the CONTRACTOR will work with providers (including hospitals regarding
notice of admission and discharge planning; see Sections 2.9.6.3.4 and 2.9.6.3.11) to ensure
appropriate communication among providers and between providers and the CONTRACTOR, training
for key CONTRACTOR and provider staff, early identification of members who may be candidates
for diversion (both CHOICES and non-CHOICES members), and follow-up activities to help sustain
community living.
	 
	 	2.9.6.7.5	 	The CONTRACTOR’s nursing facility diversion process shall include specific timelines
for each identified activity.

	 	2.9.6.8	 	Nursing Facility-to-Community Transition

	 	2.9.6.8.1	 	The CONTRACTOR shall develop and implement methods for identifying members who may
have the ability and/or desire to transition from a nursing facility to the community. Such
methods shall include, at a minimum:
	 
	 	2.9.6.8.1.1	 	Starting on the date of implementation of CHOICES in the Grand Region
covered by this Agreement, referrals, including but not limited to, treating
physician, nursing facility, other providers, community-based organizations,
family, and self-referrals;
	 
	 	2.9.6.8.1.2	 	Starting on the date of implementation of CHOICES in the Grand Region
covered by this Agreement, identification through the care coordination process,

Page 106 of 374

 

	 	 	 	including but not limited to: assessments, information gathered from nursing
facility staff or participation in Grand Rounds (as defined in Section 1); and
	 
	 	2.9.6.8.1.3	 	Upon notice from TENNCARE but no more than one hundred and
twenty (120) days following the implementation of CHOICES in the Grand Region covered by this
Agreement, review and analysis of members identified by TENNCARE based on Minimum
Data Set (MDS) data from nursing facilities.
	 
	 	2.9.6.8.2	 	For transition referrals by or on behalf of a nursing facility resident, regardless of
referral source, the CONTRACTOR shall ensure that within fourteen (14) days of the referral
the CONTRACTOR conducts an in-facility visit with the member to determine the member’s
interest in and potential ability to transition to the community, and provide orientation and
information to the member regarding transition activities. The member’s care coordinator/care
coordination team shall document in the member’s case file that transition was discussed with
the member and indicate the member’s wishes as well as the member’s potential for transition.
The CONTRACTOR shall not require a member to transition when the member expresses a desire to
continue receiving nursing facility services.
	 
	 	2.9.6.8.3	 	For identification by the CONTRACTOR by means other than referral or the care
coordination process of a member who may have the ability and/or desire to transition from a
nursing facility to the community, the CONTRACTOR shall ensure that within ninety (90) days of
such identification the CONTRACTOR conducts an in-facility visit with the member to determine
whether or not the member is interested in and potential ability to pursue transition to the
community. The member’s care coordinator/care coordination team shall document in the member’s
case file that transition was discussed with the member and indicate the member’s wishes as
well as the member’s potential for transition. The CONTRACTOR shall not require a member to
transition when the member expresses a desire to continue receiving nursing facility services.
	 
	 	2.9.6.8.4	 	If the member wishes to pursue transition to the community, within fourteen (14) days of
the initial visit (see Sections 2.9.6.8.2 and 2.9.6.8.3 above) or within fourteen (14) days of
identification through the care coordination process, the care coordinator shall conduct an
in-facility assessment of the member’s ability and/or desire to transition using tools and
protocols specified or prior approved in writing by TENNCARE. This assessment shall include
the identification of any barriers to a safe transition.
	 
	 	2.9.6.8.5	 	As part of the transition assessment, the care coordinator shall conduct a risk
assessment using a tool and protocol specified by TENNCARE, discuss with the member the risk
involved in transitioning to the community and shall begin to develop, as applicable, a risk
agreement that shall be signed by the member or his/her representative and which shall include
identified risks to the member, the consequences of such risks, strategies to mitigate the
identified risks, and the member’s decision regarding his/her acceptance of risk as part of
the plan of care. The risk agreement shall include the frequency and type of care coordinator
contacts that exceed the minimum contacts required (see Section 2.9.6.9.4), to mitigate any
additional risks associated with transition and shall address any special circumstances due to
transition. The member’s care coordinator/care coordination team shall also make a
determination regarding whether the member’s needs can be safely and

Page 107 of 374

 

	 	 	 	effectively met in the community and at a cost that does not exceed nursing facility
care. The member’s care coordinator/care coordination team shall explain to the member
the individual cost neutrality cap and notification process and obtain a signed
acknowledgement of understanding by the member or his/her representative that a change
in a member’s needs or circumstances that would result in the cost neutrality cap being
exceeded or that would result in the CONTRACTOR’s inability to safely and effectively
meet a member’s needs in the community and within the cost neutrality cap may result in
the member’s disenrollment from CHOICES Group 2, in which case, the CONTRACTOR will
assist with transition to a more appropriate care delivery setting.
	 
	 	2.9.6.8.6	 	For those members whose transition assessment indicates that they are not candidates for
transition to the community, the care coordinator shall notify them in accordance with the
specified transition assessment protocol.
	 
	 	2.9.6.8.7	 	For those members whose transition assessment indicates that they are candidates for
transition to the community, the care coordinator shall facilitate the development of and
complete a transition plan within fourteen (14) days of the member’s transition assessment.
	 
	 	2.9.6.8.8	 	The care coordinator shall include other individuals such as the member’s family and/or
caregiver in the transition planning process if the member requests and/or approves, and such
persons are willing and able to participate.
	 
	 	2.9.6.8.9	 	As part of transition planning, prior to the member’s physical move to the community, the
care coordinator shall visit the residence where the member will live to conduct an on-site
evaluation of the physical residence and meet with the member’s family or other caregiver who
will be residing with the member (as appropriate). The care coordinator shall include in the
transition plan activities and/or services needed to mitigate any perceived risks in the
residence including but not limited to an increase in face-to-face visits beyond the minimum
required contacts in Sections 2.9.6.8.18 and 2.9.6.8.17.
	 
	 	2.9.6.8.10	 	The transition plan shall address all services necessary to safely transition the member
to the community and include at a minimum member needs related to housing, transportation,
availability of caregivers, and other transition needs and supports. The transition plan shall
also identify any barriers to a safe transition and strategies to overcome those barriers.
	 
	 	2.9.6.8.11	 	The CONTRACTOR shall approve the transition plan and authorize any covered or cost
effective alternative services included in the plan within ten (10) business days of
completion of the plan. The transition plan shall be fully implemented within ninety (90) days
from approval of the transition plan, except under extenuating circumstances which must be
documented in writing.
	 
	 	2.9.6.8.12	 	The member’s care coordinator shall also complete a plan of care that meets all criteria
described in Section 2.9.6.6 for members in CHOICES Groups 2 and 3 including but not limited
to completing a comprehensive needs assessment, completing and signing the risk agreement and
making a final determination of cost neutrality. The plan of care shall be authorized and
initiated prior to the member’s transition to the community.

Page 108 of 374

 

	 	2.9.6.8.13	 	The CONTRACTOR shall not prohibit a member from transitioning to the
community once the member has been counseled regarding risk. However, the CONTRACTOR
may determine that the member’s needs cannot be safely and effectively met in the
community and at a cost that does not exceed nursing facility care. In such case, the
CONTRACTOR shall seek written review and approval from TENNCARE prior to denial of any
member’s request to transition to the community. If TENNCARE approves the CONTRACTOR’s
request, the CONTRACTOR shall notify the member in accordance with TennCare rules and
regulations and the transition assessment protocol, and the member shall have the right
to appeal the determination (see Section 2.19.3.12 of this Agreement).
	 
	 	2.9.6.8.14	 	Once completed, the CONTRACTOR shall submit to TENNCARE documentation, as specified by
TENNCARE to verify that the member’s needs can be safely and effectively met in the community
and within the cost neutrality cap. Before transitioning a member the CONTRACTOR shall verify
that the member has been approved for enrollment in CHOICES Group 2 effective as of the
planned transition date.
	 
	 	2.9.6.8.15	 	The member’s care coordinator shall monitor all aspects of the transition process and
take immediate action to address any barriers that arise during transition.
	 
	 	2.9.6.8.16	 	For members transitioning to a setting other than a community-based residential
alternative setting, the care coordinator shall upon transition utilize the EVV system to
monitor the initiation and daily provision of services in accordance with the member’s new
plan of care, and shall take immediate action to resolve any service gaps (see definition in
Section 1).
	 
	 	2.9.6.8.17	 	For members who will live independently in the community or whose on-site visit during
transition planning indicated an elevated risk, within the first twenty-four (24) hours, the
care coordinator shall visit the member in his/her residence. During the initial ninety (90)
day post-transition period, the care coordinator shall conduct monthly face-to-face in-home
visits to ensure that the plan of care is being followed, that the plan of care continues to
meet the member’s needs, and the member has successfully transitioned to the community.
	 
	 	2.9.6.8.18	 	For members transitioning to a community-based residential alternative setting or who
will live with a relative or other caregiver, within the first twenty-four (24) hours the care
coordinator shall contact the member and within seven (7) days after the member has
transitioned to the community, the care coordinator shall visit the member in his/her new
residence. During the initial ninety (90) day post-transition period, the care coordinator
shall (1) at a minimum, contact the member by telephone each month to ensure that the plan of
care is being followed, that the plan of care continues to meet the member’s needs, and the
member has successfully transitioned to the community; and (2) conduct additional face-to-face
visits as necessary to address issues and/or concerns and to ensure that the member’s needs
are met.
	 
	 	2.9.6.8.19	 	The member’s care coordinator shall monitor hospitalizations and short-term nursing
facility stays for members who transition to identify and address issues that may prevent the
member’s long-term community placement.

Page 109 of 374

 

	 	2.9.6.8.20	 	The CONTRACTOR shall monitor
hospitalizations and nursing facility re-admission
for members who transition from a nursing facility
to the community to identify issues and implement
strategies to improve transition outcomes.
	 
	 	2.9.6.8.21	 	The CONTRACTOR shall be permitted to
coordinate or subcontract with local
community-based organizations to assist in the
identification, planning and facilitation
processes related to nursing facility-to-community
transitions.
	 
	 	2.9.6.8.22	 	The CONTRACTOR shall develop and
implement any necessary assessment tools,
transition plan templates, protocols, or training
necessary to ensure that issues that may hinder a
member’s successful transition are identified and
addressed. Any tool, template, or protocol must be
prior approved in writing by TENNCARE.

	 	2.9.6.9	 	Ongoing Care Coordination

	 	2.9.6.9.1	 	For Members in CHOICES Group 1
	 
	 	2.9.6.9.1.1	 	The CONTRACTOR shall provide for the following ongoing care coordination
to CHOICES members in Group 1:
	 
	 	2.9.6.9.1.1.1	 	Develop protocols and processes to work with nursing facilities to coordinate the
provision of care. At minimum, a care coordinator assigned to a resident of the
nursing facility shall participate in quarterly Grand Rounds (as defined in Section
1). At least two of the Grand Rounds per year shall be conducted on-site in the
facility, and the Grand Rounds shall identify and address any member who has
experienced a potential significant change in needs or circumstances (see Section
2.9.6.9.1.1.5) or about whom the nursing facility or MCO has expressed concerns;
	 
	 	2.9.6.9.1.1.2	 	Develop and implement targeted strategies to improve health, functional, or
quality of life outcomes, e.g., related to disease management or pharmacy
management, or to increase and/or maintain functional abilities;
	 
	 	2.9.6.9.1.1.3	 	Coordinate with the nursing facility as necessary to facilitate access to physical
health and/or behavioral health services needed by the member and to help ensure
the proper management of the member’s acute and/or chronic health conditions,
including services covered by the CONTRACTOR that are beyond the scope of the
nursing facility services benefit;
	 
	 	2.9.6.9.1.1.4	 	Intervene and address issues as they arise regarding payment of patient liability
amounts and assist in interventions to address untimely or non-payment of patient
liability in order to avoid the consequences of non-payment; and
	 
	 	2.9.6.9.1.1.5	 	At a minimum, the CONTRACTOR shall
consider the following a potential significant change
in needs or circumstances for CHOICES Group 1 members
who are residing in a nursing facility and contact the
nursing facility to determine if a visit and
reassessment is needed:
	 
	 	2.9.6.9.1.1.5.1	 	Pattern of recurring falls;
	 
	 	2.9.6.9.1.1.5.2	 	Incident, injury or complaint;

Page 110 of 374

 

	 	2.9.6.9.1.1.5.3	 	Report of abuse or neglect;
	 
	 	2.9.6.9.1.1.5.4	 	Frequent hospitalizations; or
	 
	 	2.9.6.9.1.1.5.5	 	Prolonged or significant change in health and/or functional status.

	 	2.9.6.9.2	 	For Members in CHOICES Groups 2 and 3

	 	2.9.6.9.2.1	 	The CONTRACTOR shall provide for the following ongoing care coordination
to CHOICES members in Groups 2 and 3:
	 
	 	2.9.6.9.2.1.1	 	Coordinate a care planning team, developing a plan of care and updating the plan
as needed;
	 
	 	2.9.6.9.2.1.2	 	During the development of the member’s plan of care and as part of the annual
updates, the care coordinator shall discuss with the member his/her interest in
consumer direction of HCBS;
	 
	 	2.9.6.9.2.1.3	 	During the development of the member’s plan of care, the care coordinator shall
educate the member about his/her ability to use advance directives and document the
member’s decision in the member’s file;
	 
	 	2.9.6.9.2.1.4	 	Ensure the plan of care addresses the member’s desired outcomes, needs and
preferences;
	 
	 	2.9.6.9.2.1.5	 	For members in CHOICES Group 2, each time a member’s plan of care is updated to change the
level or type of service, document in accordance with TENNCARE policy that the projected total cost of
HCBS, home health care and private duty nursing is less than the member’s cost neutrality cap. The
CONTRACTOR shall monitor utilization to identify members who may exceed the cost neutrality cap and to
intervene as necessary to maintain the member’s community placement. The CONTRACTOR shall also educate
members in CHOICES Group 2 about the cost neutrality cap and what will happen if the cap is met;

	 
	 	2.9.6.9.2.1.6	 	For members in CHOICES Group 3, determine whether the cost of HCBS, excluding minor home
modifications, will exceed the expenditure cap for CHOICES Group 3. The CONTRACTOR shall continuously
monitor a member’s expenditures and work with the member when he/she is approaching the limit including
identifying non-long term care services that will be provided when the limit has been met to
prevent/delay the need for institutionalization. Each time the plan of care for a member in CHOICES
Group 3 is updated, the CONTRACTOR shall educate the member about the expenditure cap;
	 
	 	2.9.6.9.2.1.7	 	For new services in an updated plan of care, the care coordinator shall provide
the member with information about potential providers for each HCBS that will be
provided by the CONTRACTOR and assist members with any requests for information
that will help the member in choosing a provider and, if applicable, in changing
providers, subject to the provider’s capacity and willingness to provide service;

Page 111 of 374

 

	 	2.9.6.9.2.1.8	 	Upon the scheduled initiation of services identified in the plan of care, the
member’s care coordinator/care coordination team shall begin monitoring to ensure
that services have been initiated and continue to be provided as authorized. This
shall include ongoing monitoring via electronic visit verification to ensure that
services are provided in accordance with the member’s plan of care, including the
amount, frequency, duration and scope of each service, in accordance with the
member’s service schedule; and that services continue to meet the member’s needs;
	 
	 	2.9.6.9.2.1.9	 	Identify and address service gaps, ensure that back-up plans are implemented and
effectively working, and evaluate service gaps to determine their cause and to
minimize gaps going forward. The CONTRACTOR shall describe in policies and
procedures the process for identifying, responding to, and resolving service gaps
in a timely manner;
	 
	 	2.9.6.9.2.1.10	 	Identify changes to member’s risk, address those changes and update the member’s risk
agreement as necessary;
	 
	 	2.9.6.9.2.1.11	 	Reassess a member’s needs and update a member’s plan of care in accordance with
requirements and timelines specified Sections 2.9.6.5 and 2.9.6.6;
	 
	 	2.9.6.9.2.1.12	 	Maintain appropriate on-going communication with community and natural supports to
monitor and support their ongoing participation in the member’s care;
	 
	 	2.9.6.9.2.1.13	 	For services not covered by the CONTRACTOR, coordinate with community organizations that
provide services that are important to the health, safety and well-being of members. This may include
but shall not be limited to referrals to other agencies for assistance and assistance as needed with
applying for programs, but the CONTRACTOR shall not be responsible for the provision or quality of
non-covered services provided by other entities;
	 
	 	2.9.6.9.2.1.14	 	Notify TENNCARE immediately, in the manner specified by TENNCARE, if the CONTRACTOR
determines that the needs of a member in CHOICES Group 2 cannot be met safely in the community and
within the member’s cost neutrality cap;
	 
	 	2.9.6.9.2.1.15	 	Perform additional requirements for consumer direction of HCBS as specified in Section
2.9.6.10; and
	 
	 	2.9.6.9.2.1.16	 	At a minimum, the CONTRACTOR shall consider the following a significant change in needs
or circumstances for members in CHOICES Groups 2 and 3 residing in the community:
	 
	 	2.9.6.9.2.1.16.1	 	Change of residence or primary caregiver or loss of essential social supports;
	 
	 	2.9.6.9.2.1.16.2	 	Significant change in health and/or functional status;
	 
	 	2.9.6.9.2.1.16.3	 	Loss of mobility;
	 
	 	2.9.6.9.2.1.16.4	 	An event that significantly increases the perceived risk to a member; or

Page 112 of 374

 

	 	2.9.6.9.2.1.17	 	Identify and immediately respond to problems and issues including but not limited to
circumstances that would impact the member’s ability to continue living in the community.

	 	2.9.6.9.3	 	For ALL CHOICES Members

	 	2.9.6.9.3.1	 	The CONTRACTOR shall provide for the following ongoing care coordination
to all CHOICES members:
	 
	 	2.9.6.9.3.1.1	 	Conduct a level of care reassessment at least annually and within five (5)
business days of the CONTRACTOR’s becoming aware that the member’s functional or
medical status has changed in a way that may affect level of care eligibility.
	 
	 	2.9.6.9.3.1.1.1	 	If the level of care assessment indicates a change in the level of care or if the
assessment was prompted by a request by a member, a member’s representative or
caregiver or another entity for a change in level of services, the assessment
shall be forwarded to TENNCARE for determination;
	 
	 	2.9.6.9.3.1.1.2	 	If the level of care assessment indicates no change in level of care, the
CONTRACTOR shall document the date the level of care assessment completed in
the member’s file; any level of care assessments prompted by a request for a
change in level of services shall be submitted to TENNCARE for determination.
	 
	 	2.9.6.9.3.1.2	 	Facilitate access to physical and/or behavioral health services as needed,
including transportation to services as specified in Section 2.6.1 and Attachment
XI; except as provided in Sections 2.11.1.8 or 2.6.5, transportation for HCBS is
not included;
	 
	 	2.9.6.9.3.1.3	 	Monitor and ensure the provision of covered physical health, behavioral health,
and/or long-term care services as well as services provided as a cost-effective
alternative to other covered services and ensure that services provided meet the
member’s needs;
	 
	 	2.9.6.9.3.1.4	 	Provide assistance in resolving concerns about service delivery or providers;
	 
	 	2.9.6.9.3.1.5	 	Coordinate with a member’s PCP, specialists and other providers, such as the
member’s mental health case manager, to facilitate a comprehensive, holistic,
person-centered approach to care;
	 
	 	2.9.6.9.3.1.6	 	Contact providers and workers on a periodic basis and coordinate with providers
and workers to collaboratively address issues regarding member service delivery and
to maximize community placement strategies;
	 
	 	2.9.6.9.3.1.7	 	Share relevant information with and among providers and others when
information is available and it is necessary to share for the well-being of the
member;

Page 113 of 374

 

	 	2.9.6.9.3.1.8	 	Determine the appropriate course as specified herein upon (1) receipt of any
contact made by or on behalf of a member, regardless of source, which asserts that
the member’s needs are not met by currently authorized services; (2) the member’s
hospitalization; or (3) other circumstances which warrant review and potential
modification of services authorized for the member;
	 
	 	2.9.6.9.3.1.9	 	Ensure that all PASRR requirements are met prior to the member’s admission to a nursing
facility;
	 
	 	2.9.6.9.3.1.10	 	Update consent forms as necessary; and
	 
	 	2.9.6.9.3.1.11	 	Assure that the organization of and documentation included in the member’s file meets
all applicable CONTRACTOR standards.
	 
	 	2.9.6.9.3.2	 	The CONTRACTOR shall provide to contract providers, including but not
limited to hospitals, nursing facilities, physicians, and behavioral health
providers, and caregivers information regarding the role of the care coordinator
and shall request providers and caregivers to notify a member’s care coordinator,
as expeditiously as warranted by the member’s circumstances, of any significant
changes in the member’s condition or care, hospitalizations, or recommendations for
additional services. The CONTRACTOR shall provide training to key providers and
caregivers regarding the value of this communication and remind them that the
member identification card indicates if a member is enrolled in CHOICES.
	 
	 	2.9.6.9.3.3	 	The CONTRACTOR shall have systems in place to facilitate timely
communication between internal departments and the care coordinator to ensure that
each care coordinator receives all relevant information regarding his/her members,
e.g., member services, disease management, utilization management, and claims
processing. The care coordinator shall follow-up on this information as
appropriate, e.g., documentation in the member’s plan of care, monitoring of
outcomes, and, as appropriate, needs reassessment and updating the plan of care.
	 
	 	2.9.6.9.3.4	 	The CONTRACTOR shall monitor and evaluate a member’s emergency
department and behavioral health crisis service utilization to determine the reason
for these visits. The care coordinator shall take appropriate action to facilitate
appropriate utilization of these services, e.g., communicating with the member’s
providers, educating the member, conducting a needs reassessment, and/or updating
the member’s plan of care and to better manage the member’s physical health or
behavioral health condition(s).

	 	2.9.6.9.3.5	 	The CONTRACTOR shall develop policies and procedures to ensure that care
coordinators are actively involved in discharge planning when a CHOICES member is
hospitalized. The CONTRACTOR shall define circumstances that require that
hospitalized CHOICES members receive a face-to-face visit to complete a needs
reassessment and an update to the member’s plan of care as needed.

Page 114 of 374

 

	 	2.9.6.9.3.6	 	The CONTRACTOR shall ensure that at each face-to-face visit the care
coordinator makes the following observations and documents the observations in the
member’s file:

	 	2.9.6.9.3.6.1	 	Member’s physical condition including observations of the member’s skin,
weight changes and any visible injuries;
	 
	 	2.9.6.9.3.6.2	 	Member’s physical environment;
	 
	 	2.9.6.9.3.6.3	 	Member’s satisfaction with services and care;
	 
	 	2.9.6.9.3.6.4	 	Member’s upcoming appointments;
	 
	 	2.9.6.9.3.6.5	 	Member’s mood and emotional well-being;
	 
	 	2.9.6.9.3.6.6	 	Member’s falls and any resulting injuries;
	 
	 	2.9.6.9.3.6.7	 	A statement by the member regarding any concerns or questions; and
	 
	 	2.9.6.9.3.6.8	 	A statement from the member’s representative or caregiver regarding any
concerns or questions (when the representative/caregiver is available).
	 
	 	2.9.6.9.3.7	 	The CONTRACTOR shall identify and immediately respond to problems and
issues including but not limited to:
	 
	 	2.9.6.9.3.7.1	 	Service gaps; and
	 
	 	2.9.6.9.3.7.2	 	Complaints or concerns regarding the quality of care rendered by providers,
workers, or care coordination staff.

	 	2.9.6.9.4	 	Minimum Care Coordinator Contacts

	 	2.9.6.9.4.1	 	The care coordinator shall conduct all needs assessment and care planning
activities, and shall make all minimum care coordinator contacts as specified below
in the member’s place of residence, except under extenuating circumstances (such as
assessment and care planning conducted during the member’s hospitalization, or upon
the member’s request), which shall be documented in writing.
	 
	 	2.9.6.9.4.1.1	 	While the CONTRACTOR may grant a member’s request to conduct certain care
coordination activities outside his or her place of residence, the CONTRACTOR is
responsible for assessing the member’s living environment in order to identify any
modifications that may be needed and to identify and address, on an ongoing basis,
any issues which may affect the member’s health, safety and welfare. Repeated
refusal by the member to allow the care coordinator to conduct visits in his or her
home may, subject to review and approval by TENNCARE, constitute grounds for
disenrollment from CHOICES Groups 2 or 3, if the CONTRACTOR is unable to properly
perform monitoring and other contracted functions and to confirm that the member’s
needs can be safely and effectively met in the home setting.

Page 115 of 374

 

	 	2.9.6.9.4.2	 	A member may initiate a request to opt out of some of the minimum face-to-face
contacts, but only with TENNCARE review of circumstances and approval. The
CONTRACTOR shall not encourage a member to request a reduction in face-to- face
visits by the care coordinator.
	 
	 	2.9.6.9.4.3	 	The CONTRACTOR shall ensure that care coordinators assess each member’s
need for contact with the care coordinator, to meet the member’s individual need
and ensure the member’s health and welfare. At a minimum, CHOICES members shall be
contacted by their care coordinator according to the following timeframes:
	 
	 	2.9.6.9.4.3.1	 	Members shall receive a face-to-face visit from their care coordinator in their
residence within the timeframes specified in Sections 2.9.6.2.4, 2.9.6.2.5 and
2.9.6.3.
	 
	 	2.9.6.9.4.3.2	 	Members who are newly admitted to a nursing facility when the admission has not been
authorized by the CONTRACTOR, shall receive a face-to-face visit from their care coordinator within ten
(10) days of notification of admission.
	 
	 	2.9.6.9.4.3.3	 	Members in CHOICES Group 2 who have transitioned from a nursing facility to the community
shall be contacted per the applicable timeframe specified in Section 2.9.6.8.
	 
	 	2.9.6.9.4.3.4	 	Within five (5) business days of scheduled initiation of services, the member’s
care coordinator/care coordination team shall contact members in CHOICES Groups 2
and 3 who begin receiving HCBS after the date of enrollment in CHOICES to confirm
that services are being provided and that the member’s needs are being met (such
initial contact may be conducted by phone).
	 
	 	2.9.6.9.4.3.5	 	Within five (5) business days of scheduled initiation of HCBS in the updated
plan of care, the member’s care coordinator/care coordination team shall contact
members in CHOICES Groups 2 and 3 to confirm that services are being provided and
that the member’s needs are being met (such initial contact may be conducted by
phone).
	 
	 	2.9.6.9.4.3.6	 	Members in CHOICES Group 1 (who are residents of a nursing facility) shall receive a
face-to-face visit from their care coordinator at least twice a year at a reasonable interval.
	 
	 	2.9.6.9.4.3.7	 	Members in CHOICES Group 2 shall be contacted by their care coordinator at least
monthly either in person or by telephone. These members shall be visited in their residence
face-to-face by their care coordinator at least quarterly.
	 
	 	2.9.6.9.4.3.8	 	Members in CHOICES Group 3 shall be contacted by their care coordinator at least
quarterly either in person or by telephone. These members shall be visited in their residence
face-to-face by their care coordinator a minimum of semiannually.
	 
	 	2.9.6.9.5	 	The CONTRACTOR shall ensure a member’s care coordinator/care coordination team
coordinates with Medicare payers, Medicare Advantage plans, and Medicare

Page 116 of 374

 

	 	 	 	providers as appropriate to coordinate the care and benefits of members who are also
eligible for Medicare (see Section 2.9.12).

	 	2.9.6.9.6	 	Member Case Files

	 	2.9.6.9.6.1	 	The care coordinator/care coordination team shall maintain individual files for
each assigned CHOICES member.
	 
	 	2.9.6.9.6.2	 	For members in CHOICES Group 1, the files shall contain at a minimum:
	 
	 	2.9.6.9.6.2.1	 	Pertinent demographic information regarding the member including the name
and contact information of any representative and a list of other persons
authorized by the member to have access to health care (including long-term care)
related information;
	 
	 	2.9.6.9.6.2.2	 	Any supplements to the nursing facility plan of care, as applicable;
	 
	 	2.9.6.9.6.2.3	 	A signed acknowledgement of the member’s patient liability amount and the
member’s understanding regarding his/her responsibility with respect to payment of
patient liability, including the potential consequences for non-payment; and
	 
	 	2.9.6.9.6.2.4	 	Transition assessment and transition plan, if applicable.
	 
	 	2.9.6.9.6.3	 	For members in CHOICES Groups 2 or 3, the files shall contain at a minimum:
	 
	 	2.9.6.9.6.3.1	 	The most current plan of care, including the detailed plan for back-up providers
in situations when regularly scheduled providers are unavailable or do not arrive
as scheduled;
	 
	 	2.9.6.9.6.3.2	 	List of providers who will be providing home health, private duty nursing and
HCBS paid for by other payors;
	 
	 	2.9.6.9.6.3.3	 	Written confirmation of the member’s decision regarding participation in
consumer direction of HCBS;
	 
	 	2.9.6.9.6.3.4	 	For members who are self-directing any health care tasks, a copy of the
physician’s order;
	 
	 	2.9.6.9.6.3.5	 	For members in CHOICES Group 2, a completed risk assessment and a risk agreement
signed by the member or his/her representative; and documentation that the person’s needs can
be safely and effectively met in the community and at a cost that does not exceed nursing
facility care, including signed acknowledgement of understanding by the member or his/her
representative that a change in needs or circumstances that would result in the cost
neutrality cap being exceeded or that would result in the CONTRACTOR’s inability to safely and
effectively meet the member’s needs in the community and within the cost neutrality cap may
result in the member’s disenrollment from CHOICES Group 2;
	 
	 	2.9.6.9.6.3.6	 	For members in CHOICES Group 2, the cost neutrality cap provided by TENNCARE, a
determination by the CONTRACTOR that the projected cost of

Page 117 of 374

 

	 	 	 	HCBS, home health, and private duty nursing services will not exceed the member’s
cost neutrality cap, and signed acknowledgement of understanding by the member or
his/her representative that a change in his/her needs or circumstances that would
result in the cost neutrality cap being exceeded or that would result in the MCO’s
inability to safely and effectively meet a member’s needs in the community and
within the cost neutrality cap may result in the member’s disenrollment from
CHOICES Group 2 ; and
	 
	 	2.9.6.9.6.3.7	 	For members in CHOICES Group 3, signed acknowledgement regarding the expenditure cap.
	 
	 	2.9.6.9.6.4	 	For all CHOICES members, files shall contain at a minimum:
	 
	 	2.9.6.9.6.4.1	 	For CHOICES members in Groups 1 and 2, Freedom of Choice form signed by the member or
his/her representative;
	 
	 	2.9.6.9.6.4.2	 	Evidence that a care coordinator/the care coordination team provided the member
with CHOICES member education materials (see Section 2.17.7 of this Agreement),
reviewed the materials, and provided assistance with any questions;
	 
	 	2.9.6.9.6.4.3	 	Evidence that a care coordinator/the care coordination team provided the member
with education about the member’s ability to use an advance directive and
documentation of the member’s decision;
	 
	 	2.9.6.9.6.4.4	 	The most recent level of care assessment and needs assessment (if applicable);
	 
	 	2.9.6.9.6.4.5	 	Documentation of the member’s choice of contract providers for long-term care
services;
	 
	 	2.9.6.9.6.4.6	 	Signed consent forms as necessary in order to share confidential information with
and among providers consistent with all applicable state and federal laws and
regulations;
	 
	 	2.9.6.9.6.4.7	 	A list of emergency contacts approved by the member;
	 
	 	2.9.6.9.6.4.8	 	Documentation of observations completed during face-to-face contact by the care
coordinator; and
	 
	 	2.9.6.9.6.4.9	 	The member’s TennCare eligibility end date.

	 	2.9.6.10	 	Additional Requirements for Care Coordination Regarding Consumer Direction of
HCBS 

	 	2.9.6.10.1	 	In addition to the roles and responsibilities otherwise specified in this Section 2.9.6,
the CONTRACTOR shall ensure that the following additional care coordination functions related
to consumer direction of HCBS are fulfilled.
	 
	 	2.9.6.10.2	 	The CONTRACTOR shall be responsible for providing all needed eligible HCBS using
contract providers until all necessary requirements have been fulfilled in order to implement
consumer direction of HCBS, including but not limited to: the FEA verifies that workers for
these services meet all necessary requirements (see Section

Page 118 of 374

 

	 	2.9.7.6.1	 	of this Agreement); service agreements are completed and signed; and
authorizations for consumer directed services are in place. The CONTRACTOR, in
conjunction with the FEA, shall facilitate a seamless transition between contract
providers and workers and ensure that there are no interruptions or gaps in services.

	 	2.9.6.10.3	 	If a member is interested in participating in consumer direction of HCBS and the member
does not intend to appoint a representative, the care coordinator shall determine the extent
to which the member may require assistance to direct his/her services (see Section 2.9.7.4.5).
If the care coordinator determines that the member requires assistance to direct his/her
services, based upon the results of a completed self-assessment instrument developed by
TENNCARE, the care coordinator shall inform the member that he/she will need to designate a
representative to assume the consumer direction functions on his/her behalf (see Section
2.9.7.4.5.1).
	 
	 	2.9.6.10.4	 	The member’s care coordinator/care coordination team shall ensure that the person
identified to serve as the representative meets all qualifications (see Section 2.9.7.2.1) and
that a representative agreement is completed and signed by the member prior to forwarding a
referral to the FEA (see Section 2.9.7.4.7).
	 
	 	2.9.6.10.5	 	Within two (2) business days of signing the representative agreement or completion of
the self-assessment instrument if the member does not use a representative, the CONTRACTOR
shall forward to the FEA a referral initiating the member’s participation in consumer
direction of HCBS.
	 
	 	2.9.6.10.6	 	The care coordinator, in conjunction with the FEA, shall assist the member and/or the
representative as needed in developing a back-up plan for consumer direction that adequately
identifies how the member will address situations when a scheduled worker fails to show up.
The member and his/her representative (as applicable) shall have primary responsibility for
the development of the back-up plan for consumer directed services. The back-up plan shall
include the names and telephone number of contacts for alternate care, the order in which
contact shall be made and the services to be provided by contacts. Back-up workers may include
paid and non-paid supports; however, it is the responsibility of the member electing consumer
direction and/or his/her representative to secure paid (as well as unpaid) back-up staff who
are willing and available to serve in this capacity. The CONTRACTOR shall not be expected or
required to maintain contract providers “on standby” to serve in a backup capacity for
services a member has elected to receive through consumer direction. All persons and/or
organizations noted in back-up plan for consumer directed services shall first be contacted by
the member and/or representative to determine their willingness and availability to serve as
back-up workers. The care coordinator shall follow-up with these persons and/or organizations
to confirm their willingness and availability to provide care when needed.
	 
	 	2.9.6.10.7	 	On an ongoing basis, the CONTRACTOR shall ensure that needs reassessments and updates to
the plan of care occur per requirements specified in Sections 2.9.6.9 of this Agreement. The
care coordinator shall ensure that the member’s supports broker is invited to participate in
these meetings.
	 
	 	2.9.6.10.8	 	Within two (2) business days of receipt of the notification from the FEA indicating that
all requirements have been fulfilled and the date that the consumer direction can begin for a
member, the CONTRACTOR shall forward to the FEA an authorization

Page 119 of 374

 

	 	 	 	for consumer directed services for that member. Each authorization for consumer
directed services shall include the required elements for a referral (see Section
2.9.7.4.7) including: authorized service, authorized units of service, including
amount, frequency and duration, start and end dates, and service code.
	 
	 	2.9.6.10.9	 	The member’s care coordinator/care
coordination team shall work with and coordinate
with a member’s supports broker in implementing
and monitoring consumer direction of HCBS (see
Section 2.9.7.3.4).
	 
	 	2.9.6.10.10	 	The CONTRACTOR shall establish a
process that allows for the efficient exchange
of all relevant member information between the
CONTRACTOR and the FEA.
	 
	 	2.9.6.10.11	 	The care coordinator shall determine
a member’s interest in enrolling in or
continuing to participate in consumer direction
annually and shall document the member’s
decision in the member’s plan of care.
	 
	 	2.9.6.10.12	 	If at any time the care coordinator
or FEA suspects abuse or neglect on the part of
the representative or worker, the care
coordinator and/or FEA shall report the
allegations to the CONTRACTOR. The CONTRACTOR
shall report the representative and/or worker to
APS. The representative and/or worker shall
immediately be released from his/her duties
until the APS investigation is complete. The
care coordinator shall work with the member to
find a new representative, and the FEA shall
work with the member to find a suitable
replacement worker. If the allegations are
substantiated as a result of the APS
investigation, the representative and/or worker
shall no longer be allowed to participate in the
CHOICES program in any capacity.
	 
	 	2.9.6.10.13	 	In the event the CONTRACTOR believes
that it cannot safely and effectively serve the
member in the community, the care coordinator,
with the assistance of and input from the FEA,
shall review with the member the previously
developed risk agreement and update it to ensure
that any additional identified risks are
incorporated and measures are identified to
mitigate risks. The representative (if
applicable) shall participate in the process.
The updated risk assessment shall be signed by
the member or representative and the care
coordinator. A copy shall be given to the member
or representative. The care coordinator and the
FEA shall file a copy in the member’s files. If
the CONTRACTOR does not believe the member can
be safely and effectively served in the
community, the CONTRACTOR may request to
involuntarily withdraw the member from consumer
direction of HCBS (see Section 2.9.7.9).

	 	2.9.6.11	 	Care Coordination Staff

	 	2.9.6.11.1	 	The CONTRACTOR shall establish qualifications for care coordinators. At a minimum, care
coordinators shall be an RN or LPN or have a bachelor’s degree in social work, nursing or
other health care profession. A care coordinator’s direct supervisor shall be a licensed
social worker or registered nurse with a minimum of two (2) years of relevant health care
(preferably long-term care) experience.
	 
	 	2.9.6.11.2	 	If the CONTRACTOR elects to use a care coordination team, the CONTRACTOR’s policies and
procedures shall specify the qualifications, experience and training of each member of the
team and ensure that functions specific to the assigned care coordinator are performed by a
qualified care coordinator (see Section 2.9.6.4.4).

Page 120 of 374

 

	 	2.9.6.11.3	 	The CONTRACTOR shall ensure an adequate number of care coordinators are
available and that sufficient staffing ratios are maintained to address the needs of
CHOICES members and meet all the requirements described in this Agreement.
	 
	 	2.9.6.11.4	 	The CONTRACTOR shall monitor staffing ratios and adjust ratios as necessary to ensure
that care coordinators are able to meet the requirements of this Agreement and address
members’ needs.
	 
	 	2.9.6.11.5	 	While care coordination staffing ratios are not specified, the CONTRACTOR shall submit
to TennCare for review and approval at least 120 days in advance of CHOICES implementation in
the Grand Region covered by this Agreement a Care Coordination Staffing Plan, which shall
specify the number of care coordinators, care coordination supervisors, other care
coordination team members the CONTRACTOR plans to initially employ, the ratio of care
coordinators to members the CONTRACTOR plans to maintain, an explanation of the methodology
for determining such ratio, and how the CONTRACTOR will ensure that such ratios are sufficient
to fulfill the requirements specified in this Agreement and roles and responsibilities for
each member of the care coordination team. TENNCARE shall notify the CONTRACTOR in writing if
the Care Coordination Staffing Plan is insufficient and may require modifications to ensure,
prior to implementation of CHOICES, that the CONTRACTOR has sufficient care coordination
staff. After CHOICES has been implemented, the CONTRACTOR shall notify TENNCARE in writing of
substantive changes to its Care Coordination Staffing Plan, including a variance of twenty
(20) percent or more from the planned staffing ratio. TENNCARE may request changes in the
CONTRACTOR’s Care Coordination Staffing Plan at any time it determines that the CONTRACTOR
does not have sufficient care coordination staff to properly and timely perform its
obligations under this Agreement.
	 
	 	2.9.6.11.6	 	The CONTRACTOR shall establish a system to assign care coordinators and to notify the
member of his/her assigned care coordinator’s name and contact information in accordance with
Section 2.9.6.4.3.
	 
	 	2.9.6.11.7	 	The CONTRACTOR shall ensure that members have a telephone number to call to directly
contact (without having to disconnect or place a second call) their care coordinator or a
member of their care coordination team (if applicable) during normal business hours. If the
member’s care coordinator or a member of the member’s care coordination team is not available,
the call shall be answered by another qualified staff person in the care coordination unit. If
the call requires immediate attention from a care coordinator, the staff member answering the
call shall immediately transfer the call to the member’s care coordinator (or another care
coordinator if the member’s care coordinator is not available) as a “warm transfer” (see
definition in Section 1). After normal business hours, calls that require immediate attention
by a care coordinator shall be transferred to a care coordinator as specified in Section 2.
18.1.6.
	 
	 	2.9.6.11.8	 	The CONTRACTOR shall permit members to change to a different care coordinator if the
member desires and there is an alternative care coordinator available. Such availability may
take into consideration the CONTRACTOR’s need to efficiently deliver care coordination in
accordance with requirements specified herein, including

Page 121 of 374

 

	 	 	 	for example, the assignment of a single care coordinator to all CHOICES members
receiving nursing facility or community-based residential alternative services from a
particular provider. Subject to the availability of an alternative care coordinator,
the CONTRACTOR may impose a six (6) month lock-in period with an exception for cause
after a member has been granted one (1) change in care coordinators.
	 
	 	2.9.6.11.9	 	In order to ensure quality and continuity of care, the CONTRACTOR shall make efforts
to minimize the number of changes in care coordinator assigned to a member. A CONTRACTOR
initiated change in care coordinators may be appropriate in the following circumstances:
	 
	 	2.9.6.11.9.1	 	Care coordinator is no longer employed by the CONTRACTOR;
	 
	 	2.9.6.11.9.2	 	Care coordinator has a conflict of interest and cannot serve the member;
	 
	 	2.9.6.11.9.3	 	Care coordinator is on temporary leave from employment; and
	 
	 	2.9.6.11.9.4	 	Care coordinator caseloads must be adjusted due to the size or intensity of
an individual care coordinator’s caseload.
	 
	 	2.9.6.11.10	 	The CONTRACTOR shall develop policies and procedures regarding notice to members of
care coordinator changes initiated by either the CONTRACTOR or the member, including advance
notice of planned care coordinator changes initiated by the CONTRACTOR.
	 
	 	2.9.6.11.11	 	The CONTRACTOR shall ensure continuity of care when care coordinator changes are made
whether initiated by the member or by the CONTRACTOR. The CONTRACTOR shall demonstrate use of
best practices by encouraging newly assigned care coordinators to attend a face-to-face
transition visit with the member and the out-going care coordinator when possible.
	 
	 	2.9.6.11.12	 	The CONTRACTOR shall provide initial training to newly hired care coordinators and
ongoing training at least annually to care coordinators. Initial training topics shall include
at a minimum:
	 
	 	2.9.6.11.12.1	 	The CHOICES program including a description of the CHOICES groups; eligibility for
CHOICES enrollment; enrollment in CHOICES; enrollment targets for Groups 2 and 3, including
reserve capacity and administration of waiting lists; and CHOICES benefits, including benefit
limits, the individual cost neutrality cap for Group 2, the expenditure cap for Group 3, and
the limited benefit package for members enrolled on the basis of Immediate Eligibility;
	 
	 	2.9.6.11.12.2	 	Facilitating CHOICES enrollment for current members;
	 
	 	2.9.6.11.12.3	 	Level of care and needs assessment and reassessment, development of a plan of care,
and updating the plan of care including training on the tools and protocols;
	 
	 	2.9.6.11.12.4	 	Development and implementation of back-up plans;
	 
	 	2.9.6.11.12.5	 	Consumer direction of HCBS;

Page 122 of 374

 

	 	2.9.6.11.12.6	 	Self-direction of health care tasks;
	 
	 	2.9.6.11.12.7	 	Coordination of care for duals;
	 
	 	2.9.6.11.12.8	 	Electronic visit verification;
	 
	 	2.9.6.11.12.9	 	Conducting a home visit and use of the monitoring checklist;
	 
	 	2.9.6.11.12.10	 	How to immediately identify and address service gaps;
	 
	 	2.9.6.11.12.11	 	Management of critical transitions (including hospital discharge planning);
	 
	 	2.9.6.11.12.12	 	Nursing facility diversion;
	 
	 	2.9.6.11.12.13	 	Nursing facility to community transitions, including training on tools and
protocols;
	 
	 	2.9.6.11.12.14	 	For members in CHOICES Group 1, members’ responsibility regarding patient
liability, including the consequences of not paying patient liability;
	 
	 	2.9.6.11.12.15	 	Alzheimer’s, dementia and cognitive impairments;
	 
	 	2.9.6.11.12.16	 	Traumatic brain injury;
	 
	 	2.9.6.11.12.17	 	Physical disabilities;
	 
	 	2.9.6.11.12.18	 	Disease management;
	 
	 	2.9.6.11.12.19	 	Behavioral health;
	 
	 	2.9.6.11.12.20	 	Evaluation and management of risk;
	 
	 	2.9.6.11.12.21	 	Identifying and reporting abuse/neglect (see Section 2.24.4);
	 
	 	2.9.6.11.12.22	 	Fraud and abuse, including reporting fraud and abuse;
	 
	 	2.9.6.11.12.23	 	Advance directives and end of life care;
	 
	 	2.9.6.11.12.24	 	HIPAA;
	 
	 	2.9.6.11.12.25	 	Cultural competency;
	 
	 	2.9.6.11.12.26	 	Disaster planning; and
	 
	 	2.9.6.11.12.27	 	Available community resources for non-covered services.
	 
	 	2.9.6.11.13	 	The CONTRACTOR shall establish roles and job responsibilities for care coordinators.
The job responsibilities shall include a description of activities and required timeframes for
completion. These activities shall include the requirements specified in this Section 2.9.6.

Page 123 of 374

 

	 	2.9.6.12	 	Care Coordination Monitoring

	 	2.9.6.12.1	 	The CONTRACTOR shall develop a comprehensive program for monitoring, on an ongoing basis,
the effectiveness of its care coordination processes. The CONTRACTOR shall immediately remediate all
individual findings identified through its monitoring process, and shall also track and trend such
findings and remediations to identify systemic issues of poor performance and/or non-compliance,
implement strategies to improve care coordination processes and resolve areas of non-compliance, and
shall measure the success of such strategies in addressing identified issues. At a minimum, the
CONTRACTOR shall ensure that:
	 
	 	2.9.6.12.1.1	 	Care coordination tools and protocols are consistently and objectively applied
and outcomes are continuously measured to determine effectiveness and
appropriateness of processes;
	 
	 	2.9.6.12.1.2	 	Level of care assessments and reassessments occur on schedule and are
submitted to TENNCARE in accordance with requirements in Section 2.9.6.9.3.1.1;
	 
	 	2.9.6.12.1.3	 	Needs assessments and reassessment, as applicable, occur on schedule and in
compliance with this Agreement;
	 
	 	2.9.6.12.1.4	 	Plans of care for CHOICES Groups 2 and 3 are developed and updated on
schedule and in compliance with this Agreement;
	 
	 	2.9.6.12.1.5	 	Plans of care for CHOICES Groups 2 and 3 reflect needs identified in the needs
assessment and reassessment process;
	 
	 	2.9.6.12.1.6	 	Plans of care for CHOICES Groups 2 and 3 are appropriate and adequate to
address member needs;
	 
	 	2.9.6.12.1.7	 	Services are delivered as described in the plan of care and authorized by the
CONTRACTOR;
	 
	 	2.9.6.12.1.8	 	Services are appropriate to address the member’s needs;
	 
	 	2.9.6.12.1.9	 	Services are delivered in a timely manner;
	 
	 	2.9.6.12.1.10	 	Service utilization is appropriate;
	 
	 	2.9.6.12.1.11	 	Service gaps are identified and addressed in a timely manner;
	 
	 	2.9.6.12.1.12	 	Minimum care coordinator contacts are conducted;

	 
	 	2.9.6.12.1.13	 	Care coordinator-to-member ratios are appropriate;
	 
	 	2.9.6.12.1.14	 	The cost neutrality cap for members in CHOICES Group 2 and the expenditure cap for
members in CHOICES Group 3 are monitored and appropriate action is taken if a member is
nearing or exceeds his/her cost neutrality or expenditure cap; and

Page 124 of 374

 

	 	2.9.6.12.1.15	 	That benefit limits are monitored and that appropriate action is taken if a member is
nearing or exceeds a benefit limit.
	 
	 	2.9.6.12.2	 	The CONTRACTOR shall provide to TENNCARE the reports required by Section 2.30.
	 
	 	2.9.6.12.3	 	The CONTRACTOR shall purchase and implement an electronic visit verification system to
monitor member receipt and utilization of HCBS including at a minimum, personal care,
attendant care, homemaker services and home-delivered meals. The CONTRACTOR shall select its
own electronic visit verification vendor and shall ensure, in the development of such system,
the following minimal functionality:
	 
	 	2.9.6.12.3.1	 	The ability to log the arrival and departure of individual provider staff
person or consumer direction worker;
	 
	 	2.9.6.12.3.2	 	The ability to verify in accordance with business rules that services are
being delivered in the correct location (e.g., the member’s home);
	 
	 	2.9.6.12.3.3	 	The ability to verify the identity of the individual provider staff person or
worker providing the service to the member;
	 
	 	2.9.6.12.3.4	 	The ability to match services provided to a member with services authorized
in the plan of care;
	 
	 	2.9.6.12.3.5	 	The ability to ensure that the provider/worker delivering the service is
authorized to deliver such services;
	 
	 	2.9.6.12.3.6	 	The ability to establish a schedule of services for each member which
identifies the time at which each service is needed, and the amount, frequency,
duration and scope of each service, and to ensure adherence to the established
schedule;
	 
	 	2.9.6.12.3.7	 	The ability to provide immediate (i.e., “real time”) notification to care
coordinators if a provider or worker does not arrive as scheduled or otherwise
deviates from the authorized schedule so that service gaps and the reason the service
was not provided as scheduled, are immediately identified and addressed, including
through the implementation of back-up plans, as appropriate;
	 
	 	2.9.6.12.3.8	 	The ability for a provider of home-delivered meals to log in and enter the
meals that have been delivered during the day, including the member’s name, time
delivered and the reason a meal was not delivered (when applicable);
	 
	 	2.9.6.12.3.9	 	The ability for a provider, e.g., adult day care provider, to log in and
enter attendance for the day;
	 
	 	2.9.6.12.3.10	 	The ability for the provider/worker to submit claims to the CONTRACTOR (claims from
workers shall be submitted initially to the FEA, and the FEA shall provide claims information
to the CONTRACTOR as specified in the subcontract with the FEA; see Section 2.26); and
	 
	 	2.9.6.12.3.11	 	The ability to reconcile paid claims with service authorizations.

Page 125 of 374

 

	 	2.9.6.12.4	 	The CONTRACTOR shall not require that provider staff delivering
home-delivered meals log in at arrival and departure. Instead, the provider may opt to
log in on a daily basis after meals have been delivered and enter information on all
the meals that were delivered that day (see Section 2.9.6.12.3.8 above).
	 
	 	2.9.6.12.5	 	The CONTRACTOR shall monitor and use information from the electronic visit verification
system to verify that services are provided as specified in the plan of care, and in
accordance with the established schedule, including the amount, frequency, duration, and scope
of each service, and that services are provided by the authorized provider/worker; and to
identify and immediately address service gaps, including late and missed visits. The
CONTRACTOR shall monitor services anytime a member is receiving services, including after the
CONTRACTOR’s regular business hours.
	 
	 	2.9.6.12.6	 	The CONTRACTOR shall develop and maintain an electronic case management system that
includes the functionality to ensure compliance with all requirements specified in the Section
1115 TennCare Demonstration Waiver, federal and state laws and regulations, this Agreement,
and TennCare policies and protocols, including but not limited to the following:
	 
	 	2.9.6.12.6.1	 	The ability to capture and track key dates and timeframes specified in this
Agreement, e.g., as applicable, date of referral for potential CHOICES enrollment,
date the level of care assessment and plan of care were submitted to TENNCARE, date
of CHOICES enrollment, date of development of the plan of care, date of authorization
of the plan of care, date of initial service delivery for each service in the plan of
care, date of each level of care and needs reassessment, date of each update to the
plan of care, and dates regarding transition from a nursing facility to the
community;
	 
	 	2.9.6.12.6.2	 	The ability to capture and track compliance with minimum care coordination
contacts as specified in Section 2.9.6.9.4 of this Agreement;
	 
	 	2.9.6.12.6.3	 	The ability to notify the care coordinator about key dates, e.g., TennCare
eligibility end date, date for annual level of care reassessment, date of needs
reassessment, and date for update to the plan of care;
	 
	 	2.9.6.12.6.4	 	The ability to capture and track eligibility/enrollment information, level of
care assessments and reassessments, and needs assessments and reassessments;
	 
	 	2.9.6.12.6.5	 	The ability to capture and monitor the plan of care;
	 
	 	2.9.6.12.6.6	 	The ability to track requested and approved service authorizations, including
covered long-term care services and any services provided as a cost-effective
alternative to other covered services;
	 
	 	2.9.6.12.6.7	 	The ability to document all referrals received by the care coordinator on
behalf of the member for covered long-term care services; home health and private
duty nursing services; other physical or behavioral health services needed to help
the member maintain or improve his or her physical or behavioral health status or
functional abilities and maximize independence; and other social support services and
assistance needed in order to ensure the member’s health, safety and welfare,

Page 126 of 374

 

	 	 	 	and as applicable, to delay or prevent the need for more expensive
institutional placement, including notes regarding how such referral was
handled by the care coordinator;
	 
	 	2.9.6.12.6.8	 	The ability to establish a schedule of services for each member which
identifies
the time at which each service is needed and the amount, frequency, duration
and scope of each service;
	 
	 	2.9.6.12.6.9	 	The ability to provide, via electronic interface with the electronic visit
verification system, service authorizations on behalf of a CHOICES member,
including the schedule at which each service is needed;
	 
	 	2.9.6.12.6.10	 	The ability to provide, via electronic interface with the FEA, referrals and
service authorizations;
	 
	 	2.9.6.12.6.11	 	The ability to track service delivery against authorized services and
providers;
	 
	 	2.9.6.12.6.12	 	The ability to track actions taken by the care coordinator to immediately
address service gaps; and
	 
	 	2.9.6.12.6.13	 	The ability to document case notes relevant to the provision of care coordination.

2.9.7 Consumer Direction of HCBS

	 	2.9.7.1	 	General

	 	2.9.7.1.1	 	The CONTRACTOR shall offer consumer direction of HCBS to all CHOICES Group 2 and 3
members who are determined by a care coordinator, through the needs
assessment/reassessment process, to need attendant care, personal care, homemaker,
in-home respite, companion care services and/or any other service specified in TennCare
rules and regulations as available for consumer direction. (Companion care is only
available for persons electing consumer direction of HCBS.) A service that is not
specified in TennCare rules and regulations as available for consumer direction shall
not be consumer directed. Consumer direction in CHOICES affords members the opportunity
to have choice and control over how eligible HCBS are provided, who provides the
services and how much workers are paid for providing care, up to a specified maximum
amount established by TENNCARE (see Section 2.9.7.6.11). Member participation in
consumer direction of HCBS is voluntary. Members may elect to participate in or withdraw
from consumer direction of HCBS at any time, service by service, without affecting their
enrollment in CHOICES. To the extent possible, the member shall provide his/her care
coordinator ten (10) days advance notice regarding his/her intent to no longer direct
one or more eligible HCBS or to withdraw from participation in consumer direction of
HCBS entirely. The CONTRACTOR shall respond to the member’s request in keeping with the
timeframes and processes set forth in this Section, in order to facilitate a seamless
transition to appropriate service delivery. TENNCARE shall establish reasonable
limitations on the frequency with which members may opt into and out of consumer
direction of HCBS.

Page 127 of 374

 

	 	2.9.7.1.2	 	Consumer direction is a process by which eligible HCBS are delivered; it is
not a service. If a member chooses not to direct his/her care, he/she shall receive
authorized HCBS through contract providers. While the denial of a member’s request to
participate in consumer direction or the termination of a member’s participation in
consumer direction gives rise to due process including the right to fair hearing,
such appeals shall be processed by the TennCare Division of Long Term Care rather
than the TennCare Solutions Units, which manages medical appeals pertaining to
TennCare benefits (i.e., services).
	 
	 	2.9.7.1.3	 	Members who participate in consumer direction of HCBS choose either to
serve as the employer of record of their workers or to designate a representative
(see definition below in Section 2.9.7.2.1) to serve as the employer of record on
his/her behalf. As the employer of record the member or his/her representative is
responsible for the following:
	 
	 	2.9.7.1.3.1	 	Hiring/Firing workers;
	 
	 	2.9.7.1.3.2	 	Determining workers’ duties and developing job descriptions;
	 
	 	2.9.7.1.3.3	 	Scheduling workers;
	 
	 	2.9.7.1.3.4	 	Supervising workers;
	 
	 	2.9.7.1.3.5	 	Evaluating worker performance and addressing any identified deficiencies or
concerns;
	 
	 	2.9.7.1.3.6	 	Setting wages up to a specified maximum amount established by TENNCARE;
	 
	 	2.9.7.1.3.7	 	Training workers to provide personalized care based on the member’s needs and
preferences;
	 
	 	2.9.7.1.3.8	 	Reviewing and approving timesheets;
	 
	 	2.9.7.1.3.9	 	Reviewing and ensuring proper documentation for services provided; and
	 
	 	2.9.7.1.3.10	 	Developing and activating as needed a back-up plan to address instances when a
scheduled worker does not show up.
	 
	 	2.9.7.1.3.10.1	 	The back-up plan developed by the member may include both paid and unpaid supports;
however, it is the responsibility of the member electing consumer direction and/or his/her
representative to secure paid (as well as unpaid) back-up staff who are willing and available
to serve in this capacity for consumer directed services. The CONTRACTOR shall not be expected
or required to maintain contract providers “on standby” to serve in a back-up capacity for
services a member has elected to receive through consumer direction. The member must make
arrangements for the provision of needed medical care and does not have the option of going
without needed services.
	 
	 	2.9.7.1.3.10.2	 	In some respects, the back-up plan for consumer direction is similar to the backup
plan that contract providers are obligated to maintain (i.e., to address instances where an
agency staff person does not show up). As the employer of record, the

Page 128 of 374

 

	 	 	 	member and/or representative have willingly taken on the responsibilities that
would otherwise be performed by the contract provider agency. However, the back-up
plan for consumer directed workers is more comprehensive in that it is intended to
facilitate the provision of needed care even when another paid worker is not
available and is thus comparable to and shall be integrated with the backup plan
which is part of the member’s plan of care and which also addresses (as applicable)
instances in which a contract provider is authorized to provide care and the
contract provider’s back-up plan fails. The CONTRACTOR shall assess the adequacy of
the back-up plan.
	 
	 	2.9.7.2	 	Representative
	 
	 	2.9.7.2.1	 	A member may designate, or have appointed by a guardian, a representative to assume the
consumer direction responsibilities on his/her behalf. A representative shall meet, at minimum
the following requirements: be at least 18 years of age, have a personal relationship with the
member and understand his/her support needs; know the member’s daily schedule and routine,
medical and functional status, medication regimen, likes and dislikes, and strengths and
weaknesses; and be physically present in the member’s residence on a regular basis or at least
at a frequency necessary to supervise and evaluate workers.
	 
	 	2.9.7.2.2	 	In order to participate in consumer direction of HCBS with the assistance of a
representative, one of the following must apply: (1) the member must have the ability to
designate a person to serve as his/her representative or (2) the member has a legally
appointed representative who may serve as the member’s representative.
	 
	 	2.9.7.2.3	 	The care coordinator shall determine if the member requires assistance in carrying out
the responsibilities required for consumer direction and therefore requires a representative.
The member’s care coordinator/care coordination team shall verify that a representative meets
the qualifications as described in Section 2.9.7.2.1 above.
	 
	 	2.9.7.2.4	 	A member’s representative shall not receive payment for serving in this capacity and
shall not serve as the member’s worker for any consumer directed service. The CONTRACTOR shall
use a representative agreement developed by TENNCARE to document a member’s choice of a
representative for consumer direction of HCBS and the representative’s contact information,
and to confirm the individual’s agreement to serve as the representative and to accept the
responsibilities and perform the associated duties defined therein. Ongoing, the fiscal
employer agent (FEA) shall notify the CONTRACTOR within one (1) business day when it becomes
aware of any changes to a representative’s contact information. Conversely, the CONTRACTOR
shall notify the FEA within one (1) business day when it becomes aware of any changes to a
representative’s contact information.
	 
	 	2.9.7.2.5	 	The representative agreement shall be signed by the member (or person authorized to sign
on member’s behalf which shall not also be the representative for consumer direction) and the
representative in the presence of the care coordinator. The care coordinator shall include the
representative agreement in the member’s file and provide copies to the member and/or the
member’s representative and the FEA (see Section 2.9.7.3 below).

Page 129 of 374

 

	 	2.9.7.2.6	 	A member may change his/her representative
at any time. To the extent possible, the member
shall notify his/her care coordinator ten (10) days
in advance of initiating a change in
representatives. The CONTRACTOR shall respond to the
member’s request in keeping with the timeframes and
processes set forth in this Section, in order to
facilitate a seamless transition to a new
representative. TENNCARE shall establish reasonable
limitations on the frequency with which members may
change representatives. In the event a member’s
representative is unexpectedly no longer willing or
able to fulfill the consumer direction functions on
behalf of the member, the CONTRACTOR shall, as soon
as possible, work with the member to find an
alternate representative.
	 
	 	2.9.7.2.7	 	The member’s care coordinator/care
coordination team shall verify that the new
representative meets the qualifications as described
in Section 2.9.7.2.1 above. A new representative
agreement shall be completed and signed, in the
presence of a care coordinator, prior to the new
representative assuming the respective
responsibilities. The member’s care coordinator/care
coordination team shall immediately notify the FEA
when a member changes his/her representative and
provide a copy of the representative agreement. The
CONTRACTOR shall facilitate a seamless transition to
the new representative, and ensure that there are no
interruptions or gaps in services. As part of the
needs assessment and plan of care process, the care
coordinator shall educate the member about the
importance of notifying the care coordinator prior
to changing a representative.

	 
	 	2.9.7.2.8	 	The FEA shall ensure that the new
representative signs all service agreements (see
Section 2.9.7.6.6).
	 
	 	2.9.7.3	 	Fiscal Employer Agent (FEA)
	 
	 	2.9.7.3.1	 	The CONTRACTOR shall enter into a subcontract with the FEA specified by TENNCARE to
provide assistance to members choosing consumer direction.
	 
	 	2.9.7.3.2	 	The FEA shall fulfill, at a minimum, the following financial administrative and supports
broker functions for all CHOICES members electing consumer direction of HCBS:
	 
	 	2.9.7.3.2.1	 	Assign a supports broker to each CHOICES member electing to participate in
consumer direction of HCBS;
	 
	 	2.9.7.3.2.2	 	Assist in identifying and addressing in the risk assessment and planning
processes any additional risk associated with receiving consumer directed services;
	 
	 	2.9.7.3.2.3	 	Provide initial and ongoing training to members and their representatives (as
applicable) on consumer direction and other relevant issues (see Section 2.9.7.7 of
this Agreement);
	 
	 	2.9.7.3.2.4	 	Verify worker qualifications, including, as specified by TENNCARE, conduct
background checks on workers, enroll workers into Medicaid, assign provider
Medicaid ID numbers, and hold Medicaid provider agreements (see Section 2.9.7.6.1
of this Agreement);

Page 130 of 374

 

	 	2.9.7.3.2.5	 	Provide initial and ongoing training to workers on consumer direction and
other relevant issues (see Section 2.9.7.7 of this Agreement);

	 	2.9.7.3.2.6	 	Assist the member and/or representative in developing and updating service
agreements (see Section 2.9.7.6.6);
	 
	 	2.9.7.3.2.7	 	Receive, review and process timesheets;
	 
	 	2.9.7.3.2.8	 	Resolve timesheet discrepancies;
	 
	 	2.9.7.3.2.9	 	Obtain documentation from the member and/or representative to ensure that
services were provided prior to payment of timesheets;

	 	2.9.7.3.2.10	 	Withhold, file and pay applicable: federal, state and local income taxes;
employment and unemployment taxes; and worker’s compensation;

	 	2.9.7.3.2.11	 	Pay workers for services rendered;

	 	2.9.7.3.2.12	 	Facilitate resolution of any disputes regarding payment to workers for services
rendered;

	 	2.9.7.3.2.13	 	Monitor quality of services provided by workers; and

	 	2.9.7.3.2.14	 	Report to the CONTRACTOR on worker and/or staff identification of, response to,
participation in and/or investigation of critical incidents (see Section 2.15.8).

	 	2.9.7.3.3	 	The FEA shall also fulfill, at a minimum, the following financial administrative and
supports broker functions for CHOICES members electing consumer direction of HCBS on an as needed
basis:
	 
	 	2.9.7.3.3.1	 	Assist the member and/or representative in developing job descriptions;
	 
	 	2.9.7.3.3.2	 	Assist the member and/or representative in locating and recruiting workers;

	 	2.9.7.3.3.3	 	Assist the member and/or representative in interviewing workers (developing
questions, evaluating responses);

	 	2.9.7.3.3.4	 	Assist the member and/or representative in scheduling workers;

	 	2.9.7.3.3.5	 	Assist the member and/or representative in managing and monitoring payments
to workers; and
	 
	 	2.9.7.3.3.6	 	Assist the member and/or representative in monitoring and evaluating the
performance of workers.

	 	2.9.7.3.4	 	The CONTRACTOR’s care coordination functions shall not duplicate the supports broker
functions performed by the FEA or its subcontractor. A member’s care coordinator shall work
with and coordinate with a member’s supports broker in implementing and monitoring consumer
direction.

Page 131 of  374

 

	 	2.9.7.3.5	 	The CONTRACTOR’s subcontract with the FEA shall include the provisions
specified by TENNCARE in the model FEA subcontract. The subcontract shall specify at a
minimum the functions noted in Section 2.9.7.3.2 through 2.9.7.3.3. above (or a
reference to the functions); the FEA’s responsibilities for communicating with the
CONTRACTOR, members and workers; customer service requirements; processes and
timeframes for authorizations of consumer directed services; processes and timeframes
for service initiation; requirements and timeframes for processing employee payroll;
process and requirements for billing; systems requirements and information exchange
requirements; requirements for notifying MCO regarding readiness to initiate consumer
direction of HCBS for a member; role and responsibility for training staff,
contractors, members, representatives and workers regarding abuse and neglect plan
protocols as described in Section 2.24.4.3 of this Agreement; and role and
responsibility for critical incident reporting and management (see Section 2.15.8.4.6
of this Agreement).

	 	2.9.7.3.6	 	The CONTRACTOR in collaboration with the FEA shall establish a process that allows for
the efficient exchange of all relevant member information between the CONTRACTOR and the FEA.

	 	2.9.7.3.7	 	The CONTRACTOR and FEA shall develop a protocol for interfaces and transfers of customer
service inquiries per the requirements of Section 2.18 of this Agreement.

	 	2.9.7.3.8	 	The CONTRACTOR shall provide to the FEA copies of all relevant initial and updated member
documents, including at a minimum, plans of care, representative agreements and risk
agreements. The CONTRACTOR shall provide to the FEA all relevant documentation prior to
service delivery.

	 	2.9.7.4	 	Needs Assessment/Plan of Care Process

	 	2.9.7.4.1	 	A CHOICES member may choose to direct needed eligible HCBS at anytime: during CHOICES
intake, through the needs assessment/reassessment and plan of care and plan of care update
processes; and outside of these processes. The care coordinator shall assess the member’s
needs for eligible HCBS per requirements in Sections 2.9.6.2.4, 2.9.6.3 and 2.9.6.5, as
applicable. The care coordinator shall use the plan of care process (including updates) to
identify the eligible services that the member will direct and to facilitate the member’s
enrollment in consumer direction of HCBS.

	 	2.9.7.4.2	 	The CONTRACTOR shall obtain written confirmation of the member’s decision to participate
in consumer direction of HCBS.

	 	2.9.7.4.2.1	 	The care coordinator shall assist the member in identifying which of the needed
eligible HCBS shall be consumer directed, provided by contract providers or a
combination of both, in which case, there must be a set schedule which clearly
defines when contract providers will be utilized. The CONTRACTOR shall not be
expected or required to maintain contract providers “on standby” to serve in a
back-up capacity for services a member has elected to receive through consumer
direction.

	 	2.9.7.4.3	 	If the member intends to direct one or more needed eligible HCBS, throughout the period
of time that consumer direction is being initiated, the CONTRACTOR shall arrange for the
provision of needed HCBS through contract providers in accordance

Page 132 of  374

 

	 	 	 	with 2.9.6. The care coordinator shall obtain from the member his/her choice of
contract providers who will provide HCBS until such time as workers are secured and
ready to begin delivering care through consumer direction,.

	 	2.9.7.4.3.1	 	If a member has been assessed to need companion care services, the CONTRACTOR
shall identify non-residential services that will offer interim support to address the
member’s needs and assist the member in obtaining contract providers for these
services.

	 	2.9.7.4.4	 	The CONTRACTOR shall be responsible for providing all needed eligible HCBS using contract
providers until all necessary requirements have been fulfilled in order to implement consumer
direction of HCBS, including but not limited to: the FEA verifies that workers for these
services meet all necessary requirements (see Section 2.9.7.6.1 of this Agreement); service
agreements are completed and signed; and authorizations for consumer directed services are in
place. The CONTRACTOR, in conjunction with the FEA, shall facilitate a seamless transition
between contract providers and workers and ensure that there are no interruptions or gaps in
services.

	 	2.9.7.4.5	 	The care coordinator shall determine if the member will appoint a representative to
assume the consumer direction functions on his/her behalf (see Section 2.9.7.6.1 of this
Agreement). If the member does not intend to appoint a representative, the care coordinator
shall determine the extent to which a member requires assistance to participate in consumer
direction of HCBS, based upon the results of the member’s responses to the self-assessment
instrument developed by TENNCARE. The self- assessment instrument shall be completed by the
member with assistance from the member’s care coordinator as appropriate. The care coordinator
shall file the completed self-assessment in the member’s file.

	 	2.9.7.4.5.1	 	If, based on the results of the self-assessment, the care coordinator determines
that a member requires assistance to direct his/her services, and the member has not
already designated a representative to assume the consumer direction functions, the
care coordinator shall inform the member that he/she will need to designate a
representative to assume the consumer direction functions on his/her behalf.

	 	2.9.7.4.5.2	 	The CONTRACTOR shall forward to TENNCARE for disposition, pursuant to TennCare
policy, any cases in which the CONTRACTOR plans to deny participation in consumer
direction because a care coordinator has determined that the health, safety and welfare
of the member would be in jeopardy if the member participates in consumer direction
without a representative but the member does not want to appoint a representative to
assist in directing his/her services. The CONTRACTOR shall abide by TENNCARE’s
decision.

	 	2.9.7.4.6	 	The member’s care coordinator/care coordination team shall ensure that the person
identified to serve as the representative meets all qualifications (see Section 2.9.7.2.1 of
this Agreement) and that a representative agreement is completed and signed by the member and
the person prior to forwarding a referral to the FEA (see Section 2.9.7.4.7 below).

	 	2.9.7.4.7	 	Within two (2) business days of signing the representative agreement, the CONTRACTOR
shall forward to the FEA a referral initiating the member’s

Page 133 of  374

 

	 	 	 	participation in consumer direction of HCBS. The referral shall include at a minimum:
the date of the referral; the member’s name, address, telephone number, social security
number; the name of the representative and telephone number, if applicable, (if known
at the time) and social security number; member TennCare ID number; member’s CHOICES
enrollment date; eligible selected HCBS, including amount, frequency and duration of
each; and care coordinator name and contact information. The CONTRACTOR shall also
forward to the FEA a copy of the written confirmation of the member’s decision to
participate in consumer direction of HCBS.

	 	2.9.7.4.8	 	Within two (2) business days of receipt of the referral, the FEA shall assign a supports
broker to the member and shall notify the care coordinator of the assignment.

	 	2.9.7.4.9	 	Within five (5) days of receipt of the referral, the FEA shall contact the member to
inform the member of his/her assigned supports broker, provide contact information for the
supports broker, and to begin the process of initiating consumer direction of HCBS.

	 	2.9.7.4.10	 	The care coordinator, in conjunction with the FEA, shall assist the member and/or the
representative as needed in developing a back-up plan for consumer direction that adequately
identifies how the member will address situations when a scheduled worker fails to show up.
The member and his/her representative (as applicable) shall have primary responsibility for
the development of the back-up plan for consumer directed services. The back-up plan shall
include the names and telephone numbers of contacts for alternate care, the order in which
contact shall be made and the services to be provided by contacts. Back-up workers may include
paid and non-paid supports; however, it is the responsibility of the member electing consumer
direction and/or his/her representative to secure paid (as well as unpaid) back-up staff who
are willing and available to serve in this capacity. The CONTRACTOR shall not be expected or
required to maintain contract providers “on standby” to serve in a backup capacity for
services a member has elected to receive through consumer direction. All persons and/or
organizations noted in back-up plan for consumer directed services shall first be contacted by
the member and/or representative to determine their willingness and availability to serve as
back-up workers. The care coordinator shall follow-up with these persons and/or organizations
to confirm their willingness and availability to provide care when needed. The CONTRACTOR
shall give a copy of the back-up plan, and any updates, to the FEA.

	 	2.9.7.4.11	 	The care coordinator, with assistance from the FEA, shall assist the member and/or the
representative in reviewing and updating the risk agreement (as prescribed in Section
2.9.6.9.2.1.10 of this Agreement) in order to ensure that any additional risks associated with
the member’s decision to direct his/her services are taken into consideration and that
additional measures to mitigate these risks are identified. The representative (if applicable)
shall participate in the process. The updated risk
agreement shall be signed by the care coordinator and the member (or the member’s
representative). A copy of the risk agreement shall be given to the member or the
member’s representative and the FEA. The FEA and care coordinator shall file a copy of
the updated risk assessment in the member’s files.

Page 134 of  374

 

	 	2.9.7.4.12	 	On an ongoing basis, the CONTRACTOR shall ensure that needs reassessments
and updates to the plan of care occur per requirements specified in Sections 2.9.6.9 of
this Agreement. The care coordinator shall ensure that the member’s supports broker is
invited to participate in these meetings.

	 	2.9.7.5	 	Authorizations for Consumer Directed Services and Service Initiation

	 	2.9.7.5.1	 	Consumer direction of HCBS shall not be initiated until all requirements are fulfilled
including but not limited to the following: (1) the FEA verifies that the member’s
employer and related documentation is in order; (2) the FEA verifies that workers meet
all qualifications, including participation in required training; (3) there is a signed
service agreement specific to each individual worker (see Section 2.9.7.6.7 of this
Agreement); and (4) the CONTRACTOR issues to the FEA an authorization for consumer
directed services (see 2.9.7.5.6 below) for each service.

	 	2.9.7.5.2	 	The FEA shall work with the member to determine the appropriate level of assistance
necessary to recruit, interview and hire workers and provide the assistance.

	 	2.9.7.5.3	 	Once potential workers are identified, the FEA shall verify that a potential worker meets
all applicable qualifications (see Section 2.9.7.6.1 of this Agreement).

	 	2.9.7.5.4	 	The FEA shall ensure that a service agreement is signed between the member or member’s
representative and his/her worker within five (5) business days following the FEA’s
verification that a worker meets all qualifications.

	 	2.9.7.5.5	 	Within ten (10) days of receipt of the referral and every ten (10) days thereafter, the
FEA shall update the care coordinator of the status of completing required functions necessary
to initiate consumer direction, including obtaining workers for each identified consumer
directed service and anticipated timeframes by which qualified workers shall be secured and
consumer directed services may begin.

	 	2.9.7.5.6	 	The provision of consumer directed services shall begin as soon as possible but no longer
than sixty (60) days from the date of the CONTRACTOR’s referral to the FEA. Prior to beginning
the provision of consumer directed services, the FEA shall notify the CONTRACTOR that all
requirements have been fulfilled, and the date that consumer directed services can begin.
Within two (2) business days of receipt of the notification from the FEA, the CONTRACTOR shall
forward to the FEA an authorization for consumer directed services. Each authorization for
consumer
directed services shall include the required elements for a referral (see Section
2.9.7.4.7 of this Agreement) including: authorized service, authorized units of
service, including amount, frequency and duration, start and end dates, and service
code.

	 	2.9.7.5.7	 	If initiation of consumer directed services does not begin within sixty (60) days from
the date of the CONTRACTOR’s referral to the FEA, the FEA shall contact the CONTRACTOR
regarding the cause of the delay. The CONTRACTOR shall determine the appropriate next steps,
including but not limited to whether an extension is warranted or if the member is still
interested in participating in consumer direction of HCBS.

Page 135 of  374

 

	 	2.9.7.5.8	 	Upon the scheduled start date of consumer directed services, the member’s
care coordinator/care coordination team shall begin monitoring to ensure that services
have been initiated and continue to be provided as authorized. This shall include
ongoing monitoring via electronic visit verification to ensure that services are
provided in accordance with the member’s plan of care, including the amount, frequency,
duration and scope of each service, in accordance with the member’s service schedule.
Upon the identification of any gaps in care, the member’s care coordinator/care
coordination team shall contact the FEA who will be responsible for assisting the
member or his/her representative as needed in activating the member’s back-up plan for
consumer direction.

	 	2.9.7.5.9	 	Within five (5) business days of the scheduled start date of consumer directed services
as specified in the authorization of consumer directed services a member of the care
coordinator team shall contact the member or his/her representative to confirm that services
are being provided and that the member’s needs are being met.

	 	2.9.7.5.10	 	On an ongoing basis, in addition to requirements specified above in 2.9.7.5.3 –
2.9.7.5.7 above:

	 	2.9.7.5.10.1	 	The CONTRACTOR shall develop and forward to the FEA a new authorization
for consumer directed services when the following occur: a change in the number of
service units, or the frequency or duration of service delivery; or a change in the
services to be provided through consumer direction, including the provision of a
new service through consumer direction or termination of a service through consumer
direction.

	 	2.9.7.6	 	Worker Qualifications

	 	2.9.7.6.1	 	The FEA shall ensure that workers meet all requirements prior to the worker providing
services. The FEA shall ensure that workers: meet all TennCare established requirements for
providers of comparable, non-consumer directed services; pass a background check which
includes criminal background check (including fingerprinting), or, as an alternative, a
background check from a licensed private investigation company, verification that the person’s
name does not appear on the State abuse registry, verification that the person’s name does not
appear on the state and national sexual offender registries and licensure verification, as
applicable; complete all required training, including the training specified in Section
2.9.7.7 of this Agreement; complete all required applications to become a TennCare provider;
sign the TennCare provider agreement; and are assigned a Medicaid provider ID number.

	 	2.9.7.6.1.1	 	A member cannot waive a background check for a potential worker. The
following findings shall disqualify a person from serving as a worker:
	 
	 	2.9.7.6.1.1.1	 	Conviction of an offense involving physical, sexual or emotional abuse, neglect,
financial exploitation or misuse of funds, misappropriation of property, theft from
any person, violence against any person, or manufacture, sale, possession or
distribution of any drug;

Page 136 of  374

 

	 	2.9.7.6.1.1.2	 	Entering of a plea of nolo contendere or when a jury verdict of guilty is rendered
but adjudication of guilt is withheld with respect to a crime reasonably related to
the nature of the position sought or held;

	 	2.9.7.6.1.1.3	 	Identification on the abuse registry;
	 
	 	2.9.7.6.1.1.4	 	Identification on the state or national sexual offender registry;

	 	2.9.7.6.1.1.5	 	Failure to have a required license; and
	 
	 	2.9.7.6.1.1.6	 	Refusal to cooperate with a background check.
	 
	 	2.9.7.6.1.2	 	In certain instances a member may choose to hire a worker that fails a
background check. Exceptions to disqualification may be granted at the member’s
discretion and only if all of the following conditions are met:

	 	2.9.7.6.1.2.1	 	Offense is a misdemeanor;
	 
	 	2.9.7.6.1.2.2	 	Offense occurred more than five (5) years ago;
	 
	 	2.9.7.6.1.2.3	 	Offense is not related to physical or sexual or emotional abuse of another person;
	 
	 	2.9.7.6.1.2.4	 	Offense does not involve violence against another person or
the manufacture, sale, or distribution of drugs; and
	 
	 	2.9.7.6.1.2.5	 	There is only one disqualifying offense.

	 	2.9.7.6.2	 	The FEA shall make the decision regarding exceptions to disqualification. In the
event a member chooses to hire a worker that has failed a background check but has met
all of the conditions for an exception to disqualification and the FEA has granted the
exception, the FEA shall notify the care coordinator prior to initiation of services
provided by that worker.

	 	2.9.7.6.3	 	Workers are not required to be contract providers. The CONTRACTOR shall not require a
worker to sign a provider agreement or any other agreement not specified by TENNCARE.
	 
	 	2.9.7.6.4	 	Members shall have the flexibility to hire persons with whom they have a close
personal relationship to serve as a worker, such as a neighbor or a friend.

	 	2.9.7.6.5	 	Members may hire family members, excluding spouses, to serve as a worker. A family member
shall not be reimbursed for a service that he/she would have otherwise provided without pay.
The CONTRACTOR shall use the needs assessment process (Section 2.9.6.5) to assess the member’s
available existing supports, including supports provided by family members.

	 	2.9.7.6.6	 	A member may have multiple workers or both a worker and a contract provider for a given
service, in which case, there must be a set schedule which clearly defines when contract
providers will be utilized. A member may elect to have a worker provide more than one service.

Page 137 of  374

 

	 	2.9.7.6.7	 	A member shall develop a service agreement with each worker. The service
agreement template shall be developed by TENNCARE and shall include, at a minimum: the
roles and responsibilities of the worker and the member; the worker’s schedule (as
developed by the member and/or representative), including hours and days; the scope of
each service, i.e., the specific tasks and functions the worker is to perform; the
service rate; and the requested start date for services. The service agreement shall
serve as the worker’s written confirmation of his/her commitment to initiate services
on or before the date specified and to provide services in accordance with specified
terms (including the tasks and functions to be performed and the schedule at which care
is needed). If necessary, the FEA shall assist in this process. Service agreements
shall be updated anytime there is a change in any of the terms or conditions specified
in the agreement. Service agreements shall be signed by the new representative when
there is a change in representatives.

	 	2.9.7.6.8	 	The service agreement shall also stipulate if a worker will provide one or more self-
directed health care tasks, the specific task(s) to be performed, and the frequency of each
self-directed health care task (see Section 2.7 3).

	 	2.9.7.6.9	 	The FEA shall ensure that a service agreement is in place for each worker prior to the
worker providing services.

	 	2.9.7.6.10	 	A copy of each service agreement shall be provided to the member and/or representative.
The FEA shall give a copy of the service agreement to the worker and shall maintain a copy for
its files.

	 	2.9.7.6.11	 	A member may terminate a worker at any time if he/she feels that the worker is not
adhering to the terms of the service agreement and/or is not providing quality services. If
the FEA or care coordinator has concerns that a worker is unable to deliver appropriate care
as prescribed in the service agreement and the plan of care, but the member and/or
representative chooses to continue to employ the worker, the care coordinator shall note the
concern and the member’s choice to continue using the worker in the member’s plan of care, and
shall update the risk assessment and/or risk agreement as needed. The FEA and care coordinator
shall collaborate to develop strategies to address identified issues and concerns. The FEA
shall inform the member and/or representative of any potential risks associated with
continuing to use the worker. The CONTRACTOR shall forward to TENNCARE for disposition,
pursuant to TennCare policy, any cases in which the CONTRACTOR plans to disenroll the member
from consumer direction because a care coordinator has determined that the health, safety and
welfare of the member may be in jeopardy if the member continues to employ a worker but the
member and/or representative does not want to terminate the worker. The CONTRACTOR and FEA
shall abide by TENNCARE’s decision.

	 	2.9.7.6.12	 	A member shall have the flexibility to choose from a range of TENNCARE specified
reimbursement levels for all eligible consumer directed HCBS, excluding companion care
services which shall be reimbursed at the rate specified by TENNCARE.

	 	2.9.7.6.13	 	In order to receive payment for services rendered, all workers must:

	 	2.9.7.6.13.1	 	Submit to the member and the FEA planned work schedules two weeks in
advance and when billing. The FEA shall input schedules into the EVV; and

Page 138 of  374

 

	 	2.9.7.6.13.2	 	Maintain and submit timesheets and documentation of service delivery (i.e.,
documentation of the tasks and functions performed during the provision of
services), and any other documentation, as required, for units of service
delivered; and

	 	2.9.7.6.13.3	 	Provide no more than forty (40) hours of services within a consecutive seven (7)
day period, with the following exceptions:

	 	2.9.7.6.13.3.1	 	The worker provides companion care services; or

	 	2.9.7.6.13.3.2	 	The worker serves as a back-up worker during this period, in which case payment
shall be at the established rate, with no overtime pay, in accordance with applicable labor
law. The FEA shall monitor the frequency of instances in which a worker provides more than
forty (40) hours of service within a consecutive seven day period for this reason, and shall
work with the member and/or representative to develop an adequate supply of reliable workers.

	 	2.9.7.6.13.4	 	The FEA shall enter worker schedules into the EVV, but may delegate this
responsibility to the member and/or representative when appropriate.

	 	2.9.7.7	 	Training

	 	2.9.7.7.1	 	The CONTRACTOR shall require all members electing to enroll in consumer direction of HCBS
and/or their representatives to receive relevant training prior to service initiation. The FEA
shall be responsible for providing or arranging for the training. When training is not
directly provided by the FEA, the FEA shall validate completion of training.

	 	2.9.7.7.2	 	At a minimum, consumer direction training for members and/or representatives shall
address the following issues:

	 	2.9.7.7.2.1	 	Understanding the role of members and representatives in consumer direction;
	 
	 	2.9.7.7.2.2	 	Understanding the role of the care coordinator and the FEA;
	 
	 	2.9.7.7.2.3	 	Selecting workers;
	 
	 	2.9.7.7.2.4	 	Abuse and neglect identification and reporting;
	 
	 	2.9.7.7.2.5	 	Being an employer, evaluating worker performance and managing employees;
	 
	 	2.9.7.7.2.6	 	Fraud and abuse;
	 
	 	2.9.7.7.2.7	 	Performing administrative tasks such as reviewing and approving time sheets;
and
	 
	 	2.9.7.7.2.8	 	Scheduling workers and back-up planning.

Page 139 of  374

 

	 	2.9.7.7.3	 	Ongoing training shall be provided by the FEA to members and/or
representatives upon request and/or if a care coordinator or FEA, through monitoring,
determines that additional training is warranted.

	 	2.9.7.7.4	 	The FEA shall be responsible for providing or arranging for the training of all workers
prior to service initiation. When training is not directly provided by the FEA, the FEA shall
validate completion of training. At a minimum, training shall consist of the following
required elements:

	 	2.9.7.7.4.1	 	Overview of the CHOICES program and consumer direction of HCBS;
	 
	 	2.9.7.7.4.2	 	Caring for elderly and disabled populations;
	 
	 	2.9.7.7.4.3	 	Abuse and neglect identification and reporting;
	 
	 	2.9.7.7.4.4	 	CPR and first aid certification;
	 
	 	2.9.7.7.4.5	 	Critical incident reporting;
	 
	 	2.9.7.7.4.6	 	Submission of timesheets, required documentation and withholdings;
	 
	 	2.9.7.7.4.7	 	EVV system functionality, requirements and how to use; and
	 
	 	2.9.7.7.4.8	 	As appropriate, administration of self-directed health care task(s).

	 	2.9.7.7.5	 	The member or representative, with assistance of the FEA, shall determine to what extent
the member or representative shall be involved in the above-specified training, except that
the member or representative must direct training regarding the administration of
self-directed health care tasks.

	 	2.9.7.7.6	 	In addition to the training noted above in 2.9.7.7.4.1 – 2.9.7.7.4.8, the member shall
provide training to the worker regarding individualized service needs and preference.

	 	2.9.7.7.7	 	The FEA shall verify that workers have successfully completed all required training prior
to service initiation and payment for services.

	 	2.9.7.7.8	 	Ongoing, the FEA shall ensure that workers maintain CPR and first aid certification and
receive required refresher training as a condition of continued employment and shall arrange
for the appropriate training. Additional training components may be provided to a worker to
address issues identified by the FEA, care coordinator, member and/or the representative or at
the request of the worker.

	 	2.9.7.7.9	 	Refresher training may be provided more frequently if determined necessary by the FEA,
care coordinator, member and/or representative or at the request of the worker.

	 	2.9.7.8	 	Monitoring

	 	2.9.7.8.1	 	The FEA shall conduct semi-annual face-to-face visits in the member’s place of
residence and conduct monthly phone contacts. These visits and contacts shall
supplement and not supplant the minimum care coordinator contacts. The FEA shall use
these visits to monitor the quality of service delivery including:

Page 140 of  374

 

	 	2.9.7.8.1.1	 	Identifying any service delivery issues;
	 
	 	2.9.7.8.1.2	 	Determining the adequacy and appropriateness of documentation of service
delivery; and
	 
	 	2.9.7.8.1.3	 	Determining the efficacy of back-up plans and processes.
	 
	 	2.9.7.8.2	 	At a minimum, the FEA shall conduct the following additional monitoring activities:
	 
	 	2.9.7.8.2.1	 	Quarterly reviews of expenditures for each member; and

	 	2.9.7.8.2.2	 	Monthly reviews of hours billed for services across all members, by each worker.

	 	2.9.7.8.3	 	The CONTRACTOR shall monitor a member’s participation in consumer direction of HCBS to
determine, at a minimum, the success and the viability of the service delivery model for the
member. The CONTRACTOR shall note any patterns, such as frequent turnover of representatives
and changing between consumer direction of HCBS and contract providers that may warrant
intervention by the CONTRACTOR. The CONTRACTOR may submit a request to TENNCARE, pursuant to
TennCare policy, to involuntarily withdraw the member from consumer direction of HCBS if the
CONTRACTOR has concerns about its ability to protect the health, safety and welfare of the
member (see Section 2.9.7.8.5).

	 	2.9.7.8.4	 	If at any time the care coordinator or FEA suspects abuse or neglect on the part of the
representative or worker, the care coordinator and/or FEA shall report the allegations to the
CONTRACTOR. The CONTRACTOR shall report the representative and/or worker to APS. The
representative and/or worker shall immediately be released from his/her duties until the APS
investigation is complete. The care coordinator shall work with the member to find a new
representative, and the FEA shall work with the member to find a suitable replacement worker.
If the allegations are substantiated as a result of the APS investigation, the representative
and/or worker shall no longer be allowed to participate in the CHOICES program in any
capacity.

	 	2.9.7.8.5	 	In the event the CONTRACTOR believes that it cannot safely and effectively serve
the member in the community, the care coordinator, with the assistance of and input
from the FEA, shall review with the member the previously developed risk agreement and
update it to ensure that any additional identified risks are incorporated and measures
are identified to mitigate risks. The representative (if applicable) shall participate
in the process. The updated risk assessment shall be signed by the member or
representative and the care coordinator. A copy shall be given to the member or
representative. The member’s care coordinator/care coordination team and the FEA shall
file a copy in the member’s files. If the CONTRACTOR does not believe the member can be
safely and effectively served in the community directing his/her services, the
CONTRACTOR may request to involuntarily withdraw the member from consumer direction of
HCBS, pursuant to TennCare policy (see Section 2.9.7.9 below).

Page 141 of  374

 

	 	2.9.7.9	 	Withdrawal from Consumer Direction of HCBS

	 	2.9.7.9.1	 	A member may voluntarily withdraw from consumer direction of HCBS at any time. The member
and/or representative shall notify the care coordinator as soon as he/she determines that
he/she is no longer interested in participating in consumer direction of HCBS.

	 	2.9.7.9.2	 	Upon receipt of a member’s request to withdraw from consumer direction of HCBS, the
CONTRACTOR shall conduct a face-to-face visit and update the member’s plan of care, as
appropriate, to initiate the process to transition the member to contract providers.

	 	2.9.7.9.3	 	The CONTRACTOR may initiate involuntary withdrawal of a member from consumer direction of
HCBS:

	 	2.9.7.9.3.1	 	If a member’s representative fails to perform in accordance with the terms of the
representative agreement and the health, safety and welfare of the member is at
risk, and the member wants to continue to use the representative.

	 	2.9.7.9.3.2	 	If a member has consistently demonstrated that he/she is unable to manage, with
sufficient supports (including appointment of a representative) his/her services
and the care coordinator or FEA has identified health, safety and/or welfare
issues.

	 	2.9.7.9.3.3	 	A care coordinator has determined that the health, safety and welfare of the
member may be in jeopardy if the member continues to employ a worker but the member
and/or representative does not want to terminate the worker.

	 	2.9.7.9.3.4	 	Other significant concerns regarding the member’s participation in consumer
direction which jeopardize the health, safety or welfare of the member.

	 	2.9.7.9.4	 	The CONTRACTOR shall forward to TENNCARE, pursuant to TennCare policy, a request to
involuntarily withdraw a member from consumer direction of HCBS. The request shall include the
reasons for withdrawing the member and the measures taken by the CONTRACTOR and/or the FEA to
address identified issues.

	 	2.9.7.9.5	 	If TENNCARE approves the CONTRACTOR’s request, the CONTRACTOR shall notify the member in
accordance with TennCare rules and regulations, and the member shall have the right to appeal
the determination (see Section 2.19.3.1 2of this Agreement). Upon notification or the
resolution of a timely filed appeal, the CONTRACTOR, in conjunction with the FEA, shall
facilitate a seamless transition from workers to contract providers, with no interruptions or
gaps in services.

	 	2.9.7.9.6	 	Voluntary or involuntary withdrawal of a member from consumer direction of HCBS shall not
affect a member’s eligibility for long-term care services or enrollment in CHOICES.

	 	2.9.7.9.7	 	Members who have been involuntarily withdrawn may request to be reinstated in consumer
direction of HCBS. The care coordinator shall work with the FEA to ensure that the issues
previously identified as reasons for withdrawal have been adequately addressed prior to
reinstatement. All members shall be required to

Page 142 of  374

 

	 	 	 	participate in consumer direction training programs prior to re-instatement in
consumer direction of HCBS.

2.9.8 Coordination and Collaboration for Members with Behavioral Health Needs

	 	2.9.8.1	 	General 

	 	 	 	As provided in Section 2.6.1 of this Agreement, the CONTRACTOR shall be
responsible for providing a full continuum of physical health, behavioral
health, and long-term care services. The CONTRACTOR shall also be responsible
for ensuring continuity and coordination between covered physical health,
behavioral health, and long-term care services and ensuring collaboration
between physical health, behavioral health, and long-term care providers. The
CONTRACTOR shall develop policies and procedures that address key elements in
meeting this requirement. These elements include, but are not limited to,
screening for behavioral health needs (including the screening tool), referral
to physical health, behavioral health, and long-term care providers, exchange of
information, confidentiality, assessment, treatment plan and plan of care
development and implementation, collaboration, MCO case management, care
coordination (for CHOICES members) and disease management, provider training,
and monitoring implementation and outcomes.

	 	2.9.8.2	 	Subcontracting for Behavioral Health Services

	 	 	 	If the CONTRACTOR subcontracts for the provision of behavioral health services,
the CONTRACTOR shall develop and implement a written agreement with the
subcontractor regarding the coordination of services provided by the CONTRACTOR
and those provided by the subcontractor. The agreement shall address the
responsibilities of the CONTRACTOR and the subcontractor regarding, at a
minimum, the items identified in Section 2.9.8.2 as well as prior authorization,
claims payment, claims resolution, contract disputes, and reporting. The
subcontract shall comply with all of the requirements regarding subcontracts
included in Section 2.26 of this Agreement.

	 	2.9.8.3	 	Screening for Behavioral Health Needs

	 	2.9.8.3.1	 	The CONTRACTOR shall ensure that the need for behavioral health services is
systematically identified by and addressed by the member’s PCP at the earliest possible
time following initial enrollment of the member in the CONTRACTOR’s MCO or after the
onset of a condition requiring mental health and/or substance abuse treatment.

	 	2.9.8.3.2	 	The CONTRACTOR shall encourage PCPs and other providers to use a screening tool
prior approved in writing by the State as well as other mechanisms to facilitate early
identification of behavioral health needs.

	 	2.9.8.3.3	 	As part of the care coordination process (see Section 2.9.6), the CONTRACTOR shall
ensure that behavioral health needs of CHOICES members are identified and addressed.

Page 143 of  374

 

	 	2.9.8.4	 	Referrals to Behavioral Health Providers

	 	 	 	The CONTRACTOR shall ensure through screening that members with a need for behavioral
health services, particularly members with SED/SPMI are appropriately referred to
behavioral health providers. The CONTRACTOR shall develop provider education and
training materials to ensure that physical health and long-term care providers know
when and how to refer members who need specialty behavioral health services. This shall
include education about behavioral health services, including the recovery process and
resilience for children. The CONTRACTOR shall develop a referral process to be used by
its providers, including what information must be exchanged and when to share this
information, as well as notification to the member’s care coordinator.

	 	2.9.8.5	 	Referrals to PCPs

	 	 	 	The CONTRACTOR shall ensure that members with both physical health and behavioral
health needs are appropriately referred to their PCPs for treatment of their physical
health needs. The CONTRACTOR shall develop provider education and training materials to
ensure that behavioral health providers know when and how to refer members who need
physical health services. The CONTRACTOR shall develop a referral process to be used by
its providers. The referral process shall include providing a copy of the physical
health consultation and results to the behavioral health provider.

	 	2.9.8.6	 	Referrals to CHOICES

	 	 	 	The CONTRACTOR shall ensure that members with both long-term care and behavioral health
needs are referred to the CONTRACTOR for CHOICES intake (see Section 2.9.6.3). The
CONTRACTOR shall develop provider education and training materials to ensure that
behavioral health providers know when and how to refer members who need long-term care
services to the CONTRACTOR.

	 	2.9.8.7	 	Behavioral Health Assessment and Treatment Plan

	 	 	 	The CONTRACTOR’s policies and procedures shall identify the role of physical health and
behavioral health providers in assessing a member’s behavioral health needs and
developing an individualized treatment plan. For members with chronic physical
conditions that require ongoing treatment who also have behavioral health
needs, the CONTRACTOR shall encourage participation of both the member’s physical
health provider (PCP or specialist) and behavioral health provider in the assessment
and individualized treatment plan development process as well as the ongoing provision
of services. For CHOICES members in Groups 2 and 3 with behavioral health needs, the
member’s care coordinator shall encourage participation of the member’s behavioral
health provider in the care planning process and shall incorporate relevant information
from the member’s behavioral health treatment plan (see Section 2.7.2.1.4) in the
member’s plan of care (see Section 2.9.6.6).

	 	2.9.8.8	 	MCO Case Management, Disease Management, and CHOICES Care Coordination

	 	 	 	The CONTRACTOR shall use its MCO case management, disease management, and
CHOICES care coordination programs (see Sections 2.9.5, 2.8, and 2.9.6) to support

Page 144 of  374

 

	 	 	 	the continuity and coordination of covered physical health, behavioral health,
and long-term care services and the collaboration between physical health,
behavioral health, and long-term care providers. The CONTRACTOR has the option
to allow members, e.g., members who have been determined to be high risk based
on disease management stratification (see Section 2.8.3), to be enrolled in both
a disease management program and MCO case management. For CHOICES members, MCO
case management and/or disease management activities shall be integrated with
the care coordination process (see Sections 2.9.5.4, and 2.9.6.1.8).

	 	2.9.8.9	 	Monitoring

	 	 	 	The CONTRACTOR shall evaluate and monitor the effectiveness of its policies and
procedures regarding the continuity and coordination of covered physical,
behavioral health, and long-term care services and collaboration between
physical health, behavioral health, and long-term care providers. This shall
include, but not be limited to, an assessment of the appropriateness of the
diagnosis, treatment, and referral of behavioral health disorders commonly seen
by PCPs; an evaluation of the appropriateness of psychopharmacological
medication; and analysis of data regarding access to appropriate services. Based
on these monitoring activities, the CONTRACTOR shall develop and implement
interventions to improve continuity, coordination, and collaboration for
physical health, behavioral health, and long-term care services.

2.9.9 Coordination and Collaboration Among Behavioral Health Providers

	 	2.9.9.1	 	The CONTRACTOR shall ensure communication and coordination between mental
health providers and substance abuse providers, including:

	 	2.9.9.1.1	 	Assignment of a responsible party to ensure communication and coordination occur;

	 	2.9.9.1.2	 	Determination of the method of mental health screening to be completed by
substance abuse service providers; screening and assessment tools to be designated by
TENNCARE;

	 	2.9.9.1.3	 	Determination of the method of substance abuse screening to be completed by mental
health service providers; screening and assessment tools to be designated by TENNCARE;

	 	2.9.9.1.4	 	Description of how treatment plans will be coordinated between behavioral health
service providers; and

	 	2.9.9.1.5	 	Assessment of cross training of behavioral health providers: mental health
providers being trained on substance abuse issues and substance abuse providers being
trained on mental health issues.

	 	2.9.9.2	 	The CONTRACTOR shall ensure coordination between the children and adolescent
service delivery system as they transition into the adult mental health service
delivery system, through such activities as communicating treatment plans and
exchange of information.

Page 145 of  374

 

	 	2.9.9.3	 	The CONTRACTOR shall coordinate inpatient and community services, including
the following requirements related to hospital admission and discharge:
	 
	 	2.9.9.3.1	 	The outpatient provider shall be involved in the admissions process when possible; if
the outpatient provider is not involved, the outpatient provider shall be
notified promptly of the member’s hospital admission;

	 	2.9.9.3.2	 	Psychiatric hospital and residential treatment facility discharges shall not occur
without a discharge plan in which the member has participated (an outpatient
visit shall be scheduled before discharge, which ensures access to proper
provider/medication follow-up; also, an appropriate placement or housing site
shall be secured prior to discharge);

	 	2.9.9.3.3	 	An evaluation shall be performed prior to discharge to determine if mental health
case management services are medically necessary. Once deemed medically necessary, the
mental health case manager shall be involved in discharge planning; if there is no
mental health case manager, then the outpatient provider shall be involved; and

	 	2.9.9.3.4	 	A procedure to ensure continuity of care regarding medication shall be developed
and implemented.

	 	2.9.9.4	 	The CONTRACTOR shall identify and develop community alternatives to inpatient
hospitalization for those members who are receiving inpatient psychiatric
facility services who could leave the facility if appropriate community or
residential care alternatives were available in the community. In the event the
CONTRACTOR does not provide appropriate community alternatives, the CONTRACTOR
shall remain financially responsible for the continued inpatient care of these
individuals.

	 	2.9.9.5	 	The CONTRACTOR is responsible for providing a discharge plan as outlined in
Section 2.9.9.3.2.

2.9.10 Coordination of Pharmacy Services

	 	2.9.10.1	 	Except as provided in Section 2.6.1.3, the CONTRACTOR is not responsible for the
provision and payment of pharmacy benefits; TENNCARE contracts with a pharmacy
benefits manager (PBM) to provide these services. However, the CONTRACTOR shall
coordinate with the PBM as necessary to ensure that members receive appropriate
pharmacy services without interruption. The CONTRACTOR shall monitor and manage
its contract providers as it relates to prescribing patterns and its members as
it relates to utilization of prescription drugs. The CONTRACTOR shall
participate in regularly scheduled meetings with the PBM and TENNCARE to discuss
operational and programmatic issues.

	 	2.9.10.2	 	The CONTRACTOR shall accept and maintain prescription drug data from
TENNCARE or its PBM.

	 	2.9.10.3	 	The CONTRACTOR shall monitor and manage members by, at a minimum, conducting the
activities as described below:

Page 146 of  374

 

	 	2.9.10.3.1	 	Analyzing prescription drug data and/or reports provided by the PBM
or TENNCARE to identify high-utilizers and other members who inappropriately use
pharmacy services and assign them to MCO case management and/or disease
management programs and/or refer them to CHOICES intake (see Section 2.9.6) as
appropriate; if a CHOICES member is identified as a high-utilizer or as
inappropriately using pharmacy services, relevant prescription drug data and/or
reports for the member shall be provided to the member’s care coordinator, and
the care coordinator shall take appropriate next steps, which may include
coordination with the member’s PCP;

	 	2.9.10.3.2	 	Analyzing prescription drug data and/or reports provided by the PBM to identify
potential pharmacy lock-in candidates and referring them to TENNCARE; and

	 	2.9.10.3.3	 	Regularly providing information to members about appropriate prescription drug
usage. At a minimum, this information shall be included in the Member Handbook and in
at least two (2) quarterly member newsletters within a twelve (12) month period.

	 	2.9.10.4	 	The CONTRACTOR shall monitor and manage providers’ prescription patterns by,
at a minimum, conducting the activities described below:

	 	2.9.10.4.1	 	Collaborating with the PBM to educate the MCO’s contract providers regarding
compliance with the State’s preferred drug list (PDL) and appropriate prescribing
practices; and

	 	2.9.10.4.2	 	Intervening with contract providers whose prescribing practices appear to be
operating outside industry or peer norms as defined by TENNCARE, are noncompliant as it
relates to adherence to the PDL and/or generic prescribing patterns, and/or who are
failing to follow required prior authorization processes and procedures. The goal of
these interventions will be to improve prescribing practices among the identified
contract providers, as appropriate. Interventions shall be personal and one-on-one.

	 	2.9.10.5	 	At any time, upon request from TENNCARE, the CONTRACTOR shall provide assistance in
educating, monitoring and intervening with providers. For example, TENNCARE may require
assistance in monitoring and intervening with providers regarding prescribing patterns
for narcotics.

2.9.11 Coordination of Dental Benefits

	 	2.9.11.1	 	General

	 	2.9.11.1.1	 	The CONTRACTOR is not responsible for the provision and payment of dental
benefits; TENNCARE contracts with a dental benefits manager (DBM) to provide these
services.

	 	2.9.11.1.2	 	As provided in Section 2.6.1.3, the CONTRACTOR is responsible for transportation
to and from dental services as well as the facility, medical and anesthesia services
related to medically necessary and approved dental services that are not provided by a
dentist or in a dentist’s office.

Page 147 of  374

 

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

	 	2.9.11.2	 	Services and Responsibilities
	 
	 	 	 	The CONTRACTOR shall coordinate with the DBM for dental services. Coordination of
dental services, at a minimum, includes establishing processes for:

	 	2.9.11.2.1	 	Means for referral that ensures immediate access for emergency care and provision of
urgent and routine care according to TennCare guidelines for specialty care (see Attachment
III);

	 	2.9.11.2.2	 	Means for the transfer of information (to include items before and after the
visit);
	 
	 	2.9.11.2.3	 	Maintenance of confidentiality;

	 	2.9.11.2.4	 	Resolving disputes related to prior authorizations and claims and payment issues; and
	 
	 	2.9.11.2.5	 	Cooperation with the DBM regarding training activities provided by the DBM.

	 	2.9.11.3	 	Operating Principles 

	 	 	 	Coordinating the delivery of dental services to TennCare members is the primary
responsibility of the DBM. However, the CONTRACTOR shall provide coordination
assistance and shall be responsible for communicating the DBM provider services,
provider relations, and/or claim coordinator contact information to all of its contract
providers. With respect to specific member issues, the CONTRACTOR shall work with the
DBM coordinator towards a resolution. Should systemic issues arise, the CONTRACTOR
shall meet and resolve the issues with the DBM. In the event that such issues cannot be
resolved, the MCO and the DBM shall meet with TENNCARE to reach final resolution of
matters involved. Final resolution of system issues shall occur within ninety (90)
calendar days from referral to TENNCARE.

	 	2.9.11.4	 	Resolution of Requests for Prior Authorization

	 	2.9.11.4.1	 	The CONTRACTOR agrees, and recognizes that the DBM has agreed through its contractual
arrangement with the State, that any dispute concerning which party should respond to a
request for prior authorization shall not cause a denial, delay, reduction, termination or
suspension of any appropriate service to a TennCare enrollee. The CONTRACTOR shall require
that its DBM care coordinators will, in addition to their responsibilities for DBM care
coordination, deal with issues related to requests for prior authorization that require
coordination between the DBM and the CONTRACTOR. The CONTRACTOR shall provide the DBM with a
list of its DBM care coordinators and telephone number(s) at which each DBM care coordinator
may be contacted. When the CONTRACTOR receives a request for prior authorization from a
provider for a member and the CONTRACTOR believes the service is the

Page 148 of  374

 

	 	 	 	responsibility of the DBM, the CONTRACTOR’s DBM care coordinator shall contact the
DBM’s care coordinator by the next business day after receiving the request for prior
authorization. The DBM care coordinator shall also contact the member and/or member’s
provider. For routine requests contact to the member or member’s provider shall be made
within fourteen (14) days or less of the provider’s request for prior authorization and
shall comply with all applicable consent decrees and court orders and TennCare rules
and regulations. For urgent requests, contact shall be made immediately after receiving
the request for prior authorization.

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

	 	2.9.11.5	 	Claim Resolution Processes

	 	2.9.11.5.1	 	The CONTRACTOR shall designate one or more claims coordinators to deal with issues
related to claims and payment issues that require coordination between the DBM and the
CONTRACTOR. The CONTRACTOR agrees and recognizes that the DBM has agreed through its
contractual arrangement with the State, to also designate one or more claims coordinators to
deal with issues related to claims and payment issues that require coordination between the
DBM and the CONTRACTOR. The CONTRACTOR shall provide the DBM and TennCare, with a list of its
claims coordinators and telephone number(s) at which each claims coordinator may be contacted.

	 	2.9.11.5.2	 	When the CONTRACTOR receives a disputed claim for payment from a provider for a member
and believes care is the responsibility of the DBM, the CONTRACTOR’s claims coordinators shall
contact the DBM’s claims coordinators within four (4) calendar days of receiving such claim
for payment. If the CONTRACTOR’s claims coordinator is unable to reach agreement with the
DBM’s claims coordinators on which party is responsible for payment of the claim, the claim
shall be referred to the Claims Coordination Committee (described below) for review.

	 	2.9.11.5.3	 	The CONTRACTOR shall assign claims coordinators and other representatives, as needed, to
a joint CONTRACTOR/DBM Claims Coordination Committee. The number of members serving on the
Claims Coordination Committee shall be determined within ten (10) calendar days of the
execution of this Agreement by the mutual agreement of the DBM and MCO. The CONTRACTOR shall,
at a minimum, assign two (2) representatives to the committee. The make-up of the committee
may

Page 149 of  374

 

	 	 	 	be revisited from time to time during the term of this Agreement. The Claims
Coordination Committee shall review any disputes and negotiate responsibility between
the CONTRACTOR and the DBM. Unless otherwise agreed, such meeting shall take place
within ten (10) calendar days of receipt of the initial disputed claim or request from
the provider. If resolution of the claim results in the party who assumed
responsibility for authorization and payment having no liability, the other party shall
reimburse and abide by the prior decisions of that party. Reimbursement shall be made
within ten (10) calendar days of the Claims Coordination Committee’s decision.

	 	2.9.11.5.4	 	If the Claims Coordination Committee cannot reach an agreement as to the proper division
of financial responsibility within ten (10) calendar days of the initial referral to the
Claims Coordination Committee, said claim shall be referred to both the CONTRACTOR’s and the
DBM’s CEO or the CEO’s designee, for resolution immediately. A meeting shall be held among the
CEOs or their designee(s) as soon as possible, but not longer than ten (10) calendar days
after the meeting of the Claims Coordination Committee.

	 	2.9.11.5.5	 	If the meeting between the CEOs, or their designee(s), of the DBM and MCO does not
successfully resolve the dispute within ten (10) calendar days, the parties shall, within
fourteen (14) calendar days of the meeting, submit a Request for Resolution of the dispute to
the State or the State’s designee for a decision on responsibility.

	 	2.9.11.5.6	 	The process before the submission of a Request for Resolution, as described above, shall
be completed within thirty (30) calendar days of receiving the claim for payment. In the event
the parties cannot agree within thirty (30) calendar days of receiving the claim for payment,
the MCO and the DBM shall be responsible for enforcing hold harmless protections for the
member and the party who first received the request or claim from the provider shall be
responsible for authorization and payment to the provider in accordance with the requirements
of the MCO’s or DBM’s respective Agreement/contract with the State of Tennessee. Moreover, the
party that first received the request or claim from the provider shall also make written
request of all requisite documentation for payment and shall provide written reasons for any
denial.

	 	2.9.11.5.7	 	The Request for Resolution shall contain a concise description of the facts regarding
the dispute, the applicable Agreement/contract provisions, and the position of the party
making the request. A copy of the Request for Resolution shall also be delivered to the other
party. The other party shall then submit a Response to the Request for Resolution within
fifteen (15) calendar days of the date of the Request for Resolution. The Response shall
contain the same information required of the Request for Resolution. Failure to timely file a
Response or obtain an extension from the State shall be deemed a waiver of any objections to
the Request for Resolution.

	 	2.9.11.5.8	 	The State or its designee shall make a decision in writing regarding who is responsible
for the payment of services within ten (10) calendar days of the receipt of the required
information (“Decision”). The Decision may reflect a split payment responsibility that
designates specific proportions to be paid by the MCO and the DBM. The Decision shall be
determined solely by the State or its designee based on specific circumstances regarding each
individual case. Within five (5) business days of receipt of the Decision, the non-successful
party shall reimburse any payments

Page 150 of  374

 

	 	 	 	made by the successful party for the services. The non-successful party shall also pay
to the State, within thirty (30) calendar days of the Decision, an administrative fee
equal to ten percent (10%) of the value of the claims paid, not to exceed one- thousand
dollars ($1,000), for each Request for Resolution. The amount of the DBM’s or MCO’s
payment responsibility shall be contained in the State’s Decision. These payments may
be made with reservation of rights regarding any judicial resolution. If a party fails
to pay the State for the party’s payment responsibility as described in this Section,
Section 2.9.11.5.8, within thirty (30) calendar days of the date of the State’s
Decision, the State may deduct amounts of the payment responsibility from any current
or future amount owed the party by the State.

	 	2.9.11.6	 	Denial, Delay, Reduction, Termination or Suspension

	 	 	 	The CONTRACTOR agrees that any claims payment dispute or request for authorization
shall not cause a denial, delay, reduction, termination or suspension of any
appropriate services to a TennCare member. In the event there is a claim for emergency
services, the party receiving a request for authorization to treat any member shall
insure that the member is treated immediately and payment for the claim shall be
approved or disapproved based on the definition of emergency services specified in this
Agreement.

	 	2.9.11.7	 	Emergencies 

	 	 	 	Prior authorization shall not be required for emergency services prior to stabilization.

	 	2.9.11.8	 	Claims Processing Requirements 

	 	 	 	All claims shall be processed in accordance with the requirements of the MCO’s and
DBM’s respective Agreements/contracts with the State of Tennessee.

	 	2.9.11.9	 	Appeal of Decision

	 	 	 	Appeal of any Decision shall be to a court or commission of competent jurisdiction and
shall not constitute a procedure under the Administrative Procedure Act, TCA 4- 5-20 1
et seq. Exhaustion of the above-described process shall be required before filing of
any claim or lawsuit on issues covered by this Section, Section 2.9.11.9

	 	2.9.11.10	 	 Duties and Obligations

	 	 	 	The existence of any dispute under this Agreement shall in no way affect the duty of
the CONTRACTOR and the DBM to continue to perform their respective obligations,
including their obligations established in their respective Agreements/contracts with
the State pending resolution of the dispute under this Section, Section 2.9.11.10. In
accordance with TCA 56-32-126(b), a provider may elect to resolve the claims payment
dispute through independent review.

	 	2.9.11.11	 	Confidentiality

	 	2.9.11.11.1	 	The CONTRACTOR agrees, and recognizes that the DBM has agreed through its contractual
arrangement with the State, to cooperate with the State to develop confidentiality guidelines
that (1) meet state, federal, and other regulatory

Page 151 of  374

 

	 	 	 	requirements; (2) meet the requirements of the professions or facilities
providing care and maintaining records; and (3) meet both DBM and MCO standards.
These standards shall apply to both DBM’s and MCO’s providers and staff. If the
CONTRACTOR or DBM believes that the standards require updating, or operational
changes are needed to enforce the standards, the CONTRACTOR shall meet with the
DBM to resolve these issues. Such standards shall provide for the exchange of
confidential e-mails to ensure the privacy of the members.

	 	2.9.11.11.2	 	The DBM and MCO shall ensure all materials and information directly or
indirectly identifying any current or former member which is provided to or obtained by
or through the MCO’s or DBM’s performance of this Agreement, whether verbal, written,
tape, or otherwise, shall be maintained in accordance with the standards of
confidentiality of TCA 33-4-22, Section 4.33 of this Agreement, 42 CFR Part 2, and the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and, unless
required by applicable law, shall not be disclosed except in accordance with those
requirements or to TENNCARE, and CMS, or their designees. Nothing stated herein shall
prohibit the disclosure of information in summary, statistical, or other form that does
not identify any current or former member or potential member.

	 	2.9.11.12	 	 Access to Service

	 	 	 	The CONTRACTOR agrees and recognizes that the DBM has agreed through its
contractual arrangement with the State, to establish methods of referral which
ensure immediate access to emergency care and the provision of urgent and
routine care in accordance with TennCare guidelines.

2.9.12 Coordination with Medicare

	 	2.9.12.1	 	The CONTRACTOR is responsible for providing medically necessary covered
services to members who are also eligible for Medicare if the service is not
covered by Medicare.

	 	2.9.12.2	 	The CONTRACTOR shall ensure that services covered and provided pursuant to
this Agreement are delivered without charge to members who are dually eligible for
Medicare and Medicaid services.

	 	2.9.12.3	 	The CONTRACTOR shall coordinate with Medicare payers, Medicare Advantage
plans, and Medicare providers as appropriate to coordinate the care and benefits
of members who are also eligible for Medicare.

Page 152 of  374

 

2.9.13 ICF/MR Services and Alternatives to ICF/MR Services

	 	2.9.13.1	 	The CONTRACTOR is not responsible for services in an Intermediate Care
Facility for the Mentally Retarded (ICF/MR) or for services provided through Home
and Community Based Services (HCBS) waivers as an alternative to ICF/MR services
(hereinafter referred to as “HCBS MR waiver”). However, to the extent that
services available to a member through a HCBS MR waiver are also covered services
pursuant to this Agreement, the CONTRACTOR shall be responsible for providing all
medically necessary covered services. HCBS MR waiver services may supplement, but
not supplant, medically necessary covered services. ICF/MR services and HCBS MR
waiver services shall be provided to qualified members as described in TennCare
rules and regulations through contracts between TENNCARE and appropriate
providers.

	 	2.9.13.2	 	The CONTRACTOR is responsible for covered services for members residing in an
ICF/MR or enrolled in a HCBS MR waiver. For members residing in an ICF/MR, the
CONTRACTOR is responsible for providing covered services that are not included in
the per diem reimbursement for institutional services (e.g., prosthetics, some
items of durable medical equipment, non-emergency ambulance transportation, and
non- emergency transportation). Except as provided below for NEMT, for members
enrolled in a HCBS MR waiver, the CONTRACTOR shall provide all medically necessary
covered services, including covered services that may also be provided through the
HCBS MR waiver. The HCBS MR waiver is the payor of last resort. However, the
CONTRACTOR is not responsible for providing non-emergency medical transportation
(NEMT) to any service that is being provided to the member through the HCBS MR
waiver.

	 	2.9.13.3	 	The CONTRACTOR shall coordinate the provision of covered services with
services provided by ICF/MR and HCBS MR waiver providers to minimize disruption
and duplication of services.

2.9.14 Inter-Agency Coordination

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

	 	2.9.14.1	 	Tennessee Department of Mental Health and Developmental Disabilities
(TDMHDD) for the purpose of interfacing with and assuring continuity of care and
for coordination of specialized services in accordance with federal PASRR
requirements;

	 	2.9.14.2	 	Tennessee Department of Children’s Services (DCS) for the purpose of interfacing
with and assuring continuity of care;
	 
	 	2.9.14.3	 	Tennessee Department of Health (DOH), for the purposes of establishing and
maintaining relationships with member groups and health service providers;
	 
	 	2.9.14.4	 	Tennessee Department of Human Services (DHS) and DCS Protective Services
Section, for the purposes of reporting and cooperating in the investigation of
abuse and neglect;

Page 153 of  374

 

	 	2.9.14.5	 	The Division of Mental Retardation Services (DMRS), for the purposes of interfacing
with and assuring continuity of care and for coordination of specialized services in
accordance with federal PASRR requirements;

	 	2.9.14.6	 	Tennessee Department of Education (DOE) and local education agencies for the
purposes of coordinating educational services in compliance with the requirements of
Individuals with Disabilities Education Act (IDEA) and to ensure school-based services
for students with special needs are provided;

	 	2.9.14.7	 	Area Agencies on Aging and Disability (AAADs) regarding intake of members new to both
TennCare and CHOICES, assisting CHOICES members in Groups 2 and 3 with the TennCare
eligibility redetermination process, and facilitating the transition of members during CHOICES
implementation and when members are moving to a Grand Region where CHOICES has not yet been
implemented;

	 	2.9.14.8	 	Tennessee Commission on Aging and Disability (TCAD) regarding TCAD’s role in
monitoring the performance of the AAADs in conducting SPOE functions;

	 	2.9.14.8.1	 	The CONTRACTOR is responsible for the delivery of medically necessary covered services
to school-aged children. MCOs are encouraged to work with school-based providers to manage the
care of students with special health care needs. The State has implemented a process, referred
to as TENNderCARE Connection, to facilitate notification of MCOs when a school-aged child
enrolled in TennCare has an Individualized Education Plan (IEP) that identifies a need for
medical services. In such cases, the school is responsible for obtaining parental consent to
share the IEP with the MCO and for subsequently sending a copy of the parental consent and IEP
to the MCO. The school is also responsible for clearly delineating the services on the IEP
that the MCOs are to consider for payment. If a school-aged member, needing medical services,
is identified by the CONTRACTOR by another means, the CONTRACTOR shall request the IEP from
the appropriate school system.

	 	2.9.14.8.2	 	The CONTRACTOR shall designate a contact person to whom correspondence concerning
children with medical services included in their IEPs will be directed. After receipt of an
IEP, the CONTRACTOR shall:

	 	2.9.14.8.2.1	 	Either accept the IEP as indication of a medical problem and treat the IEP as a
request for service or assist in making an appointment to have the child evaluated
by the child’s PCP or another contract provider. If the CONTRACTOR does not accept
the documentation provided with the IEP as indication of a medical problem, the
CONTRACTOR shall have the child re-evaluated in order to make a decision about the
appropriateness of the requested service.

	 	2.9.14.8.2.2	 	Send a copy of the IEP and any related information (e.g. action taken by the
MCO in response to receipt of the IEP, action the MCO expects the PCP to take) to
the PCP.

	 	2.9.14.8.2.3	 	Notify the designated school contact of the ultimate disposition of the request
(e.g. what services have been approved for the child, what arrangements have
been made for service delivery) within 14 days of the CONTRACTOR’s receipt of the
IEP.

Page 154 of  374

 

	 	2.9.14.9	 	Local law enforcement agencies and hospital emergency rooms for the purposes of
crisis service provider relationships, and the transportation of individuals
certified for further assessment for emergency psychiatric hospitalization.

12. Section 2.11 shall be deleted in its entirety and replaced with the following:

2.11 PROVIDER NETWORK

2.11.1 General Provisions

	 	2.11.1.1	 	The CONTRACTOR shall provide or ensure the provision of all covered services
specified in Section 2.6.1 of this Agreement. Accessibility of covered services,
including geographic access and appointments and wait times shall be in
accordance with the access standards in Attachment III, the Specialty Network
Standards in Attachment IV, the Access and Availability for Behavioral Health
Services in Attachment V and the requirements herein. These minimum requirements
shall not release the CONTRACTOR from the requirement to provide or arrange for
the provision of any medically necessary covered service required by its
members, whether specified above or not.

	 	2.11.1.2	 	The CONTRACTOR may provide covered physical health and behavioral health
services directly or may enter into written agreements with providers and
provider subcontracting entities or organizations that will provide covered
physical health and behavioral health services to the members in exchange for
payment by the CONTRACTOR for services rendered. The CONTRACTOR shall enter into
written agreements with providers to provide covered long-term care services.
The CONTRACTOR shall not directly provide long-term care services.

	 	2.11.1.3	 	When the CONTRACTOR contracts with providers, the CONTRACTOR shall:

	 	2.11.1.3.1	 	Not execute provider agreements with providers who have been excluded from
participation in the Medicare, Medicaid, and/or SCHIP programs pursuant to Sections
1128 or 1156 of the Social Security Act or who are otherwise not in good standing with
the TennCare program;

	 	2.11.1.3.2	 	Consider: the anticipated TennCare enrollment; the expected utilization of
services, taking into consideration the characteristics of specific TennCare
populations included in this Agreement; the number and types of providers required to
furnish TennCare services; the number of contract providers who are not accepting new
members; and the geographic location of providers and TennCare members, considering
distance, travel time, the means of transportation ordinarily used by TennCare members,
and whether the location provides physical access for members with disabilities;

	 	2.11.1.3.3	 	Have in place, written policies and procedures for the selection and retention of
providers. These policies and procedures shall not discriminate against particular
providers that service high risk populations or specialize in conditions that require
costly treatment;

Page 155 of  374

 

	 	2.11.1.3.4	 	Not discriminate for the participation, reimbursement, or indemnification of
any provider who is acting within the scope of his or her license or certification
under applicable state law, solely on the basis of that license or certification. The
CONTRACTOR’s ability to credential providers as well as maintain a separate network and
not include any willing provider is not considered discrimination;

	 	2.11.1.3.5	 	Give affected providers written notice if it declines to include individual or groups of
providers in its network; and

	 	2.11.1.3.6	 	Maintain all provider agreements in accordance with the provisions specified in 42 CFR
438.12, 438.2 14 and Section 2.12 of this Agreement.

	 	2.11.1.4	 	Section 2.11.1.3 shall not be construed to:

	 	2.11.1.4.1	 	Require the CONTRACTOR to contract with providers beyond the number necessary to meet
the needs of its members and the access standards of this Agreement; however, the CONTRACTOR
shall contract with nursing facilities pursuant to the requirements of Section 2.11.6 of this
Agreement and shall contract with at least two (2) providers for each HCBS to cover each
county in the Grand Region, as specified in Section 2.11.6.3;

	 	2.11.1.4.2	 	Preclude the CONTRACTOR from using different reimbursement amounts for different
specialties or for different providers in the same specialty; however, the CONTRACTOR shall
reimburse long-term care services in accordance with Sections 2.13.3 and 2.13.4; or

	 	2.11.1.4.3	 	Preclude the CONTRACTOR from establishing measures that are designed to maintain quality
of services and control costs and are consistent with its responsibilities to members.

	 	2.11.1.5	 	The CONTRACTOR may not prohibit, or otherwise restrict, a health care
professional acting within the lawful scope of practice, from advising or advocating on
behalf of a member who is his or her patient for the following:

	 	2.11.1.5.1	 	The member’s health status, medical, behavioral health, or long-term care, or treatment
options, including any alternative treatment that may be self administered;

	 	2.11.1.5.2	 	Any information the member needs in order to decide among all relevant treatment
options;

	 	2.11.1.5.3	 	The risks, benefits, and consequences of treatment or non-treatment; or

	 	2.11.1.5.4	 	The member’s right to participate in decisions regarding his or her health care,
including the right to refuse treatment, and to express preferences about future treatment
decisions.

	 	2.11.1.6	 	Prior to including a provider on the Provider Enrollment File (see Section 2.30.7.1)
and/or paying a provider’s claim, the CONTRACTOR shall ensure that the provider has a
National Provider Identifier (NPI) Number, where applicable, and has obtained a
Medicaid provider number from TENNCARE.

Page 156 of  374

 

	 	2.11.1.7	 	If a member requests a provider located outside the access standards, and the
CONTRACTOR has an appropriate provider within the access requirements who accepts new
members, it shall not be considered a violation of the access requirements for the
CONTRACTOR to grant the member’s request. However, in such cases the CONTRACTOR shall
not be responsible for providing transportation for the member to access care from this
selected provider, and the CONTRACTOR shall notify the member in writing as to whether
or not the CONTRACTOR will provide transportation for the member to seek care from the
requested provider.

	 	2.11.1.8	 	If the CONTRACTOR is unable to meet the access standard for a covered service for
which the CONTRACTOR is responsible for providing non-emergency transportation to a
member, the CONTRACTOR shall provide transportation regardless of whether the member has
access to transportation.

	 	2.11.1.8.1	 	In the event the CONTRACTOR is unable to meet the access standard for adult day care
(see Attachment III), the CONTRACTOR shall provide and pay for the cost of transportation for
the member to the adult day care facility until such time the CONTRACTOR has sufficient
provider capacity.

	 	2.11.1.8.2	 	The CONTRACTOR is not required to provide non-emergency transportation for HCBS,
including services provided through a 1915(c) waiver program for persons with mental
retardation and HCBS provided through the CHOICES program, except as provided in Section
2.11.1.8.1 above.

	 	2.11.1.9	 	If the CONTRACTOR is unable to provide medically necessary covered services to a
particular member using contract providers, the CONTRACTOR shall adequately and timely
cover these services for that member using non-contract providers, for as long as the
CONTRACTOR’s provider network is unable to provide them. At such time that the required
services become available within the CONTRACTOR’s network and the member can be safely
transferred, the CONTRACTOR may transfer the member to an appropriate contract provider
as specified in Section 2.9.4.

	 	2.11.1.10	 	The CONTRACTOR shall monitor provider compliance with access requirements specified in
Attachment III, including but not limited to appointment and wait times and take corrective
action for failure to comply. The CONTRACTOR shall conduct surveys and office visits to
monitor compliance with appointment waiting time standards and shall report findings and
corrective actions to TENNCARE in accordance with Section 2.30.7.2.

	 	2.11.1.11	 	The CONTRACTOR shall use its best efforts to contract with providers to whom the
CONTRACTOR routinely refers members.

	 	2.11.1.12	 	TENNCARE reserves the right to direct the CONTRACTOR to terminate or modify any provider
agreement when TENNCARE determines it to be in the best interest of the State.

	 	2.11.1.13	 	To demonstrate sufficient accessibility and availability of covered services, the
CONTRACTOR shall comply with all reporting requirements specified in Section 2.30.7.

Page 157 of  374

 

2.11.2 Primary Care Providers (PCPs)

	 	2.11.2.1	 	With the exception of members dually eligible for Medicare and TennCare, the
CONTRACTOR shall ensure that each member has an assigned PCP, as defined in
Section 1, who is responsible for coordinating the covered services provided to
the member. For CHOICES members, the CONTRACTOR shall develop and implement
protocols that address, at a minimum, the roles and responsibilities of the PCP
and care coordinator and collaboration between a member’s PCP and care
coordinator.

	 	2.11.2.2	 	The CONTRACTOR shall ensure that there are PCPs willing and able to provide
the level of care and range of services necessary to meet the medical and
behavioral health needs of its members, including those with chronic conditions.
There shall be a sufficient number of PCPs who accept new TennCare members within
the CONTRACTOR’s service area so that the CONTRACTOR meets the access standards
provided in Attachment III.

	 	2.11.2.3	 	To the extent feasible and appropriate, the CONTRACTOR shall offer each member
(other than members who are dually eligible for Medicare and TennCare) the
opportunity to select a PCP.

	 	2.11.2.4	 	The CONTRACTOR may, at its discretion, allow vulnerable populations (for
example, persons with multiple disabilities, acute, or chronic conditions, as
determined by the CONTRACTOR) to select their attending specialists as their PCP
so long as the specialist is willing to perform all responsibilities of a PCP as
defined in Section 1.

	 	2.11.2.5	 	If a member who is not dually eligible for Medicare and TennCare fails or
refuses to select a PCP from those offered within thirty (30) calendar days of
enrollment, the CONTRACTOR shall assign a PCP. The CONTRACTOR may assign a PCP in
less than thirty (30) calendar days if the CONTRACTOR provides the enrollee an
opportunity to change PCPs upon receipt of notice of PCP assignment.

	 	2.11.2.6	 	The CONTRACTOR shall establish policies and procedures to enable members
reasonable opportunities to change PCPs. Such policies and procedures may not
specify a length of time greater than twelve (12) months between PCP changes
under normal circumstances. If the ability to change PCPs is limited, the
CONTRACTOR shall include provisions for more frequent PCP changes with good
cause. The
policies and procedures shall include a definition of good cause as well as the
procedures to request a change.

	 	2.11.2.7	 	If a member requests assignment to a PCP located outside the distance/time
requirements in Attachment III and the CONTRACTOR has PCPs available within the
distance/time requirements who accept new members, it shall not be considered a
violation of the access requirements for the CONTRACTOR to grant the member’s
request. However, in such cases the CONTRACTOR shall have no responsibility for
providing transportation for the member to access care from this selected
provider, and the CONTRACTOR shall notify the member in writing as to whether or
not the CONTRACTOR will provide transportation for the member to seek care from
the requested provider. In these cases, the CONTRACTOR shall allow the member to
change assignment to a PCP within the distance/time requirements at any time if
the member requests such a change.

Page 158 of  374

 

2.11.3 Specialty Service Providers

	 	2.11.3.1	 	Essential Hospital Services and Centers of Excellence

	 	2.11.3.1.1	 	The CONTRACTOR shall demonstrate sufficient access to essential hospital services
which means that, at a minimum, in each Grand Region served by the CONTRACTOR, the
CONTRACTOR shall demonstrate a contractual arrangement with at least one (1) tertiary
care center for each of the following:

	 	2.11.3.1.1.1	 	Neonatal services;
	 
	 	2.11.3.1.1.2	 	Perinatal services;
	 
	 	2.11.3.1.1.3	 	Pediatric services;
	 
	 	2.11.3.1.1.4	 	Trauma services; and
	 
	 	2.11.3.1.1.5	 	Burn services.

	 	2.11.3.1.2	 	The CONTRACTOR shall demonstrate sufficient access to comprehensive care for
people with HIV/AIDS which means that, at a minimum, in each Grand Region in which the
CONTRACTOR operates, the CONTRACTOR shall demonstrate a contractual arrangement with at
least two (2) HIV/AIDS Centers of Excellence located within the CONTRACTOR’s approved
Grand Region(s). HIV/AIDS centers of Excellence are designated by the DOH.

	 	2.11.3.1.3	 	The CONTRACTOR shall demonstrate a contractual arrangement with all Centers of
Excellence for Behavioral Health located within the Grand Region(s) served by the
CONTRACTOR.

	 	2.11.3.2	 	Physician Specialists

	 	2.11.3.2.1	 	The CONTRACTOR shall establish and maintain a network of physician specialists
that is adequate and reasonable in number, in specialty type, and in geographic
distribution to meet the medical and behavioral health needs of its members (adults and
children) without excessive travel requirements. This means that, at a minimum:

	 	2.11.3.2.1.1	 	The CONTRACTOR has signed provider agreements with providers of the
specialty types listed in Attachment IV who accept new TennCare enrollees and
are available on at least a referral basis; and

	 	2.11.3.2.1.2	 	The CONTRACTOR is in compliance with the access and availability
requirements in Attachments III, IV, and V.

	 	2.11.3.3	 	TENNCARE Monitoring

	 	2.11.3.3.1	 	TENNCARE will monitor CONTRACTOR compliance with specialty network standards on
an ongoing basis. TENNCARE will use data from the monthly Provider Enrollment File
required in Section 2.30.7.1, to verify compliance with the specialty network
requirements. TENNCARE will use these files to confirm the

Page 159 of  374

 

	 	 	 	CONTRACTOR has a sufficient number and distribution of physician specialists and in
conjunction with MCO enrollment data to calculate member to provider ratios. TENNCARE
will also periodically phone providers listed on these reports to confirm that the
provider is a contract provider as reported by the CONTRACTOR. TENNCARE shall also
monitor appeals data for indications that problems exist with access to specialty
providers.

	 	2.11.3.3.2	 	TENNCARE will require a corrective action plan from the CONTRACTOR when:

	 	2.11.3.3.2.1	 	Twenty-five percent (25%) or more of non-dual members do not have access to
one or more of the physician specialties listed in Attachment IV within sixty (60)
miles;

	 	2.11.3.3.2.2	 	Any non-dual member does not have access to one or more of the physician
specialties listed in Attachment IV within ninety (90) miles; or

	 	2.11.3.3.2.3	 	The member to provider ratio exceeds that listed in Attachment IV.

	 	2.11.3.3.3	 	TENNCARE will review all corrective action plans and determine, based on the actions
proposed by the CONTRACTOR, appeals data, and the supply of specialty providers available to
non-TennCare members, whether the corrective action plan will be accepted. Corrective action
plans shall include, at a minimum, the following:

	 	2.11.3.3.3.1	 	The addition of contract providers to the provider network as documented on
the provider enrollment file that resolves the specialty network deficiency;

	 	2.11.3.3.3.2	 	A list of providers with name, location, and expected date of provider
agreement execution with whom the CONTRACTOR is currently negotiating a provider
agreement and, if the provider becomes a contract provider would resolve the
specialty network deficiency;

	 	2.11.3.3.3.3	 	For those deficiencies that are not resolved, a detailed account of attempts
to secure an agreement with each provider that would resolve the deficiency. This
shall include the provider name(s), address(es), date(s) contacted, and a detailed
explanation as to why the CONTRACTOR is unable to secure an agreement, e.g., lack of
provider willingness to participate in
the TennCare program, provider prefers to limit access to practice, or rate
requests are inconsistent with TennCare actuarial assumptions;

	 	2.11.3.3.3.4	 	A listing of non-contract providers, including name and location, who are
being used to provide the deficient specialty provider services and the rates the
CONTRACTOR is currently paying these non-contract providers;

	 	2.11.3.3.3.5	 	Affirmation that transportation will be provided for members to obtain
services from providers who are willing to provide services to members but do not
meet the specialty network standards;

	 	2.11.3.3.3.6	 	Documentation of how these arrangements are communicated to the member; and

	 	2.11.3.3.3.7	 	Documentation of how these arrangements are communicated to the PCPs.

Page 160 of  374

 

2.11.4 Special Conditions for Prenatal Care Providers

	 	2.11.4.1	 	The CONTRACTOR shall have a sufficient number of contract providers who
accept members in accordance with TennCare access standards in Attachment III so
that prenatal or other medically necessary covered services are not delayed or
denied to pregnant women at any time, including during their presumptive
eligibility period. Additionally, the CONTRACTOR shall make services available
from non-contract providers, if necessary, to provide medically necessary covered
services to a woman enrolled in the CONTRACTOR’s MCO.
	 
	 	2.11.4.2	 	Regardless of whether prenatal care is provided by a PCP, physician extender
or an obstetrician who is not the member’s PCP, the access standards for PCP
services shall apply when determining access to prenatal care except for cases of
a first prenatal care appointment for women who are past their first trimester of
pregnancy on the day they are determined to be eligible for TennCare. For women
who are past their first trimester of pregnancy on the day they are determined to
be eligible, a first prenatal care appointment shall occur within fifteen (15)
calendar days of the day they are determined to be eligible. Failure to do so
shall be considered a material breach of the provider’s provider agreement with
the CONTRACTOR (see Sections 2.7.5.2 and 2.11.4).

2.11.5 Special Conditions for Behavioral Health Services

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

2.11.6 Special Conditions for Long-Term Care Providers

	 	 	In addition to the requirements in Section 2.11.1 of this Agreement and the access
standards specified in Attachment III of this Agreement, the CONTRACTOR shall meet the
following requirements for long-term care providers.

	 	2.11.6.1	 	The CONTRACTOR shall contract with all current nursing facilities (as defined
in TCA 71-5-1412(b)), that meet all CMS certification requirements, for a minimum
of three (3) years following the effective date of CHOICES implementation.
Thereafter, the CONTRACTOR shall contract with a sufficient number of nursing
facilities in order to have adequate capacity to meet the needs of CHOICES
members for nursing facility services.
	 
	 	2.11.6.2	 	For community-based residential alternatives, the CONTRACTOR shall
demonstrate good faith efforts to develop the capacity to have a travel

Page 161 of 374

 

	 	 	 	distance of no more than sixty (60) miles between a member’s
community-based residential alternative placement and the member’s
residence before entering the facility.

	 	2.11.6.3	 	At a minimum, the CONTRACTOR shall contract with at least two (2) providers for each
HCBS, other than community-based residential alternatives, to cover each county in the
Grand Region covered under this Agreement. For HCBS provided in a member’s place of
residence, the provider does not need to be located in the county of the member’s
residence but must be willing and able to serve residents of that county. For adult day
care, the provider does not have to be located in the county of the member’s residence
but must meet the access standards for adult day care specified in Attachment III.
	 
	 	2.11.6.4	 	The CONTRACTOR shall have adequate HCBS provider capacity to meet the needs of each and
every CHOICES member in Group 2 and 3 and to provide authorized HCBS within the timeframe
prescribed in Sections 2.9.2, 2.9.3, and 2.9.6 of this Agreement. This includes initiating
HCBS in the member’s plan of care within the timeframes specified in this Agreement and
continuing services in accordance with the member’s plan of care, including the amount,
frequency, duration and scope of each service in accordance with the member’s service
schedule.
	 
	 	2.11.6.5	 	Following the first quarter of implementation, TENNCARE will review all relevant
reports submitted by the CONTRACTOR, including but not limited to reports that address
provider network, service initiation, missed visits, and service utilization. TENNCARE
will use the data provided in these reports to establish long-term care provider
capacity requirements and develop performance standards, benchmarks and associated
liquidated damages for failure to meet the specified performance standards and
benchmarks. TENNCARE will notify the CONTRACTOR of the performance standards,
benchmarks, and liquidated damages including the timeframe for imposing liquidated
damages.
	 
	 	2.11.6.6	 	The CONTRACTOR shall develop and maintain a network development plan to ensure the
adequacy and sufficiency of its provider network. The network development plan shall be
submitted to TENNCARE annually, monitored by TENNCARE per the requirements in Section 2.25 of
the Agreement, and include the following minimum elements:
	 
	 	2.11.6.6.1	 	Summary of nursing facility provider network, by county.
	 
	 	2.11.6.6.2	 	Summary of HCBS provider network, including community-based residential alternatives, by
service and county.
	 
	 	2.11.6.6.3	 	Demonstration of and monitoring activities to ensure that access standards for longterm
care services are met, including requirements in Attachment III and in this Section 2.11.6.
	 
	 	2.11.6.6.4	 	Demonstration of the CONTRACTOR’s ongoing activities to track and trend every time a
member does not receive initial or ongoing long-term care services in accordance with the
requirements of this Agreement due to inadequate provider capacity, identify systemic issues,
and implement remediation and quality improvement (QI) activities. This shall include a
summary of provider network

Page 162 of 374

 

	 	 	 	capacity issues by service and county, the CONTRACTOR’s remediation and QI
activities and the targeted and actual completion dates for those activities.
	 
	 	2.11.6.6.5	 	HCBS network deficiencies (in addition to those specified in Section 2.11.6.6.4
above) by service and by county and interventions to address the deficiencies.
	 
	 	2.11.6.6.6	 	Demonstration of the CONTRACTOR’s efforts to develop and enhance existing
community-based residential alternatives (including adult care homes) capacity for
elders and/or adults with physical disabilities. The CONTRACTOR shall specify related
activities, including provider recruitment activities, and provide a status update on
capacity building.
	 
	 	2.11.6.6.7	 	Where there are deficiencies or as otherwise applicable, annual target increase
in HCBS providers by service and county.
	 
	 	2.11.6.6.8	 	Ongoing activities for HCBS provider development and expansion taking into
consideration identified provider capacity, network deficiencies, and service delivery
issues and future needs relating to growth in membership and long-term needs.
	 
	 	2.11.6.7	 	The CONTRACTOR shall assist in developing an adequate qualified workforce for
covered long-term care services. The CONTRACTOR shall develop and implement
strategies to increase the pool of available qualified direct care staff and to
improve retention of qualified direct care staff. The strategies may include,
for example, establishing partnerships with local colleges and technical
training schools; establishing partnerships with professional and trade
associations and pursuing untapped labor pools such as elders. The CONTRACTOR
shall report annually to TENNCARE on the status of its qualified workforce
development strategies (see Section 2.30.7.8).

2.11.7 Safety Net Providers

	 	2.11.7.1	 	Federally Qualified Health Centers (FQHCs)
	 
	 	2.11.7.1.1	 	The CONTRACTOR is encouraged to contract with FQHCs and other safety net
providers (e.g., rural health clinics) in the CONTRACTOR’s service area to the extent
possible and practical. Where FQHCs are not utilized, the CONTRACTOR shall demonstrate
to DHHS, the Tennessee DHS and TENNCARE that both adequate capacity and an appropriate
range of services for vulnerable populations exist to serve the expected enrollment in
the CONTRACTOR’s service area without contracting with FQHCs.
	 
	 	2.11.7.1.2	 	FQHC reporting information shall be submitted to TENNCARE as described in Section
2.30.7.9 of this Agreement.
	 
	 	2.11.7.2	 	Community Mental Health Agencies (CMHAs)
	 
	 	 	 	The CONTRACTOR is encouraged to contract with CMHAs and other behavioral health
safety net providers in the CONTRACTOR’s service area to the extent possible and
practical. Where CMHAs are not utilized, the CONTRACTOR shall demonstrate that
both adequate capacity and an appropriate range of services for all

Page 163 of 374

 

	 	 	 	populations, but in particular SPMI/SED populations, exist to serve the expected
enrollment in the CONTRACTOR’s service area without contracting with CMHAs.
	 
	 	2.11.7.3	 	Local Health Departments
	 
	 	 	 	The CONTRACTOR shall contract with each local health department in the Grand
Region(s) served by the CONTRACTOR for the provision of TENNderCare screening
services until such time as the CONTRACTOR achieves an adjusted periodic
screening percentage of eighty percent (80%) or greater. Payment to local health
departments shall be in accordance with Section 2.13.7.

2.11.8 Credentialing and Other Certification

	 	2.11.8.1	 	Credentialing of Contract Providers
	 
	 	2.11.8.1.1	 	Except as provided in sections 2.11.8.3 and 2.11.8.4 below, the CONTRACTOR shall
utilize the current NCQA Standards and Guidelines for the Accreditation of MCOs for the
credentialing and recredentialing of licensed independent providers and provider groups
with whom it contracts or employs and who fall within its scope of authority and
action.
	 
	 	2.11.8.1.2	 	The CONTRACTOR shall completely process credentialing applications from all types
of providers (physical health, behavioral health and long-term care providers) within
thirty (30) calendar days of receipt of a completed credentialing application,
including all necessary documentation and attachments, and a signed provider agreement.
Completely process shall mean that the CONTRACTOR shall review, approve and load
approved applicants to its provider files in its claims processing system or deny the
application and assure that the provider is not used by the CONTRACTOR.
	 
	 	2.11.8.2	 	Credentialing of Non-Contract Providers
	 
	 	2.11.8.2.1	 	The CONTRACTOR shall utilize the current NCQA Standards and Guidelines for the
Accreditation of MCOs for the credentialing and recredentialing of licensed independent
providers with whom it does not contract but with whom it has an independent
relationship. An independent relationship exists when the CONTRACTOR selects and
directs its members to see a specific provider or group of providers.
	 
	 	2.11.8.2.2	 	The CONTRACTOR shall completely process credentialing applications within thirty
(30) calendar days of receipt of a completed credentialing application, including all
necessary documentation and attachments, and a signed contract/agreement if applicable.
Completely process shall mean that the CONTRACTOR shall review, approve and load
approved applicants to its provider files in its claims processing system or deny the
application and assure that the provider is not used by the CONTRACTOR.

Page 164 of 374

 

	 	2.11.8.3	 	Credentialing of Behavioral Health Entities
	 
	 	2.11.8.3.1	 	The CONTRACTOR shall ensure each behavioral health
provider’s service delivery site meets all applicable requirements
of law and has the necessary and current
license/certification/accreditation/designation approval per state
requirements.
	 
	 	2.11.8.3.2	 	When individuals providing behavioral health treatment
services are not required to be licensed or certified, it is the
responsibility of the CONTRACTOR to ensure, based on applicable
state licensure rules and/or programs standards, that they are
appropriately educated, trained, qualified, and competent to
perform their job responsibilities.
	 
	 	2.11.8.4	 	Credentialing of Long-Term Care Providers
	 
	 	2.11.8.4.1	 	The CONTRACTOR shall develop and implement a process for credentialing and
recredentialing long-term care providers. The CONTRACTOR’s process shall, as applicable, meet
the minimum NCQA requirements as specified in the NCQA Standards and Guidelines for the
Accreditation of MCOs. In addition, the CONTRACTOR shall ensure that all long-term care
providers, including those credentialed/recredentialed in accordance with NCQA Standards and
Guidelines for the Accreditation of MCOs, meet applicable State requirements, as specified by
TENNCARE.
	 
	 	2.11.8.4.2	 	To the extent possible the CONTRACTOR shall develop a streamlined credentialing process
for nursing facility and HCBS providers enrolled in TennCare prior to the effective date of
CHOICES implementation, and, to the extent permitted under NCQA Standards and Guidelines for
the Accreditation of MCOs, the CONTRACTOR shall use credentialing requirements that are
consistent with the State provider qualifications in place for long-term care providers at
CHOICES implementation.
	 
	 	2.11.8.5	 	Compliance with the Clinical Laboratory Improvement Amendments (CLIA) of 1988
	 
	 	 	 	The CONTRACTOR shall require that all laboratory testing sites providing services under
this Agreement have either a current CLIA certificate of waiver or a certificate of
registration along with a CLIA identification number. Those laboratories with
certificates of waiver will provide only the types of tests permitted under the terms
of their waiver. Laboratories with certificate of registration may perform a full range
of laboratory tests. The CONTRACTOR shall comply with the provisions of CLIA 1988.
	 
	 	2.11.8.6	 	Weight Watchers Centers or Other Weight Management Program
	 
	 	 	 	The CONTRACTOR is not required to credential Weight Watchers centers(s) or another
weight management program used as a cost effective alternative service pursuant to
Section 2.8.8 of this Agreement.

Page 165 of 374

 

2.11.9 Network Notice Requirements

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

Page 166 of 374

 

	 	2.11.9.1.4	 	Non-PCP Provider Termination
	 
	 	 	 	If a non-PCP provider, including but not limited to a specialist or hospital, ceases
participation in the CONTRACTOR’s MCO, the CONTRACTOR shall provide written notice to
members who have been seen and/or treated by the non-PCP provider within the last six
(6) months. Notice shall be issued no less than thirty (30) days prior to the effective
date of the termination of the non-PCP provider when possible or immediately upon the
CONTRACTOR becoming aware of the termination.
	 
	 	2.11.9.1.5	 	Long-Term Care Provider Termination
	 
	 	 	 	If a long-term care provider ceases participation in the CONTRACTOR’s MCO the
CONTRACTOR shall provide written notice as soon as possible, but no less than thirty
(30) calendar days prior to the effective date of the termination and no more than
fifteen (15) calendar days after receipt or issuance of the termination notice, to each
member who has chosen or is authorized to receive long-term care services from that
provider. Notices regarding termination by a nursing facility shall comply with state
and federal requirements. The requirement in this Section 2.11.9.1.5 to provide notice
thirty (30) calendar days prior to the effective date of termination shall be waived in
instances where a provider becomes physically unable to care for members due to
illness, a provider dies, the provider fails to provide thirty (30) calendar days
advance notice to the CONTRACTOR, the provider moves from the service area and fails to
notify the CONTRACTOR or a provider fails credentialing, and instead shall be made
immediately upon the CONTRACTOR becoming aware of the circumstances. See Section 2.9.4
of this Agreement regarding requirements for transitioning from a terminating provider
to a new provider.
	 
	 	2.11.9.1.6	 	Network Deficiency
	 
	 	 	 	Upon notification from TENNCARE that a corrective action plan designed to remedy a
network deficiency has not been accepted, the CONTRACTOR shall immediately provide
written notice to members living in the affected area of a provider shortage in the
CONTRACTOR’s network.
	 
	 	2.11.9.2	 	TENNCARE Notification
	 
	 	2.11.9.2.1	 	Subcontractor Termination
	 
	 	 	 	When a subcontract that relates to the provision of services to members or claims
processing is being terminated between the CONTRACTOR and a subcontractor, the
CONTRACTOR shall give at least thirty (30) calendar days prior written notice of the
termination to TENNCARE and TDCI. Said notices shall include, at a minimum: a
CONTRACTOR’s intent to change to a new subcontractor for the provision of said
services; an effective date for termination and/or change; and any other pertinent
information that may be needed to access services. In addition to prior written notice,
the CONTRACTOR shall also provide a transition plan to TENNCARE within fifteen (15)
calendar days, which shall include, at a minimum, information regarding how prior
authorization requests will be handled during and after the transition and how
continuity of care will be maintained for the members.

Page 167 of 374

 

	 	2.11.9.2.2	 	Hospital Termination
	 
	 	 	 	Termination of the CONTRACTOR’s provider agreement with any hospital, whether or
not the termination is initiated by the hospital or by the CONTRACTOR, shall be
reported by the CONTRACTOR in writing to the TENNCARE no less than thirty (30)
calendar days prior to the effective date of the termination.
	 
	 	2.11.9.2.3	 	Other Provider Terminations
	 
	 	2.11.9.2.3.1	 	The CONTRACTOR shall notify TENNCARE of any provider termination and
shall submit an Excel spreadsheet that includes the provider’s name, TennCare
provider identification number, NPI number, and the number of members
affected within five (5) business days of the provider’s termination. If the
termination was initiated by the provider, the notice to TENNCARE shall
include a copy of the provider’s notification to the CONTRACTOR. The
CONTRACTOR shall maintain documentation of all information, including a copy
of the actual member notice(s), on-site. Upon request, the CONTRACTOR shall
provide TENNCARE a copy of the following: one or more of the actual member
notices mailed, an electronic listing in Excel identifying each member to
whom a notice was sent, a transition plan for the members affected, and
documentation from the CONTRACTOR’s mail room or outside vendor indicating
the quantity and date member notices were mailed as proof of compliance with
the member notification requirements.
	 
	 	2.11.9.2.3.2	 	If termination of the CONTRACTOR’s provider agreement with any PCP or
physician group or clinic or long-term care provider, whether or not the
termination is initiated by the provider or by the CONTRACTOR, places the
CONTRACTOR out of compliance with Section 2.11 and Attachments III, IV and V,
such termination shall be reported by the CONTRACTOR in writing to TENNCARE,
in the standard format provided by TENNCARE to demonstrate compliance with
provider network and access requirements, within five (5) business days of
the date that the agreement has been terminated.

13. Section 2.12 shall be deleted in its entirety and replaced with the following:

2.12 PROVIDER AGREEMENTS

	 	2.12.1	 	Provider agreements, as defined in Section 1 of this Agreement, shall be administered
in accordance with this Agreement and shall contain or incorporate by reference
to the provider handbook all of the items listed in this Section 2.12. Any
requirements revised or added to Section 2.12 as part of amendment #4 may, for
non-long-term care providers, be incorporated by reference to the provider
handbook and included, as appropriate, in the next amendment to provider
agreements.
	 
	 	2.12.2	 	All template provider agreements and revisions thereto must be approved in writing
in advance by TDCI in accordance with statutes regarding the approval of a
certificate of authority (COA) and any material modifications thereof.
	 
	 	2.12.3	 	The CONTRACTOR shall revise provider agreements as directed by TENNCARE.

Page 168 of 374

 

	 	2.12.4	 	All single case agreements shall be reported to TENNCARE in accordance with
Section 2.30.8; however, prior approval will not be required unless TENNCARE
determines, upon review of said reports, that it appears single case agreements are
being used to circumvent the provider agreement review and approval process.
	 
	 	2.12.5	 	No provider agreement terminates or reduces the legal responsibility of the
CONTRACTOR to TENNCARE to ensure that all activities under this Agreement are carried
out. It shall be the responsibility of the CONTRACTOR to provide all necessary training
and information to providers to ensure satisfaction of all CONTRACTOR responsibilities
as specified in this Agreement.
	 
	 	2.12.6	 	The CONTRACTOR shall not execute provider agreements with providers who have
been excluded from participation in the Medicare, Medicaid, and/or SCHIP programs
pursuant to Sections 1128 or 1156 of the Social Security Act or who are otherwise not
in good standing with the TennCare program.
	 
	 	2.12.7	 	The CONTRACTOR shall not include covenant-not-to-compete requirements in its
provider agreements. The CONTRACTOR shall not execute provider agreements that require
that a provider not provide services for any other TennCare MCO.
	 
	 	2.12.8	 	The CONTRACTOR shall not execute provider agreements that contain
compensation terms that discourage providers from serving any specific eligibility
category or population covered by this Agreement.
	 
	 	2.12.9	 	All provider agreements executed by the CONTRACTOR, and all provider
agreements executed by subcontracting entities or organizations, shall, except as
otherwise provided in Section 2.12.13, at a minimum, meet the following requirements:
	 
	 	2.12.9.1	 	Be in writing. All new provider agreements and existing provider agreements as they
are renewed, shall include a signature page which contains CONTRACTOR and provider
names which are typed or legibly written, provider company with titles, and dated
signatures of all appropriate parties;
	 
	 	2.12.9.2	 	Specify the effective dates of the provider agreement;
	 
	 	2.12.9.3	 	Specify that the provider agreement and its attachments contain all the terms and
conditions agreed upon by the parties;
	 
	 	2.12.9.4	 	Assure that the provider shall not enter into any subsequent agreements or
subcontracts for any of the work contemplated under the provider agreement without the
prior written approval of the CONTRACTOR;
	 
	 	2.12.9.5	 	Identify the population covered by the provider agreement;
	 
	 	2.12.9.6	 	Specify that the provider may not refuse to provide covered medically necessary or
covered preventive services to a child under the age of twenty-one (21) or a TennCare
Medicaid patient under this Agreement for non-medical reasons. However, the provider
shall not be required to accept or continue treatment of a patient with whom the
provider feels he/she cannot establish and/or maintain a professional relationship;

Page 169 of 374

 

	 	2.12.9.7	 	Specify the functions and/or services to be provided by the provider and
assure that the functions and/or services to be provided are within the scope of
his/her professional/technical practice;
	 
	 	2.12.9.8	 	Specify the amount, duration and scope of services to be provided by the provider
and inform the provider of TennCare non-covered services as described in Section 2.10
of this Agreement and the TennCare rules and regulations;
	 
	 	2.12.9.9	 	Provide that emergency services be rendered without the requirement of prior
authorization of any kind;
	 
	 	2.12.9.10	 	Require compliance with applicable access requirements, including but not limited to
appointment and wait times as referenced in Section 2.11 of the CONTRACTOR’s Agreement with
TENNCARE;
	 
	 	2.12.9.11	 	Specify that unreasonable delay in providing care to a pregnant member seeking prenatal
care shall be considered a material breach of the provider’s agreement with the CONTRACTOR and
include the definition of unreasonable delay as described in Section 2.7.5.2.3 of this
Agreement;
	 
	 	2.12.9.12	 	If the provider performs laboratory services, require the provider to meet all applicable
requirements of the Clinical Laboratory Improvement Amendments (CLIA) of 1988;
	 
	 	2.12.9.13	 	Require the provider to have and maintain documentation necessary to demonstrate that
covered services were provided in compliance with state and federal requirements;
	 
	 	2.12.9.14	 	Require that an adequate record system be maintained and that all records be maintained
for five (5) years from the close of the provider agreement (behavioral health records shall
be maintained at the provider level for ten (10) years after the termination of the provider
agreement pursuant to TCA 33-3-101) or retained until all evaluations, audits, reviews or
investigations or prosecutions are completed for recording enrollee services, servicing
providers, charges, dates and all other commonly accepted information elements for services
rendered to enrollees pursuant to the provider agreement (including but not limited to such
records as are necessary for the evaluation of the quality, appropriateness, and timeliness of
services performed under the provider agreement and administrative, civil or criminal
investigations and prosecutions);
	 
	 	2.12.9.15	 	Include a statement that as a condition of participation in TennCare, enrollees shall
give TENNCARE, the Office of the Comptroller of the Treasury, and any health oversight agency,
such as OIG, TBI MFCU, DHHS Office of Inspector General (DHHS OIG), and DOJ, and any other
authorized state or federal agency, access to their records. Said records shall be made
available and furnished immediately upon request by the provider for fiscal audit, medical
audit, medical review, utilization review, and other periodic monitoring as well as for
administrative, civil and criminal investigations or prosecutions upon the request of an
authorized representative of the CONTRACTOR, TENNCARE or authorized federal, state and Office
of the

Page 170 of 374

 

	 	 	 	Comptroller of the Treasury personnel, including, but not limited to, the OIG, the TBI
MFCU, the DHHS OIG and the DOJ;
	 
	 	2.12.9.16	 	Include medical records requirements found in Section 2.24.6 of this Agreement;
	 
	 	2.12.9.17	 	Contain the language described in Section 2.25.6 of this Agreement regarding Audit
Requirements and Section 2.25.5 of this Agreement regarding Availability of Records;
	 
	 	2.12.9.18	 	Provide that TENNCARE, DHHS OIG, Office of the Comptroller of the Treasury, OIG, TBI
MFCU, and DOJ, as well as any authorized state or federal agency or entity shall have the
right to evaluate through inspection, evaluation, review or request, whether announced or
unannounced, or other means any records pertinent to this Agreement including, but not limited
to medical records, billing records, financial records, and/or any records related to services
rendered, quality, appropriateness and timeliness of services and/or any records relevant to
an administrative, civil and/or criminal investigation and/or prosecution and such evaluation,
inspection, review or request, and when performed or requested, shall be performed with the
immediate cooperation of the provider. Upon request, the provider shall assist in such reviews
including the provision of complete copies of medical records. Include a statement that HIPAA
does not bar disclosure of protected health information (PHI) to health oversight agencies,
including, but not limited to, OIG, TBI MFCU, DHHS OIG and DOJ. Provide that any authorized
state or federal agency or entity, including, but not limited to TENNCARE, OIG, TBI MFCU, DHHS
OIG, DOJ, Office of the Comptroller of the Treasury, may use these records and information for
administrative, civil or criminal investigations and prosecutions;
	 
	 	2.12.9.19	 	Provide for monitoring, whether announced or unannounced, of services rendered to
members;
	 
	 	2.12.9.20	 	Provide for the participation and cooperation in any internal and external QM/QI,
monitoring, utilization review, peer review and/or appeal procedures established by the
CONTRACTOR and/or TENNCARE;
	 
	 	2.12.9.21	 	Specify CONTRACTOR’s responsibilities under this Agreement and its agreement with the
provider, including but not limited to, provision of a copy of the member handbook and
provider handbook whether via web site or otherwise and requirement that the CONTRACTOR notice
a provider of denied authorizations;
	 
	 	2.12.9.22	 	Specify that the CONTRACTOR shall monitor the quality of services delivered under the
provider agreement and initiate corrective action where necessary to improve quality of care,
in accordance with that level of medical, behavioral health, or long-term care which is
recognized as acceptable professional practice in the respective community in which the
provider practices and/or the standards established by TENNCARE;
	 
	 	2.12.9.23	 	Require that the provider comply with corrective action plans initiated by the
CONTRACTOR;
	 
	 	2.12.9.24	 	Provide for the timely submission of all reports and clinical information required by the
CONTRACTOR;

Page 171 of 374

 

	 	2.12.9.25	 	Provide the name and address of the official payee to whom payment shall be made;
	 
	 	2.12.9.26	 	Make full disclosure of the method and amount of compensation or other consideration to
be received from the CONTRACTOR;
	 
	 	2.12.9.27	 	Specify that the CONTRACTOR shall only pay providers for services (1) provided in
accordance with the requirements of this Agreement, the CONTRACTOR’s policies and procedures
implementing this Agreement, and state and federal law and (2) provided to TennCare enrollees
who are enrolled with the CONTRACTOR; and specify that the provider is responsible for (1)
ensuring that any applicable authorization requirements are met and (2) verifying that a
person is eligible for TennCare on the date of service;
	 
	 	2.12.9.28	 	Provide for prompt submission of information needed to make payment. Specify that a
provider shall have one hundred twenty (120) calendar days from the date of rendering a
covered service to file a claim with the CONTRACTOR except in situations regarding
coordination of benefits or subrogation in which case the provider is pursuing payment from a
third party or if an enrollee is enrolled in the MCO with a retroactive eligibility date. In
situations of third party benefits, the maximum time frames for filing a claim shall begin on
the date that the third party documented resolution of the claim. In situations of enrollment
in the CONTRACTOR’s MCO with a retroactive eligibility date, the time frames for filing a
claim shall begin on the date that the CONTRACTOR receives notification from TENNCARE of the
enrollee’s eligibility/enrollment;
	 
	 	2.12.9.29	 	Provide for payment to the provider upon receipt of a clean claim properly submitted by
the provider within the required time frames as specified in TCA 56-32-126 and Section 2.22.4
of this Agreement;
	 
	 	2.12.9.30	 	Specify the provider shall accept payment or appropriate denial made by the CONTRACTOR
(or, if applicable, payment by the CONTRACTOR that is supplementary to the enrollee’s third
party payer) plus the amount of any applicable TennCare cost sharing responsibilities, as
payment in full for covered services provided and shall not solicit or accept any surety or
guarantee of payment from the enrollee in excess of the amount of applicable TennCare cost
sharing responsibilities. Enrollee shall include the patient, parent(s), guardian, spouse or
any other legally responsible person of the enrollee being served;
	 
	 	2.12.9.31	 	 Specify that in the event that TENNCARE deems the CONTRACTOR unable to timely process
and reimburse claims and requires the CONTRACTOR to submit provider claims for reimbursement
to an alternate claims processor to ensure timely reimbursement, the provider shall agree to
accept reimbursement at the CONTRACTOR’s contracted reimbursement rate or the rate established
by TENNCARE, whichever is greater;
	 
	 	2.12.9.32	 	Specify the provider’s responsibilities and prohibited activities regarding cost sharing
as provided in Section 2.6.7 of this Agreement;
	 
	 	2.12.9.33	 	Specify the provider’s responsibilities regarding third party liability (TPL) , including
the provider’s obligation to identify third party liability coverage, including Medicare

Page 172 of 374

 

	 	 	 	and long-term care insurance as applicable, and, except as otherwise provided in the
CONTRACTOR’s Agreement with TENNCARE, to seek such third party liability payment before
submitting claims to the CONTRACTOR;
	 
	 	2.12.9.34	 	For those agreements where the provider is compensated via a capitation arrangement,
language which requires:
	 
	 	2.12.9.34.1	 	That if a provider becomes aware for any reason that he or she is not entitled to a
capitation payment for a particular enrollee (a patient dies, for example), the provider shall
immediately notify both the CONTRACTOR and TENNCARE by certified mail, return receipt
requested; and
	 
	 	2.12.9.34.2	 	The provider shall submit utilization or encounter data as specified by the CONTRACTOR
so as to ensure the CONTRACTOR’s ability to submit encounter data to TENNCARE that meets the
same standards of completeness and accuracy as required for proper adjudication of
fee-for-service claims;
	 
	 	2.12.9.35	 	Require the provider to comply with fraud and abuse requirements described in Section
2.20 of this Agreement;
	 
	 	2.12.9.36	 	Require the provider to report suspected abuse, neglect, and exploitation of adults in
accordance with TCA 71-6-103 and to report suspected brutality, abuse, or neglect of children
in accordance with TCA 37-1-403 and TCA 37-1-605;
	 
	 	2.12.9.37	 	Require that, for CHOICES members, the provider facilitate notification of the member’s
care coordinator by notifying the CONTRACTOR, in accordance with the CONTRACTOR’s processes,
as expeditiously as warranted by the member’s circumstances, of any known significant changes
in the member’s condition or care, hospitalizations, or recommendations for additional
services;
	 
	 	2.12.9.38	 	Require hospitals, including psychiatric hospitals, to cooperate with the CONTRACTOR in
developing and implementing protocols as part of the CONTRACTOR’s nursing facility diversion
plan (see Section 2.9.6.7), which shall, include, at a minimum, the hospital’s obligation to
promptly notify the CONTRACTOR upon admission of an eligible member regardless of payor source
for the hospitalization; how the hospital will identify members who may need home health,
private duty nursing, nursing facility, or HCBS upon discharge, and how the hospital will
engage the CONTRACTOR in the discharge planning process to ensure that members receive the
most appropriate and cost-effective medically necessary services upon discharge;
	 
	 	2.12.9.39	 	Require the provider to conduct background checks in accordance with state law and
TennCare policy;
	 
	 	2.12.9.40	 	As a condition of reimbursement for global procedures codes for obstetric care, the
provider shall submit utilization or encounter data as specified by the CONTRACTOR in a timely
manner to support the individual services provided;
	 
	 	2.12.9.41	 	Except as otherwise specified in Sections 2.12.11 or 2.12.12, require the provider to
secure all necessary liability and malpractice insurance coverage as is necessary to
adequately protect the CONTRACTOR’s members and the CONTRACTOR under

Page 173 of 374

 

	 	 	 	the provider agreement. The provider shall maintain such insurance coverage at all
times during the provider agreement and upon execution of the provider agreement
furnish the CONTRACTOR with written verification of the existence of such coverage;
	 
	 	2.12.9.42	 	Specify both the CONTRACTOR and the provider agree to recognize and abide by all state
and federal laws, regulations and guidelines applicable to the CONTRACTOR and the provider.
Provide that the agreement incorporates by reference all applicable federal law and state
laws, TennCare rules and regulations, consent decrees or court orders, and revisions of such
laws, regulations, consent decrees or court orders shall automatically be incorporated into
the provider agreement, as they become effective;
	 
	 	2.12.9.43	 	Specify procedures and criteria for any alterations, variations, modifications, waivers,
extension of the provider agreement termination date, or early termination of the agreement
and specify the terms of such change. If provision does not require amendments be valid only
when reduced to writing, duly signed and attached to the original of the provider agreement,
then the terms shall include provisions allowing at least thirty (30) calendar days to give
notice of rejection and requiring that receipt of notification of amendments be documented
(e.g., certified mail, facsimile, hand- delivered receipt, etc);
	 
	 	2.12.9.44	 	Include provisions that allow the CONTRACTOR to suspend, deny, refuse to renew or
terminate any provider agreement in accordance with the terms of the CONTRACTOR’s Agreement
with TENNCARE (see Section 4.4) and applicable law and regulation;
	 
	 	2.12.9.45	 	Specify that TENNCARE reserves the right to direct the CONTRACTOR to terminate or modify
the provider agreement when TENNCARE determines it to be in the best interest of the State.
	 
	 	2.12.9.46	 	Specify that both parties recognize that in the event of termination of this Agreement
between the CONTRACTOR and TENNCARE for any of the reasons described in Section 4.4 of this
Agreement, the provider shall immediately make available, to TENNCARE, or its designated
representative, in a usable form, any or all records, whether medical or financial, related to
the provider’s activities undertaken pursuant to the CONTRACTOR/provider agreement. The
provision of such records shall be at no expense to TENNCARE;
	 
	 	2.12.9.47	 	Specify that the TennCare Provider Independent Review of Disputed Claims process shall be
available to providers to resolve claims denied in whole or in part by the CONTRACTOR as
provided at TCA 56-32-126(b);
	 
	 	2.12.9.48	 	Include a Conflict of Interest clause as stated in Section 4.19 of this Agreement,
Gratuities clause as stated in Section 4.23 of this Agreement, and Lobbying clause as stated
in Section 4.24 of this Agreement between the CONTRACTOR and TENNCARE;
	 
	 	2.12.9.49	 	Specify that at all times during the term of the agreement, the provider shall indemnify
and hold TENNCARE harmless from all claims, losses, or suits relating to activities undertaken
pursuant to the Agreement between TENNCARE and the

Page 174 of 374

 

	 	 	 	CONTRACTOR. This indemnification may be accomplished by incorporating Section 4.31 of
the TENNCARE/CONTRACTOR Agreement in its entirety in the provider agreement or by use
of other language developed by the CONTRACTOR and approved in writing by TENNCARE;
	 
	 	2.12.9.50	 	Require safeguarding of information about enrollees according to applicable state and
federal laws and regulations and as described in Sections 2.27 and 4.33 of this Agreement;
	 
	 	2.12.9.51	 	Specify provider actions to improve patient safety and quality;
	 
	 	2.12.9.52	 	Provide general and targeted education to providers regarding emergency appeals,
including when an emergency appeal is appropriate, and procedures for providing written
certification thereof, and specify that the provider shall comply with the appeal process,
including but not limited to the following:
	 
	 	2.12.9.52.1	 	Assist an enrollee by providing appeal forms and contact information including the
appropriate address, telephone number and/or fax number for submitting appeals for state level
review; and
	 
	 	2.12.9.52.2	 	Require in advance, that providers seek prior authorization, when they feel they cannot
order a drug on the TennCare PDL as well as taking the initiative to seek prior authorization
or change or cancel the prescription when contacted by an enrollee or pharmacy regarding
denial of a pharmacy service due to system edits (e.g., therapeutic duplication, etc.).
	 
	 	2.12.9.53	 	Require the provider to coordinate with the TennCare PBM regarding authorization and
payment for pharmacy services;
	 
	 	2.12.9.54	 	Specify any liquidated damages, sanctions or reductions in payment that the CONTRACTOR
may assess on the provider for specific failures to comply with contractual and/or
credentialing requirements. This shall include, but may not be limited to a provider’s failure
or refusal to respond to the CONTRACTOR’s request for information, the request to provide
medical records, credentialing information, etc.; at the CONTRACTOR’s discretion or a
directive by TENNCARE, the CONTRACTOR shall impose financial consequences against the provider
as appropriate;
	 
	 	2.12.9.55	 	Require that the provider display notices of the enrollee’s right to appeal adverse
action affecting services in public areas of their facility(s) in accordance with TennCare
rules and regulations, subsequent amendments, or any and all consent decrees and court orders.
The CONTRACTOR shall ensure that providers have a correct and adequate supply of public
notices;
	 
	 	2.12.9.56	 	Include language which informs providers of the package of benefits that TENNderCare
offers and which requires providers to make treatment decisions based upon children’s
individual medical and behavioral health needs. TENNderCare requirements are contained in
Section 2.7.6 of this Agreement. All provider agreements shall contain language that
references the TENNderCare requirements in this Agreement between TENNCARE and the CONTRACTOR,
and the provider agreement shall either physically incorporate these sections of the Agreement
or

Page 175 of 374

 

	 	 	 	include language to require that these sections be furnished to the provider upon
request;
	 
	 	2.12.9.57	 	Include a provision which states that providers are not permitted to encourage or suggest, in any way, that TennCare
children be placed into state custody in order to receive medical, behavioral, or long-term care services covered by TENNCARE;
	 
	 	2.12.9.58	 	Require that providers offer hours of operation that are no less than the hours of operation offered to commercial
enrollees;
	 
	 	2.12.9.59	 	Specify that the provider have written procedures for the provision of language interpretation and translation services
for any enrollee who needs such services, including but not limited to, enrollees with Limited English Proficiency;
	 
	 	2.12.9.60	 	Require the provider to comply and submit to the CONTRACTOR disclosure of information in accordance with the
requirements specified in 42 CFR Part 455, Subpart B;
	 
	 	2.12.9.61	 	Require providers to screen their employees and contractors initially and on an ongoing monthly basis to determine
whether any of them has been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as
defined in Section 1 128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been
excluded. The provider shall be required to immediately report to the CONTRACTOR any exclusion information discovered. The
provider shall be informed that civil monetary penalties may be imposed against providers who employ or enter into contracts with
excluded individuals or entities to provide items or services to TennCare members; and
	 
	 	2.12.9.62	 	Require that if any requirement in the provider agreement is determined by TENNCARE to conflict with the Agreement
between TENNCARE and the CONTRACTOR, such requirement shall be null and void and all other provisions shall remain in full force
and effect.
	 
	 	2.12.10	 	No other terms or conditions agreed to by the CONTRACTOR and the provider shall
negate or supersede the requirements listed in 2.12.9 above.
	 
	 	2.12.11	 	The provider agreement with a nursing facility shall meet the minimum requirements
specified in Section 2.12.9 above and shall also include, at a minimum, the following
requirements:
	 
	 	2.12.11.1	 	Require the nursing facility provider to promptly notify the CONTRACTOR, and/or State
entity as directed by TENNCARE, of a member’s admission or request for admission to the
nursing facility regardless of payor source for the nursing facility stay, or when there is a
change in a member’s known circumstances and to notify the CONTRACTOR, and/or State entity as
directed by TENNCARE, prior to a member’s discharge;
	 
	 	2.12.11.2	 	Require the nursing facility provider to provide written notice to TENNCARE and the
CONTRACTOR in accordance with state and federal requirements before voluntarily terminating
the agreement and to comply with all applicable state and federal requirements regarding
voluntary termination;

Page 176 of 374

 

	 	2.12.11.3	 	Require the nursing facility provider to notify the CONTRACTOR immediately if
the nursing facility is considering discharging a member and to consult with the
member’s care coordinator to intervene in resolving issues if possible and, if not, to
prepare and implement a discharge and/or transition plan as appropriate;
	 
	 	2.12.11.4	 	Require the nursing facility to notify the member and/or the member’s representative (if
applicable) in writing prior to discharge in accordance with state and federal requirements;
	 
	 	2.12.11.5	 	Specify the provider shall accept payment or appropriate denial made by the CONTRACTOR
(or, if applicable, payment by the CONTRACTOR that is supplementary to the member’s third
party payer) plus the amount of any applicable patient liability, as payment in full for
services provided and shall not solicit or accept any surety or guarantee of payment from the
member in excess of the amount of applicable patient liability responsibilities. Member shall
include the patient, parent(s), guardian, spouse or any other legally responsible person of
the member being served;
	 
	 	2.12.11.6	 	Specify the nursing facility provider’s responsibilities regarding patient liability (see
Sections 2.6.7 and 2.21.5 of this Agreement), which shall include but not be limited to
collecting the applicable patient liability amounts from CHOICES Group 1 members, notifying
the member’s care coordinator if there is an issue with collecting a member’s patient
liability, and making good faith efforts to collect payment;
	 
	 	2.12.11.7	 	Specify the role of the nursing facility provider regarding timely certification and
recertification (as applicable) of the member’s level of care eligibility for Level I and/or
Level II nursing facility care and require the nursing facility provider to cooperate fully
with the CONTRACTOR in the completion and submission of the level of care assessment;
	 
	 	2.12.11.8	 	Require the nursing facility to notify the CONTRACTOR of any change in a member’s medical
or functional condition that could impact the member’s level of care eligibility for the
currently authorized level of nursing facility services;
	 
	 	2.12.11.9	 	Require the nursing facility provider to comply with state and federal laws and
regulations applicable to nursing facilities as well as any applicable federal court orders,
including but not limited to those that govern admission, transfer, and discharge policies;
	 
	 	2.12.11.10	 	Require the nursing facility to comply with federal Preadmission Screening and Resident
Review (PASRR) requirements applicable to all nursing facility residents, regardless of payor
source, including that a level I screening be completed prior to admission, a level II
evaluation be completed prior to admission when indicated by the level I screening, and a
review be completed based upon a significant physical or mental change in the resident’s
condition that might impact the member’s need for or benefit from specialized services;
	 
	 	2.12.11.11	 	Require the nursing facility to cooperate with the CONTRACTOR in developing and
implementing protocols as part of the CONTRACTOR’s nursing facility diversion and transition
plans (see Section 2.9.6.7), which shall, include, at a minimum, the

Page 177 of 374

 

	 	 	 	nursing facility’s obligation to promptly notify the CONTRACTOR upon admission or
request for admission of an eligible member regardless of payor source for the nursing
facility stay; how the nursing facility will assist the CONTRACTOR in identifying
residents who may want to transition from nursing facility services to home and
community-based care; the nursing facility’s obligation to promptly notify the
CONTRACTOR regarding all such identified members; and how the nursing facility will
work with the CONTRACTOR in assessing the member’s transition potential and needs, and
in developing and implementing a transition plan, as applicable;
	 
	 	2.12.11.12	 	Require the nursing facility provider to coordinate with the CONTRACTOR in complying with the
requirements in 42 CFR 483.75 regarding written transfer agreements and shall use contract providers
when transfer is medically appropriate, except as authorized by the CONTRACTOR or for emergency
services;
	 
	 	2.12.11.13	 	Require the nursing facility provider to have on file a system designed and utilized to
ensure the integrity of the member’s personal financial resources. This system shall be designed in
accordance with the regulations and guidelines set out by the Comptroller of the Treasury and the
applicable federal regulations;
	 
	 	2.12.11.14	 	Require the nursing facility provider to immediately notify the CONTRACTOR of any change in
its license to operate as issued by the Tennessee Department of Health as well as any deficiencies cited
during the federal certification process;
	 
	 	2.12.11.15	 	Provide that if the nursing facility provider is involuntarily decertified by the Tennessee
Department of Health or the Centers for Medicare and Medicaid Services, the provider agreement will
automatically be terminated in accordance with federal requirements;
	 
	 	2.12.11.16	 	For a minimum of three (3) years following the effective date of CHOICES implementation (see
Section 2.11.6.1 of this Agreement and TCA 71-5-1412(b)), shall not require the nursing facility
provider to have liability insurance in excess of TENNCARE requirements in effect prior to the
implementation of CHOICES; and
	 
	 	2.12.11.17	 	Include language requiring that the provider agreement shall be assignable from the
CONTRACTOR to the State, or its designee, at the State’s discretion upon written notice to the
CONTRACTOR and the affected nursing facility provider. Further, the provider agreement shall include
language by which the nursing facility provider agrees to be bound by any such assignment, and that the
State, or its designee, shall not be responsible for past obligations of the CONTRACTOR.
	 
	 	2.12.12	 	The provider agreement with a HCBS provider shall meet the minimum requirements
specified in Section 2.12.9 above and shall also include, at a minimum, the following
requirements:
	 
	 	2.12.12.1	 	Require the HCBS provider to provide at least thirty (30) days advance notice to the
CONTRACTOR when the provider is no longer willing or able to provide services to a member,
including the reason for the decision, and to cooperate with the member’s care coordinator to
facilitate a seamless transition to alternate providers;

Page 178 of 374

 

	 	2.12.12.2	 	In the event that a HCBS provider change is initiated for a member, require that,
regardless of any other provision in the provider agreement, the transferring HCBS provider
continue to provide services to the member in accordance with the member’s plan of care until
the member has been transitioned to a new provider, as determined by the CONTRACTOR, or as
otherwise directed by the CONTRACTOR, which may exceed thirty (30) days from the date of notice
to the CONTRACTOR;
	 
	 	2.12.12.3	 	Specify that reimbursement of a HCBS provider shall be contingent upon the provision
of services to an eligible member in accordance with applicable federal and state requirements
and the member’s plan of care as authorized by the CONTRACTOR;
	 
	 	2.12.12.4	 	Require HCBS providers to immediately report any deviations from a member’s service
schedule to the member’s care coordinator;
	 
	 	2.12.12.5	 	Require HCBS providers to use the electronic visit verification system specified by
the CONTRACTOR in accordance with the CONTRACTOR’s requirements;
	 
	 	2.12.12.6	 	Require that upon acceptance by the HCBS provider to provide approved services to a
member as indicated in the member’s plan of care, the provider shall ensure that it has staff
sufficient to provide the service(s) authorized by the CONTRACTOR in accordance with the
member’s plan of care, including the amount, frequency, duration and scope of each service in
accordance with the member’s service schedule;
	 
	 	2.12.12.7	 	Require HCBS providers to provide back-up for their own staff if they are unable to
fulfill their assignment for any reason and ensure that back-up staff meet the qualifications
for the authorized service;
	 
	 	2.12.12.8	 	Prohibit HCBS providers from requiring a member to choose the provider as a provider
of multiple services as a condition of providing any service to the member;
	 
	 	2.12.12.9	 	Require HCBS providers to comply with critical incident reporting and management
requirements (see Section 2.15.8 of this Agreement); and
	 
	 	2.12.12.10	 	Shall not require the HCBS provider to have liability insurance in excess of
TENNCARE requirements in effect prior to the implementation of CHOICES.
	 
	 	2.12.13	 	The provider agreement with a HCBS provider to provide PERS, assistive
technology, minor home modifications, or pest control shall meet the requirements
specified in Sections 2.12.9, 2.12.10, and 2.12.12 except that these provider
agreements shall not be required to meet the following requirements: Section 2.12.9.9
regarding emergency services; Section 2.12.9.11 regarding delay in prenatal care;
Section 2.12.9.12 regarding CLIA; Section 2.12.9.38 regarding hospital protocols;
Section 2.12.9.40 regarding reimbursement of obstetric care; Section 2.12.9.52.2
regarding prior authorization of pharmacy; and Section 2.12.9.53 regarding coordination
with the PBM.
	 
	 	2.12.14	 	The provider agreement with a local health department (see Section 2.11.7.3) shall
meet the minimum requirements specified in Sections 2.12.9 and 2.12.10 above and
shall also specify for the purpose of TENNderCare screening services: (1) that the

Page 179 of 374

 

	 	 	 	local health department agrees to submit encounter data timely to the
CONTRACTOR; (2) that the CONTRACTOR agrees to timely process claims for services
in accordance with Section 2.22.4; (3) that the local health department may
terminate the agreement for cause with thirty (30) days advance notice; and (4)
that the CONTRACTOR agrees prior authorization shall not be required for the
provision of TENNderCare screening services.
	 
	 	2.12.15	 	The provider agreement for CRG/TPG assessments shall meet the minimum
requirements specified in Sections 2.12.9 and 2.12.10 above and shall also
specify that all CRG/TPG assessments detailed in Section 2.7.2.9 are completed
by State- certified raters and that the assessments are completed within the
specified time frames. The rater certification process shall include completing
the CRG/TPG assessments training and passing the State rater competency
examination, scored only by State-certified trainers.

14. Section 2.13 shall be deleted in its entirety and replaced with the following:

2.13 PROVIDER AND SUBCONTRACTOR PAYMENTS

2.13.1 General

	 	2.13.1.1	 	The CONTRACTOR shall agree to reasonable reimbursement standards to providers
for covered services, to be determined in conjunction with actuarially sound
rate setting. All reimbursement paid by the CONTRACTOR to providers and amounts
paid by the CONTRACTOR to any other entity is subject to audit by the State.
	 
	 	2.13.1.2	 	The CONTRACTOR shall require, as a condition of payment, that the provider
(contract or non-contract provider) accept the amount paid by the CONTRACTOR or
appropriate denial made by the CONTRACTOR (or, if applicable, payment by the
CONTRACTOR that is supplementary to the enrollee’s third party payer) plus any
applicable amount of TennCare cost sharing or patient liability responsibilities
due from the enrollee as payment in full for the service.
	 
	 	2.13.1.3	 	If the CONTRACTOR is required to reimburse a non-contract provider pursuant to
this Agreement, and the CONTRACTOR’s payment to a non-contract provider is less
than it would have been for a contract provider, and the provider contests the
payment amount, the CONTRACTOR shall notify the non-contract provider that the
provider may initiate the independent review procedures in accordance with TCA
56- 32-126, including but not limited to reconsideration by the CONTRACTOR.
	 
	 	2.13.1.4	 	The CONTRACTOR shall ensure that the member is held harmless by the provider
for the costs of medically necessary covered services except for applicable
TennCare cost sharing amounts (described in Section 2.6.7 and in Attachment II
of this Agreement) and patient liability amounts.
	 
	 	2.13.1.5	 	The CONTRACTOR shall ensure that payments are not issued to providers that have
not obtained a Tennessee Medicaid provider number or for which disclosure
requirements, as applicable, have not been obtained by the CONTRACTOR in
accordance with 42 CFR 455.100 through 106 and Section 2.12.9.60 of this
Agreement.

Page 180 of 374

 

2.13.2 All Covered Services

	 	2.13.2.1	 	Except as provided in Sections 2.13.2.2 and 2.13.2.3 below, the CONTRACTOR
shall not reimburse providers based on a percentage of billed charges.
	 
	 	2.13.2.2	 	The CONTRACTOR may, at its discretion, pay a percentage of billed charges for
covered physical health and behavioral health services for which there is no
Medicare reimbursement methodology.
	 
	 	2.13.2.3	 	As part of a stop-loss arrangement with a physical health or behavioral health
provider, the CONTRACTOR may, at its discretion, pay the provider a percentage
of billed charges for claims that exceed the applicable stop-loss threshold.

2.13.3 Nursing Facility Services

	 	2.13.3.1	 	The CONTRACTOR shall reimburse contract nursing facility providers at the rate
specified by TENNCARE, net of any applicable patient liability amount (see
Section 2.6.7).
	 
	 	2.13.3.2	 	The CONTRACTOR shall reimburse non-contract nursing facility providers as
specified in TennCare rules and regulations, net of any applicable patient
liability amount (see Section 2.6.7).
	 
	 	2.13.3.3	 	If, prior to the end date specified by TENNCARE in its approval of Level II
nursing facility services, the CONTRACTOR determines that the nursing facility is
providing Level I and not Level II nursing facility services, the CONTRACTOR shall
notify TENNCARE and, as appropriate, shall submit a request to modify the member’s
level of nursing facility services. The CONTRACTOR shall submit documentation as
specified by TENNCARE to support the request. The CONTRACTOR may adjust payment to
the nursing facility to reflect the level of nursing facility services actually
provided to the member and shall maintain documentation as specified by TENNCARE
to support the payment adjustment.

2.13.4 HCBS

	 	2.13.4.1	 	For covered HCBS and for HCBS that exceed the specified benefit limit and are
provided by the CONTRACTOR as a cost effective alternative (see Section 2.6.5),
the CONTRACTOR shall reimburse contract HCBS providers, including
community-based residential alternatives, at the rate specified by TENNCARE.
	 
	 	2.13.4.2	 	The CONTRACTOR shall reimburse non-contract HCBS providers as specified in
TennCare rules and regulations.
	 
	 	2.13.4.3	 	For HCBS that are not otherwise covered but are offered by the CONTRACTOR as a cost
effective alternative to nursing facility services (see Section 2.6.5), the CONTRACTOR
shall negotiate the rate of reimbursement.
	 
	 	2.13.4.4	 	The CONTRACTOR shall reimburse consumer-directed workers in accordance with Sections
2.9.6.7 and 2.26 of this Agreement.

Page 181 of 374

 

 

2.13.5 Hospice

Hospice services shall be provided and reimbursed in accordance with state and federal
requirements, including but not limited to the following:

	 	2.13.5.1	 	Rates shall be no less than the federally established Medicaid hospice rates
(updated each federal fiscal year (FFY)), adjusted by area wage adjustments for the
categories described by CMS;
	 
	 	2.13.5.2	 	The rates described above shall be subject to the annual cap for Medicaid
Hospice rates as provided annually by CMS; and
	 
	 	2.13.5.3	 	If a Medicaid hospice patient resides in a nursing facility (NF), the
CONTRACTOR shall pay an amount equal to at least 95 percent of the prevailing NF
room and board rate to the hospice provider (not subject to the annual cap for
Medicaid Hospice rates).

2.13.6 Behavioral Health Crisis Service Teams

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

2.13.7 Local Health Departments

	 	2.13.7.1	 	The CONTRACTOR shall reimburse contracted local health departments (see
Sections 2.11.7.3 and 2.12.1.3) for TENNderCare screenings to members under age
twenty-one (21) at the following rates, unless specified otherwise by TENNCARE.
Although the codes include preventive visits for individuals twenty-one (21) and
older, this Section only requires the CONTRACTOR to pay local health departments
for the specified visits for members under age twenty-one (21).

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

	 	2.13.7.2	 	TENNCARE may conduct an audit of the CONTRACTOR’s reimbursement methodology and
related processes on an annual basis to verify compliance with this

Page 182 of 374

 

 

	 	 	 	requirement. In addition, the Local Health Department may initiate the
independent review procedure at any time it believes the CONTRACTOR’s payment is
not the required reimbursement rate.

2.13.8 Physician Incentive Plan (PIP)

	 	2.13.8.1	 	The CONTRACTOR shall notify and make TENNCARE and TDCI aware of any operations or
plans to operate a physician incentive plan (PIP). Prior to implementation of any such
plans, the CONTRACTOR shall submit to TDCI any provider agreement templates or
subcontracts that involve a PIP for review as a material modification.
	 
	 	2.13.8.2	 	The CONTRACTOR shall not implement a PIP in the absence of TDCI review and written
approval.
	 
	 	2.13.8.3	 	If the CONTRACTOR operates a PIP, the CONTRACTOR shall ensure that no specific
payment be made directly or indirectly under a PIP to a physician or physician group as
an inducement to reduce or limit medically necessary services furnished to an
individual.
	 
	 	2.13.8.4	 	If the CONTRACTOR operates a PIP, upon TENNCARE’s request, the CONTRACTOR shall
report descriptive information about its incentive plan in sufficient detail to enable
TENNCARE to adequately monitor the CONTRACTOR. The information that may be requested
shall include, but not be limited to, the following:
	 
	 	2.13.8.4.1	 	Whether services not furnished by the physician or physician group are covered by
the incentive plan;
	 
	 	2.13.8.4.2	 	The type or types of incentive arrangements, such as, withholds, bonus,
capitation;

	 
	 	2.13.8.4.3	 	The percent of any withhold or bonus the plan uses;
	 
	 	2.13.8.4.4	 	Assurance that the physicians or physician group has adequate stop-loss
protection, and the amount and type of stop-loss protection; and
	 
	 	2.13.8.4.5	 	The patient panel size and, if the plan uses pooling, the pooling
method.

2.13.9 Emergency Services Obtained from Non-Contract Providers

	 	2.13.9.1	 	Payments to non-contract providers for emergency services may, at the
CONTRACTOR’s option, be limited to the treatment of emergency medical
conditions, including post-stabilization care services, as described in Section
1. Payment amounts shall be consistent with the pricing policies developed by
the CONTRACTOR and in accordance with TENNCARE requirements, including TennCare
rules and regulations for emergency services provided by non-contract providers.
	 
	 	2.13.9.2	 	Payment by the CONTRACTOR for properly documented claims for emergency services
rendered by a non-contract provider shall be made within thirty (30) calendar days of
receipt of a clean claim by the CONTRACTOR.

Page 183 of 374

 

 

	 	2.13.9.3	 	The CONTRACTOR shall review and approve or disapprove claims for
emergency services based on the definition of emergency services specified in
Section 1 of this Agreement. If the CONTRACTOR determines that a claim
requesting payment of emergency services does not meet the definition as
specified in Section 1 and subsequently denies the claim, the CONTRACTOR shall
notify the provider of the denial. This notification shall include information
to the provider regarding the CONTRACTOR’s process and time frames for
reconsideration. In the event a provider disagrees with the CONTRACTOR’s
decision to disapprove a claim for emergency services, the provider may pursue
the independent review process for disputed claims as provided by TCA 56-32-126,
including but not limited to reconsideration by the CONTRACTOR.

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

	 	2.13.10.1	 	The CONTRACTOR shall pay for medically necessary covered services provided to an
enrollee by a non-contract provider when TENNCARE has enrolled the enrollee in the
CONTRACTOR’s MCO, but the enrollee could not have known which MCO they were enrolled in
at the time of the service. Examples of when this may occur include, but are not
limited to, (i) when an enrollee receives services during a retroactive eligibility
period (see Section 2.4.5) and the enrollee did not select an MCO and is assigned to an
MCO by TENNCARE, or (ii) the enrollee was assigned to an MCO other than the one that
he/she requested (see Section 2.4.4.5). In these cases, the effective date of
enrollment may occur prior to the CONTRACTOR or the enrollee being notified of the
enrollee becoming a member of the CONTRACTOR’s MCO.
	 
	 	2.13.10.2	 	When this situation arises, the CONTRACTOR shall not deny payment for medically
necessary covered services provided during this period of eligibility for lack of prior
authorization or lack of referral; likewise, the CONTRACTOR shall not deny a claim on
the basis of the provider’s failure to file a claim within a specified time period
after the date of service when the provider could not have reasonably known which MCO
the enrollee was in during the timely filing period. However, in such cases the
CONTRACTOR may impose timely filing requirements beginning on the date of notification
of the individual’s enrollment.
	 
	 	2.13.10.3	 	The CONTRACTOR shall only pay for covered long-term care services for which the
member was eligible (see Section 2.6), as determined by the State and shown in the
enrollment file furnished by TENNCARE to the CONTRACTOR.

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

	 	2.13.11.1	 	The CONTRACTOR shall pay for medically necessary covered services provided to an
enrollee by a contract provider without prior authorization or referral when TENNCARE
has enrolled the enrollee in the CONTRACTOR’s MCO, but the enrollee could not have
known which MCO they were enrolled in at the time of the service.

Page 184 of 374

 

 

	 	2.13.11.2	 	When this situation arises, the CONTRACTOR shall not deny payment for
medically necessary covered services for lack of prior authorization or lack of
referral; likewise, a CONTRACTOR shall not deny a claim on the basis of the
provider’s failure to file a claim within a specified time period after the date
of service when the provider could not have reasonably known which MCO the
enrollee was in during the timely filing period. However, in such cases the
CONTRACTOR may impose timely filing requirements beginning on the date of
notification of the individual’s enrollment.
	 
	 	2.13.11.3	 	The CONTRACTOR shall only pay for covered long-term care services for which the
member was eligible (see Section 2.6), as determined by the State and shown in the
enrollment file furnished by TENNCARE to the CONTRACTOR.

2.13.12 Medically Necessary Services Obtained from Non-Contract Provider Referred by Contract
Provider

The CONTRACTOR shall pay for any medically necessary covered services provided to a member
by a non-contract provider at the request of a contract provider. The CONTRACTOR’s payment
shall not be less than eighty percent (80%) of the rate that would have been paid by the
CONTRACTOR if the member had received the services from a contract provider. The CONTRACTOR
shall only pay for covered long-term care services for which the member was eligible (see
Section 2.6) and that were authorized by the CONTRACTOR.

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

	 	2.13.13.1	 	With the exception of circumstances described in Section 2.13.12 when an enrollee
has utilized medically necessary non-emergency covered services from a noncontract
provider, and the CONTRACTOR has not authorized such use in advance, the CONTRACTOR
shall not be required to pay for the service(s) received unless payment is required
pursuant to a directive from TENNCARE or an Administrative Law Judge.
	 
	 	2.13.13.2	 	The CONTRACTOR shall not make payment to non-contract providers for covered
services that are not medically necessary or for long-term care services for which the
member was not eligible (see Section 2.6).

2.13.14 Covered Services Ordered by Medicare Providers for Dual Eligibles

	 	2.13.14.1	 	Generally, when a TennCare enrollee is dually eligible for Medicare and TennCare
and requires services that are covered under this Agreement but are not covered by
Medicare, and the services are ordered by a Medicare provider who is a non-contract
provider, the CONTRACTOR shall pay for the ordered, medically necessary service if it
is provided by a contract provider. However, if all of the following criteria are met,
the CONTRACTOR may require that the ordering physician be a contract provider:
	 
	 	2.13.14.1.1	 	The ordered service requires prior authorization; and
	 
	 	2.13.14.1.2	 	Dually eligible enrollees have been clearly informed of the contract provider
requirement and instructed in how to obtain assistance identifying and making an
appointment with a contract provider; and

Page 185 of 374

 

 

	 	2.13.14.1.3	 	The CONTRACTOR assists the enrollee in obtaining a timely
appointment with a contract provider upon request of the enrollee or upon
receipt of an order from a noncontract provider.
	 
	 	2.13.14.2	 	Reimbursement shall be at the same rate that would have been paid had the service
been ordered by a contract provider.
	 
	 	2.13.14.3	 	The CONTRACTOR shall not pay for non-covered services, services that are not
medically necessary, or services ordered and obtained from non-contract providers.

2.13.15 Transition of New Members

The CONTRACTOR shall pay for the continuation of covered services for new members pursuant
to the requirements in Section 2.9.2 regarding transition of new members.

2.13.16 Transition of Members Receiving Long-Term Care Services at the Time of CHOICES
Implementation

The CONTRACTOR shall pay for the continuation of covered long-term care services for
transitioning CHOICES members pursuant to the requirements in Section 2.9.3 regarding
transition of members receiving long-term care services at the time of CHOICES
implementation.

2.13.17 Transition of Care

In accordance with the requirements in Section 2.9.4.1 of this Agreement, if a provider has
terminated participation with the CONTRACTOR, the CONTRACTOR shall pay the noncontract
provider for the continuation of treatment through the applicable period provided in Section
2.9.4.1.

2.13.18 Limits on Payments to Providers and Subcontractors Related to the CONTRACTOR

	 	2.13.18.1	 	The CONTRACTOR shall not pay more for similar services rendered by any provider or
subcontractor that is related to the CONTRACTOR than the CONTRACTOR pays to providers
and subcontractors that are not related to the CONTRACTOR. For purposes of this
subsection, “related to” means providers or subcontractors that have an indirect
ownership interest or ownership or control interest in the CONTRACTOR, an affiliate
(see definition in Section 1 of this Agreement) of the CONTRACTOR, or the CONTRACTOR’s
management company as well as providers or subcontractors that the CONTRACTOR, an
affiliate of the CONTRACTOR or the CONTRACTOR’s management company has an indirect
ownership interest or ownership or control interest in. The standards and criteria for
determining indirect ownership interest, an ownership interest or a control interest
are set out at 42 CFR Part 455, Subpart B.
	 
	 	2.13.18.2	 	Any payments made by the CONTRACTOR that exceed the limitations set forth in this
section shall be considered non-allowable payments for covered services and shall be
excluded from medical expenses reported in the MLR report required in Section
2.30.15.3.1.

Page 186 of 374

 

 

	 	2.13.18.3	 	As provided in Section 2.30.9 of this Agreement, the CONTRACTOR shall submit
information on payments to related providers and subcontractors.

2.13.19 1099 Preparation

In accordance with federal requirements, the CONTRACTOR shall prepare and submit Internal
Revenue Service (IRS) Form 1099s for all providers who are not employees of the CONTRACTOR
to whom payment is made.

2.13.20 Payments to the FEA

The CONTRACTOR shall reimburse the Fiscal Employer Agent (FEA) for authorized HCBS provided
by consumer-directed workers as specified in the subcontract between the CONTRACTOR and the
FEA (see Section 2.26.6). TENNCARE will pay the FEA the administrative fees specified in the
contract between TENNCARE and the FEA.

15. Section 2.14 shall be deleted in its entirety and replaced with the following:

2.14 UTILIZATION MANAGEMENT (UM)

2.14.1 General

	 	2.14.1.1	 	The CONTRACTOR shall develop and maintain a utilization management (UM)
program. As part of this program the CONTRACTOR shall have policies and
procedures with defined structures and processes. The UM program shall assign
responsibility to appropriate individuals including a designated senior
physician and shall involve a designated behavioral health care practitioner in
the implementation of behavioral health aspects of the program and a designated
long-term care professional in the implementation of the long-term care aspects
of the program. The UM program shall be supported by an associated work plan and
shall be evaluated annually and updated as necessary.
	 
	 	2.14.1.2	 	The CONTRACTOR’s UM program shall include distinct policies and procedures
regarding long-term care services and shall specify the responsibilities and
scope of authority of care coordinators in authorizing long-term care services
and in submitting service authorizations to providers and/or the FEA for service
delivery.
	 
	 	2.14.1.3	 	The CONTRACTOR shall notify all network providers of and enforce compliance
with all provisions relating to UM procedures.
	 
	 	2.14.1.4	 	The UM program shall have criteria that:
	 
	 	2.14.1.4.1	 	Are objective and based on medical, behavioral health and/or long-term care
evidence, to the extent possible;
	 
	 	2.14.1.4.2	 	Are applied based on individual needs;
	 
	 	2.14.1.4.3	 	Are applied based on an assessment of the local delivery system;
	 
	 	2.14.1.4.4	 	Involve appropriate practitioners in developing, adopting and reviewing them; and

Page 187 of 374

 

 

	 	2.14.1.4.5	 	Are annually reviewed and up-dated as appropriate.
	 
	 	2.14.1.5	 	For long-term care services, the CONTRACTOR’s UM program shall have criteria
that are consistent with the guiding principles set forth in TCA 71-5-1402 and shall
take into consideration the member’s preference regarding cost-effective long-term care
services and settings.
	 
	 	2.14.1.6	 	The CONTRACTOR shall use appropriately licensed professionals to supervise all
medical necessity decisions and specify the type of personnel responsible for each
level of UM, including prior authorization and decision making. The CONTRACTOR shall
have written procedures documenting access to Board Certified Consultants to assist in
making medical necessity determinations. Any decision to deny a service authorization
request or to authorize a service in an amount, duration, or scope that is less than
requested shall be made by a physical health or behavioral health care professional who
has appropriate clinical expertise in treating the member’s condition or disease or, in
the case of long-term care services, a long-term care professional who has appropriate
expertise in providing long-term care services.
	 
	 	2.14.1.7	 	Except as provided in Section 2.6.1.3, the CONTRACTOR shall not place maximum limits
on the length of stay for members requiring hospitalization and/or surgery. The
CONTRACTOR shall not employ, and shall not permit others acting on their behalf to employ
utilization control guidelines or other quantitative coverage limits, whether explicit or
de facto, unless supported by an individualized determination of medical necessity based
upon the needs of each member and his/her medical history. The CONTRACTOR shall consider
individual member characteristics in the determination of readiness for discharge. This
requirement is not intended to limit the ability of the CONTRACTOR to use clinical
guidelines or criteria in placing tentative limits on the length of a prior authorization
or pre-admission certification.
	 
	 	2.14.1.8	 	The CONTRACTOR shall have mechanisms in place to ensure that required services are
not arbitrarily denied or reduced in amount, duration, or scope solely because of the
diagnosis, type of illness, or condition.
	 
	 	2.14.1.9	 	The CONTRACTOR shall assure, consistent with 42 CFR 438.6(h), 42 CFR 422.208
and 422.210, that compensation to individuals or entities that conduct UM activities is
not structured so as to provide incentives for the individual or entity to deny, limit,
or discontinue medically necessary covered services to any member.
	 
	 	2.14.1.10	 	As part of the provider survey required by Section 2.18.7.4, the CONTRACTOR shall assess
provider/office staff satisfaction with UM processes to identify areas for improvement.
	 
	 	2.14.1.11	 	 Inpatient Care
	 
	 	 	 	The CONTRACTOR shall provide for methods of assuring the appropriateness of inpatient
care. Such methodologies shall be based on individualized determinations of medical
necessity in accordance with UM policies and procedures and, at a minimum, shall
include the items specified in subparagraphs 2.14.1.11.1 through 2.14.1.11.5 below:

Page 188 of 374

 

 

	 	2.14.1.11.1	 	Pre-admission certification process for non-emergency admissions;
	 
	 	2.14.1.11.2	 	A concurrent review program to monitor and review continued inpatient hospitalization,
length of stay, or diagnostic ancillary services regarding their appropriateness and medical
necessity. In addition, the CONTRACTOR shall have a process in place to determine for
emergency admissions, based upon medical criteria, if and when a member can be transferred to
a contract facility in the network, if presently in a non-contract facility;
	 
	 	2.14.1.11.3	 	Admission review for urgent and/or emergency admissions, on a retroactive basis when
necessary, in order to determine if the admission is medically necessary and if the requested
length of stay for the admission is reasonable based upon an individualized determination of
medical necessity. Such reviews shall not result in delays in the provision of medically
necessary urgent or emergency care;
	 
	 	2.14.1.11.4	 	Restrictions against requiring pre-admission certification for admissions for the
normal delivery of children; and
	 
	 	2.14.1.11.5	 	Prospective review of same day surgery procedures.
	 
	 	2.14.1.12	 	 Nursing Facility 
	 
	 	2.14.1.12.1	 	If a member is enrolled in CHOICES Group 1, the CONTRACTOR shall authorize and initiate
nursing facility services for that member in accordance with Section 2.9.6. However, if, prior
to nursing facility admission, the member chooses to receive HCBS instead of nursing facility
services and is enrolled in Group 2 pursuant to Section 2.9.6, the CONTRACTOR shall authorize
and initiate HCBS in accordance with Section 2.9.6. Once the member has been admitted to a
nursing facility the CONTRACTOR may, as appropriate, implement its nursing
facility-to-community transition process pursuant to Section 2.9.6.8 of this Agreement.
	 
	 	2.14.1.12.2	 	The CONTRACTOR shall ensure that CHOICES members who have been determined by TENNCARE
to be eligible for Level II nursing facility care are authorized to receive Level II nursing
facility care for the period specified by TENNCARE. The CONTRACTOR shall monitor the member’s
condition, and if the CONTRACTOR determines that, prior to the end date specified by TENNCARE,
the member no longer requires Level II nursing facility care, the CONTRACTOR may submit to
TENNCARE a request to modify the member’s level of nursing facility services. The CONTRACTOR
shall submit documentation as specified by TENNCARE to support the request and shall only
transition the member to Level I nursing facility care once the request has been approved by
TENNCARE.
	 
	 	2.14.1.13	 	 Emergency Department (ED) Utilization
	 
	 	 	 	The CONTRACTOR shall utilize the following guidelines in identifying and managing care
for members who are determined to have excessive and/or inappropriate ED utilization:

Page 189 of 374

 

 

	 	2.14.1.13.1	 	Review ED utilization data, at a minimum, every six (6) months (in
January and July) to identify members with utilization exceeding the threshold
defined by TENNCARE in the preceding six (6) month period. The January review
shall cover ED utilization during the preceding April through September; the
July review shall cover ED utilization during the preceding October through
March;
	 
	 	2.14.1.13.2	 	Enroll non-CHOICES members whose utilization exceeds the threshold of ED visits
defined by TENNCARE in the previous six (6) month period in MCO case management and may
use the information to identify members who may be eligible for CHOICES in accordance
with the requirements in Section 2.9.6.3. if appropriate;
	 
	 	2.14.1.13.3	 	For CHOICES members whose utilization exceeds the threshold of ED visits defined
by TENNCARE in the previous six (6) month period, the care coordinator shall conduct
appropriate follow-up to identify the issues causing frequent ED utilization and
determine appropriate next steps. For CHOICES members in Group 1, appropriate next
steps may include communication with the nursing facility to determine interventions to
better manage the member’s condition. For CHOICES members in Groups 2 and 3,
appropriate next steps may include modifications to the member’s plan of care in order
to address service delivery needs and better manage the member’s condition.
	 
	 	2.14.1.13.4	 	As appropriate, make contact with members whose utilization exceeded the
threshold of ED visits defined by TENNCARE in the previous six (6) month period and
their primary care providers for the purpose of providing education on appropriate ED
utilization; and
	 
	 	2.14.1.13.5	 	Assess the most likely cause of high utilization and develop an MCO case
management plan based on results of the assessment for each non-CHOICES member.
	 
	 	2.14.1.14	 	 Hospitalizations and Surgeries
	 
	 	 	 	The CONTRACTOR shall comply with any applicable federal and state laws or rules
related to length of hospital stay. TENNCARE will closely monitor encounter data
related to length of stay and re-admissions to identify potential problems. If
indicated, TENNCARE may conduct special studies to assess the appropriateness of
hospital discharges.

2.14.2 Prior Authorization for Physical Health and Behavioral Health Covered Services

	 	2.14.2.1	 	The CONTRACTOR shall have in place, and follow, written policies and procedures
for processing requests for initial and continuing prior authorizations of
services and have in effect mechanisms to ensure consistent application of
review criteria for prior authorization decisions. The policies and procedures
shall provide for consultation with the requesting provider when appropriate. If
prior authorization of a service is granted by the CONTRACTOR and the service is
provided, payment for the prior authorized service shall not be denied based on
the lack of medical necessity, assuming that the member is eligible on the date
of service, unless it is determined that the facts at the time of the denial of
payment are significantly different than the circumstances which were described
at the time that prior authorization was granted.

Page 190 of 374

 

 

	 	2.14.2.2	 	Prior authorization for home health nurse, home health aide and
private duty nursing services shall comply with TennCare rules and
regulations.
	 
	 	2.14.2.3	 	Prior authorization requests shall be reviewed subject to the guidelines
described in TennCare rules and regulations which include, but are not limited to,
provisions regarding decisions, notices, medical contraindication, and the failure
of an MCO to act timely upon a request.

2.14.3 Referrals for Physical Health and Behavioral Health

	 	2.14.3.1	 	Except as provided in Section 2.14.4, the CONTRACTOR may require members to
seek a referral from their PCP prior to accessing non-emergency specialty
physical health services.
	 
	 	2.14.3.2	 	If the CONTRACTOR requires members to obtain PCP referral, the CONTRACTOR may
exempt certain services, identified by the CONTRACTOR in the member handbook, from PCP
referral.
	 
	 	2.14.3.3	 	For members determined to need a course of treatment or regular care
monitoring, the CONTRACTOR shall have a mechanism in place to allow members to
directly access a specialist as appropriate for the members’ condition and
identified needs.
	 
	 	2.14.3.4	 	The CONTRACTOR shall not require that a woman go in for an office visit with
her PCP in order to obtain the referral for prenatal care.
	 
	 	2.14.3.5	 	Referral Provider Listing
	 
	 	2.14.3.5.1	 	The CONTRACTOR shall provide all PCPs with a current hard copy listing of
referral providers, including behavioral health providers at least thirty (30) calendar
days prior to the start date of operations. Thereafter the CONTRACTOR shall mail PCPs
an updated version of the listing on a quarterly basis. The CONTRACTOR shall also
maintain an updated electronic, web-accessible version of the referral provider
listing.
	 
	 	2.14.3.5.2	 	The referral provider listing shall be in the format specified by TENNCARE for
the provider directory in Section 2.17.8.
	 
	 	2.14.3.5.3	 	As required in Section 2.30.10.7, the CONTRACTOR shall submit to TENNCARE a copy
of the referral provider listing, a data file of the provider information in a media
and format described by TENNCARE, and documentation regarding mailing.

2.14.4 Exceptions to Prior Authorization and/or Referrals for Physical Health and Behavioral Health

	 	2.14.4.1	 	Emergency and Post-Stabilization Care Services
	 
	 	 	 	The CONTRACTOR shall provide emergency services without requiring prior
authorization or PCP referral, as described in Section 2.7.1, regardless of
whether these services are provided by a contract or non-contract provider. The
CONTRACTOR shall provide post-stabilization care services (as defined in Section
1) in accordance with 42 CFR 422.113.

Page 191 of 374

 

 

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

2.14.5 Authorization of Long-Term Care Services

	 	2.14.5.1	 	The CONTRACTOR shall have in place an authorization process for all covered
long-term care services and cost effective alternative services that is separate
from but integrated with the CONTRACTOR’s prior authorization process for
covered physical health and behavioral health services (See section 2.9.6 of
this Agreement).
	 
	 	2.14.5.2	 	The CONTRACTOR shall authorize and initiate all long-term care services for
CHOICES members within the timeframes specified in Sections 2.9.2, 2.9.3, and
2.9.6 of this Agreement.
	 
	 	2.14.5.3	 	The CONTRACTOR shall not require that HCBS be ordered by a treating physician,
but may consult with the treating physician as appropriate regarding the member’s
physical health, behavioral health, and long-term care needs and in order to
facilitate communication and coordination regarding the member’s physical health,
behavioral health, and long-term care services.
	 
	 	2.14.5.4	 	For non-CHOICES members receiving care in non-contract nursing facilities
authorized by the CONTRACTOR as a cost-effective alternative, the CONTRACTOR
shall reimburse services in accordance with its authorization until such time
that the member is no longer eligible for services, is enrolled in CHOICES, or
such care is no longer medically necessary or cost-effective.

Page 192 of 374

 

 

2.14.6 Transition of Members Receiving Long-term Care Services at the time of CHOICES
Implementation

For members enrolling in CHOICES as of the date of CHOICES implementation, the CONTRACTOR
shall be responsible for continuing to provide the long-term care services previously
authorized for the member, as specified in Section 2.9.3 of this Agreement.

2.14.7 Notice of Adverse Action Requirements

	 	2.14.7.1	 	The CONTRACTOR shall clearly document and communicate the reasons for each
denial of a prior authorization request in a manner sufficient for the provider
and member to understand the denial and decide about requesting reconsideration
of or appealing the decision.
	 
	 	2.14.7.2	 	The CONTRACTOR shall comply with all member notice provisions in TennCare rules and
regulations.
	 
	 	2.14.7.3	 	The CONTRACTOR shall issue appropriate notice prior to any CONTRACTOR- initiated
decision to reduce or terminate CHOICES or non-CHOICES nursing facility services and
shall comply with all federal court orders, and federal and state laws and regulations
regarding members’ transfer or discharge from nursing facilities.

2.14.8 Medical History Information Requirements

	 	2.14.8.1	 	The CONTRACTOR is responsible for eliciting pertinent medical history
information from the treating provider(s), as needed, for purposes of making
medical necessity determinations. With respect to HCBS which are not primarily
medical in nature, pertinent medical history shall include assessments, case
notes, and documentation of service delivery by HCBS providers. Medical
information from the treating physician may also be pertinent in better
understanding the member’s functional needs. The CONTRACTOR shall take action
(e.g., sending a CONTRACTOR representative to obtain the information and/or
discuss the issue with the provider, imposing financial penalties against the
provider, etc.), to address the problem if a treating provider is uncooperative
in supplying needed information. The CONTRACTOR shall make documentation of such
action available to TENNCARE, upon request. Providers who do not provide
requested information for purposes of making a medical necessity determination
for a particular item or service shall not be entitled to payment for the
provision of such item or service.
	 
	 	2.14.8.2	 	Upon request by TENNCARE, the CONTRACTOR shall provide TENNCARE with individualized
medical record information from the treating provider(s). The CONTRACTOR shall take
whatever action necessary to fulfill this responsibility within the required appeal
time lines as specified by TENNCARE and/or applicable TennCare rules and regulations,
up to and including going to the provider’s office to obtain the medical record
information. Should a provider fail or refuse to respond to the CONTRACTOR’s efforts to
obtain medical information, and the appeal is decided in favor of the member, at the
CONTRACTOR’s discretion or a directive by TENNCARE, the CONTRACTOR shall impose
financial penalties against the provider as appropriate.

Page 193 of 374

 

 

2.14.9 PCP Profiling

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

	 	2.14.9.1	 	Utilization of Non-Contract Providers
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
utilization of services provided by non-contract providers by PCP panel.
	 
	 	2.14.9.2	 	Specialist Referrals
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
specialty provider utilization by PCP panel.
	 
	 	2.14.9.3	 	Emergency Room Utilization
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
emergency room utilization by PCP panel. As provided in Section 2.9.5, members
who establish a pattern of accessing emergency room services shall be referred
to MCO case management as appropriate for follow-up.
	 
	 	2.14.9.4	 	Inpatient Admissions
	 
	 	 	 	The CONTRACTOR shall maintain a procedure to identify and evaluate member
utilization of inpatient services by PCP panel.
	 
	 	2.14.9.5	 	Pharmacy Utilization
	 
	 	 	 	At a minimum, the CONTRACTOR shall profile PCP prescribing patterns for generic
versus brand name and the number of narcotic prescriptions written. In addition,
the CONTRACTOR shall comply with the requirements in Section 2.9.10 of this
Agreement.
	 
	 	2.14.9.6	 	Advanced Imaging Procedures
	 
	 	 	 	The CONTRACTOR shall profile the utilization of advanced imaging procedures by
PCP panel. Advanced imaging procedures include: PET Scans; CAT Scans and MRIs.
	 
	 	2.14.9.7	 	PCP Visits
	 
	 	 	 	The CONTRACTOR shall profile the average number of visits per member assigned to
each PCP.

Page 194 of 374

 

 

16. Section 2.15 shall be deleted in its entirety and replaced with the following:

2.15 QUALITY MANAGEMENT/QUALITY IMPROVEMENT

2.15.1 Quality Management/Quality Improvement (QM/QI) Program

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

	 
	 	2.15.1.1.7	 	Be evaluated annually and updated as appropriate.
	 
	 	2.15.1.2	 	The CONTRACTOR shall make all information about its QM/QI program available to
providers and members.
	 
	 	2.15.1.3	 	As part of the QM/QI program, the CONTRACTOR shall collect
information on providers’ actions to improve patient safety and make performance data available
to providers and members.
	 
	 	2.15.1.4	 	Any changes to the QM/QI program structure shall require
prior written approval from TENNCARE. The QM/QI program description, associated work plan, and annual
evaluation of the QM/QI Program shall be submitted to TENNCARE as required in
Section 2.30.11.1, Reporting Requirements.
	 
	 	2.15.1.5	 	The CONTRACTOR shall use the results of QM/QI activities to improve the quality
of physical health, behavioral health, and long-term care service delivery with
appropriate input from providers and members.
	 
	 	2.15.1.6	 	The CONTRACTOR shall take appropriate action to address service delivery,
provider, and other QM/QI issues as they are identified.
	 
	 	2.15.1.7	 	In addition to QM/QI activities as defined in this Section 2.15, the CONTRACTOR’s
QM/QI program shall incorporate all applicable reporting and monitoring
requirements and activities, including but not limited to such activities specified in

Page 195 of 374

 

 

	 	 	 	Sections 2.25, 2.30, and 2.9.6.12 of this Agreement; and shall include discovery
and remediation of individual findings, as well as identification and
implementation of strategies to make systemic improvements in the delivery and
quality of care.

2.15.2 QM/QI Committee

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

2.15.3 Performance Improvement Projects (PIPs)

	 	2.15.3.1	 	The CONTRACTOR shall perform at least two (2) clinical and three (3)
non-clinical PIPs.
	 
	 	2.15.3.1.1	 	The two (2) clinical PIPs shall include one (1) in the area of behavioral health.
The behavioral health PIP shall be relevant to one of the behavioral health disease
management programs for bipolar disorder, major depression, or schizophrenia.
	 
	 	2.15.3.1.2	 	Two (2) of the three (3) non-clinical PIPs shall be in the area of long-term
care. For each of these PIPs TENNCARE will select the study topic, define the study
question, select the study indicator(s), and define the methodology for measuring the
study indicator(s), including the sampling methodology, data collection, and data
analysis. TENNCARE has the discretion to change the PIPs each year (including changing
the study topic, study question, study indicator(s), and/or methodology) and to require
up to two (2) additional non-clinical PIPs, for a total of five (5) non-clinical PIPs
at any one time. TENNCARE will consult with MCOs and other stakeholders in developing
PIPs.
	 
	 	2.15.3.2	 	The CONTRACTOR shall ensure that CMS protocols for PIPs are followed and that
the following are documented for each activity:
	 
	 	2.15.3.2.1	 	Rationale for selection as a quality improvement activity;

Page 196 of 374

 

 

	 	2.15.3.2.2	 	Specific population targeted, include sampling methodology if
relevant;
	 
	 	2.15.3.2.3	 	Metrics to determine meaningful improvement and baseline
measurement;
	 
	 	2.15.3.2.4	 	Specific interventions (enrollee and provider);
	 
	 	2.15.3.2.5	 	Relevant clinical practice guidelines; and
	 
	 	2.15.3.2.6	 	Date of re-measurement.
	 
	 	2.15.3.3	 	The CONTRACTOR shall identify benchmarks and set achievable performance
goals for each of its PIPs. The CONTRACTOR shall identify and implement
intervention and improvement strategies for achieving the performance goal set
for each PIP and promoting sustained improvements.
	 
	 	2.15.3.4	 	The CONTRACTOR shall report on PIPs as required in Section 2.30.11.2,
Reporting Requirements.
	 
	 	2.15.3.5	 	After three (3) years, the CONTRACTOR shall, using evaluation criteria
established by TENNCARE, determine if one or all of the non-long-term care PIPs
should be continued. Prior to discontinuing a non-long-term care PIP, the
CONTRACTOR shall identify a new PIP and must receive TENNCARE’s approval to
discontinue the previous PIP and perform the new PIP.

2.15.4 Clinical Practice Guidelines

The CONTRACTOR shall utilize evidence-based clinical practice guidelines in its disease
management programs and shall measure performance against at least two (2) important aspects
of each of the guidelines annually as required in Section 2.8. The guidelines shall be
reviewed and revised at least every two (2) years or whenever the guidelines change.

2.15.5 NCQA Accreditation

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

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

	 	December 15, 2007

Page 197 of 374

 

 

	 	 	 
	EVENT	 	REQUIRED DEADLINE
	CALENDAR YEAR 2008
	 	 
	 
	 	 
	Submit copy of signed NCQA Survey contract to
TENNCARE

	 	January 15, 2008
	 
	 	 
	Purchase NCQA ISS Tool for 2009 MCO
Accreditation Survey

	 	August 15, 2008
	 
	 	 
	Copy of signed contract with NCQA approved
vendor to perform 2009 CAHPS surveys (Adult,
Child and Children with Chronic Conditions to
TENNCARE)

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

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

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

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

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

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

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

	 	November 30, 2009
	 	 
	•   Excellent, Commendable, or
Accredited

	 	 
	 
	 	 
	•   Provisional — Corrective
Action required
to achieve status of Excellent, Commendable, or
Accredited; resurvey within twelve ( 12)
months.

	 	 
	 
	 	 
	•   Accreditation Denied —
Results in termination of this Agreement.

	 	 

	 	2.15.5.2	 	If the CONTRACTOR consistently fails to meet the timelines as described above, the
CONTRACTOR shall be considered to be in breach of the terms of this Agreement and
may be subject to termination in accordance with Section 4.4 of this Agreement.

Page 198 of 374

 

 

	 	2.15.5.3	 	Failure to obtain NCQA accreditation by November 30, 2009 and maintain
accreditation thereafter shall be considered a breach of this Agreement and
shall result in termination of this Agreement in accordance with the terms set
forth in Section 4.4 of this Agreement. Achievement of provisional accreditation
status shall require a corrective action plan within thirty (30) calendar days
of receipt of notification from NCQA and may result in termination of this
Agreement in accordance with Section 4.4 of this Agreement.

2.15.6 HEDIS and CAHPS

	 	2.15.6.1	 	Annually, beginning with HEDIS 2009, the CONTRACTOR shall complete all
HEDIS measures designated by NCQA as relevant to Medicaid. The only exclusion
from the complete Medicaid HEDIS data set shall be dental measures. The
CONTRACTOR shall also complete specified Medicare HEDIS measures for CHOICES
members based on the Medicare CAHPS, as identified by the State. The HEDIS
measure results, except the Medicare HEDIS measures for CHOICES members, shall
be reported separately for each Grand Region in which the CONTRACTOR operates.
The Medicare HEDIS measures for CHOICES members may be reported statewide. The
CONTRACTOR shall contract with an NCQA certified HEDIS auditor to validate the
processes of the CONTRACTOR in accordance with NCQA requirements. Audited HEDIS
results shall be submitted to TENNCARE, NCQA and TENNCARE’s EQRO annually by
June 15 of each calendar year beginning in 2009.
	 
	 	2.15.6.2	 	Annually, beginning in 2009, the CONTRACTOR shall conduct a CAHPS survey. The
CONTRACTOR shall enter into an agreement with a vendor that is certified by NCQA to
perform CAHPS surveys. The CONTRACTOR’s vendor shall perform the CAHPS adult survey,
CAHPS child survey and the CAHPS children with chronic conditions survey. With regard
to the CAHPS adult survey, this shall include conducting the survey for non-CHOICES
members and conducting the survey with additional survey questions from the Medicare
CAHPS, as identified by TENNCARE, to CHOICES members in Groups 2 and 3. Survey results
shall be reported to TENNCARE separately for each required CAHPS survey listed above,
including the CAHPS adult survey with supplemental Medicare CAHPS questions for CHOICES
members. The survey results for non-CHOICES members shall be reported separately for
each Grand Region in which the CONTRACTOR operates. The survey results for CHOICES
members may be reported statewide. Survey results shall be submitted to TENNCARE, NCQA
and TENNCARE’s EQRO annually by June 15 of each calendar year beginning in 2009.

2.15.7 Medicare Health Outcomes Survey (HOS)

Annually, beginning in 2010, the CONTRACTOR shall conduct the Health Outcomes Survey (HOS)
for a representative sample of CHOICES members in Groups 2 and 3. The CONTRACTOR shall enter
into an agreement with a vendor that is certified by NCQA to administer HOS surveys. The
CONTRACTOR’s vendor shall administer the Baseline HOS each year as well as a follow-up
survey two (2) years after each Baseline HOS for the baseline cohort. The CONTRACTOR and its
vendor shall comply with applicable CMS and NCQA requirements and protocols regarding
administering and reporting HOS. The CONTRACTOR shall submit final survey data files to
TENNCARE. The CONTRACTOR shall provide the survey results

Page 199 of 374

 

 

statewide. TENNCARE will test, clean, and score the data and develop reports (see Section
2.25.9.2).

2.15.8 Critical Incident Reporting and Management

	 	2.15.8.1	 	The CONTRACTOR shall develop and implement a critical incident reporting and
management system for incidents that occur in a home and community-based
longterm care service delivery setting, including: community-based residential
alternatives; adult day care centers; other HCBS provider sites; and a member’s
home, if the incident is related to the provision of covered HCBS.
	 
	 	2.15.8.2	 	The CONTRACTOR shall identify and track critical incidents and shall review
and analyze critical incidents to identify and address potential and actual quality
of care and/or health and safety issues. The CONTRACTOR shall regularly review
the number and types of incidents (including, for example, the number and type
of incidents across settings, providers, and provider types) and findings from
investigations (including findings from APS and CPS if available); identify
trends and patterns; identify opportunities for improvement; and develop and
implement strategies to reduce the occurrence of incidents and improve the
quality of HCBS.
	 
	 	2.15.8.3	 	Critical incidents shall include but not be limited to the following incidents
when they occur in a home and community-based long-term care service delivery setting
(as defined in Section 2.15.8.1 above):
	 
	 	2.15.8.3.1	 	Unexpected death of a CHOICES member;
	 
	 	2.15.8.3.2	 	Suspected physical or mental abuse of a CHOICES member;
	 
	 	2.15.8.3.3	 	Theft or financial exploitation of a CHOICES member;
	 
	 	2.15.8.3.4	 	Severe injury sustained by a CHOICES member;
	 
	 	2.15.8.3.5	 	Medication error involving a CHOICES member;
	 
	 	2.15.8.3.6	 	Sexual abuse and/or suspected sexual abuse of a CHOICES member; and
	 
	 	2.15.8.3.7	 	Abuse and neglect and/or suspected abuse and neglect of a CHOICES member.

	 
	 	2.15.8.4	 	The CONTRACTOR shall require its staff and contract HCBS providers to report,
respond to, and document critical incidents as specified by the CONTRACTOR. This
shall include, but not be limited to the following:
	 
	 	2.15.8.4.1	 	Requiring that the CONTRACTOR’s staff and contract HCBS providers report critical
incidents to the CONTRACTOR in accordance with applicable requirements. The CONTRACTOR
shall develop and implement a critical incident reporting process, including the form
to be used to report critical incidents and reporting timeframes. The maximum timeframe
for reporting an incident to the CONTRACTOR shall be twenty-four (24) hours. The
initial report of an incident within twenty-four (24) hours may be submitted verbally,
in which case the person/agency/entity making the initial report shall submit a
follow-up written report within forty-eight (48) hours.

Page 200 of 374

 

 

	 	2.15.8.4.2	 	Requiring that suspected abuse, neglect, and exploitation of members who are
adults is immediately reported in accordance with TCA 71-6-103 and suspected brutality,
abuse, or neglect of members who are children is immediately reported in accordance
with TCA 37-1-403 or TCA 37-1-605 as applicable.
	 
	 	2.15.8.4.3	 	Requiring that its staff and contract HCBS providers immediately (which shall not exceed
twenty-four hours) take steps to prevent further harm to any and all members and respond to
any emergency needs of members.
	 
	 	2.15.8.4.4	 	Requiring that contract HCBS providers with a critical incident conduct an internal
critical incident investigation and submit a report on the investigation within the timeframe
specified by the CONTRACTOR. The timeframe for submitting the report shall be as soon as
possible, may be based on the severity of the incident, and, except under extenuating
circumstances, shall be no more than thirty (30) days after the date of the incident. The
CONTRACTOR shall review the provider’s report and follow-up with the provider as necessary to
ensure that an appropriate investigation was conducted and corrective actions were implemented
within applicable timeframes.
	 
	 	2.15.8.4.5	 	Requiring that its staff and contract HCBS providers cooperate with any investigation
conducted by the CONTRACTOR or outside agencies (e.g., TENNCARE, APS, CPS, and law
enforcement).
	 
	 	2.15.8.4.6	 	Defining the role and responsibilities of the fiscal employer agent (see definition in
Section 1) in reporting, responding to, documenting, and investigating any critical incidents,
which shall include reporting incidents to the CONTRACTOR using the process developed in a
accordance with Section 2.15.8.4.1, investigating critical incidents, and submitting a report
on investigations to the CONTRACTOR; training employees, contractors of the FEA (including
supports brokers), and consumer- directed workers regarding reporting, responding to,
documenting, and cooperating with the investigation of any critical incidents; and training
consumers and caregivers regarding critical incident reporting and management. Such role and
responsibilities shall be defined in a manner that is consistent with requirements in this
Section 2.15.8.4 as well as TENNCARE’s contract with the fiscal employer agent and the model
subcontract between the CONTRACTOR and the FEA (see Section 2.26 of this Agreement).
	 
	 	2.15.8.4.7	 	Reviewing the FEA’s reports regarding investigations of critical incidents and follow-up
with the FEA as necessary to ensure that an appropriate investigation was conducted and
corrective actions were implemented within applicable timeframes.
	 
	 	2.15.8.4.8	 	Providing appropriate training and taking corrective action as needed to ensure its
staff, contract HCBS providers, the FEA, and workers comply with critical incident
requirements.
	 
	 	2.15.8.4.9	 	Conducting oversight, including but not limited to oversight of its staff, contract HCBS
providers, and the FEA, to ensure that the CONTRACTOR’s policies and procedures are being
followed and that necessary follow-up is being conducted in a timely manner.

Page 201 of 374

 

 

	 	2.15.8.5	 	The CONTRACTOR shall report to TENNCARE any death and any incident that
could significantly impact the health or safety of a member (e.g., physical or
sexual abuse) within twenty-four (24) hours of detection or notification.
	 
	 	2.15.8.6	 	As specified in Section 2.30.11.7, the CONTRACTOR shall submit monthly reports
to TENNCARE regarding all critical incidents.

17. Section 2.17 shall be deleted in its entirety and replaced with the following:

2.17 MEMBER MATERIALS

2.17.1 Prior Approval Process for All Member Materials

	 	2.17.1.1	 	The CONTRACTOR shall submit to TENNCARE for review and prior written
approval all materials that will be distributed to members (referred to as
member materials) as well as proposed health education and outreach activities.
This includes but is not limited to member handbooks, provider directories,
member newsletters, identification cards, fact sheets, notices, brochures, form
letters, mass mailings, member education and outreach activities as described in
this Section, Section 2.17 and Section 2.7.4, system generated letters and any
other additional, but not required, materials and information provided to
members designed to promote health and/or educate members.
	 
	 	2.17.1.2	 	All member materials shall be submitted to TENNCARE on paper and electronic file
media, in the format prescribed by TENNCARE. The materials shall be accompanied
by a plan that describes the CONTRACTOR’s intent and procedure for the use of
the materials. Materials developed by a recognized entity having no association
with the CONTRACTOR that are related to management of specific types of diseases
(e.g., heart, diabetes, asthma, etc.) or general health improvement shall be
submitted for approval; however, unless otherwise requested by TENNCARE, an
electronic file for these materials is not required. The electronic files shall
be submitted in a format acceptable to TENNCARE. Electronic files submitted in
any other format than those approved by TENNCARE will not be processed.
	 
	 	2.17.1.3	 	TENNCARE shall review the submitted member materials and either approve or
deny them within fifteen (15) calendar days from the date of submission. In the
event TENNCARE does not approve the materials TENNCARE may provide written
comments, and the CONTRACTOR shall resubmit the materials.
	 
	 	2.17.1.4	 	Once member materials have been approved in writing by TENNCARE, the CONTRACTOR
shall submit to TENNCARE an electronic version (PDF) of the final printed product,
unless otherwise specified by TENNCARE, within thirty (30) calendar days from the print
date. Should TENNCARE request original prints be submitted in hard copy, photo copies
may not be submitted as a final product. Upon request, the CONTRACTOR shall provide
additional original prints of the final product to TENNCARE.
	 
	 	2.17.1.5	 	Prior to modifying any approved member material, the CONTRACTOR shall submit for
written approval by TENNCARE a detailed description of the proposed modification.
Proposed modifications shall be submitted in accordance with the requirements herein.

Page 202 of 374

 

 

	 	2.17.1.6	 	TENNCARE reserves the right to notify the CONTRACTOR to discontinue or
modify member materials after approval.

2.17.2 Written Material Guidelines

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

	 	2.17.2.1	 	All member materials shall be worded at a sixth (6th) grade reading
level, unless TENNCARE approves otherwise;
	 
	 	2.17.2.2	 	All written materials shall be clearly legible with a minimum font size of
12pt. with the exception of member I.D. cards, and unless otherwise approved in writing by
TENNCARE;
	 
	 	2.17.2.3	 	All written materials shall be printed with the assurance of
non-discrimination as provided in Section 4.32.1;
	 
	 	2.17.2.4	 	The following shall not be used on any written materials, including but not
limited to member materials, without the written approval of TENNCARE:
	 
	 	2.17.2.4.1	 	The Seal of the State of Tennessee;
	 
	 	2.17.2.4.2	 	The TennCare name unless the initials “SM” denoting a service mark, is
superscripted to the right of the name (TennCaresm);
	 
	 	2.17.2.4.3	 	The word “free” unless the service is at no cost to all members. If members have
cost sharing or patient liability responsibilities, the service is not free. Any
conditions of payments shall be clearly and conspicuously disclosed in close proximity
to the “free” good or service offer; and
	 
	 	2.17.2.4.4	 	The use of phrases to encourage enrollment such as “keep your doctor” implying
that enrollees can keep all of their providers. Enrollees in TennCare shall not be led
to think that they can continue to go to their current provider, unless that particular
provider is a contract provider with the CONTRACTOR’s MCO;
	 
	 	2.17.2.5	 	All vital CONTRACTOR documents shall be translated and available in Spanish.
Within ninety (90) calendar days of notification from TENNCARE, all vital
CONTRACTOR documents shall be translated and available to each Limited English
Proficiency group identified by TENNCARE that constitutes five percent (5%) of
the TennCare population or one-thousand (1,000) enrollees, whichever is less;
	 
	 	2.17.2.6	 	All written member materials shall notify enrollees that oral interpretation
is available for any language at no expense to them and how to access those services;
	 
	 	2.17.2.7	 	All written member materials shall be made available in alternative formats
for persons with special needs at no expense to the member; and

Page 203 of 374

 

 

	 	2.17.2.8	 	The CONTRACTOR shall provide written notice to members of any changes
in policies or procedures described in written materials previously sent to
members. The CONTRACTOR shall provide written notice at least thirty (30) days
before the effective date of the change.

2.17.3 Distribution of Member Materials

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

2.17.4 Member Handbooks

	 	2.17.4.1	 	The CONTRACTOR shall develop a member handbook based on a template
provided by TENNCARE, and update it periodically (at least annually). Upon
notice to TENNCARE of material changes to the member handbook, the CONTRACTOR
shall make appropriate revisions and immediately distribute the revised handbook
to members and providers.
	 
	 	2.17.4.2	 	The CONTRACTOR shall distribute member handbooks to members within thirty (30)
calendar days of receipt of notice of enrollment in the CONTRACTOR’s MCO or prior to
enrollees’ enrollment effective date as described in Section 2.4.5 and at least
annually thereafter. In the event of material revisions to the member handbook, the
CONTRACTOR shall distribute the new and revised handbook to all members immediately.
	 
	 	2.17.4.3	 	In situations where there is more than one member in a TennCare case, it shall
be acceptable for the CONTRACTOR to mail one (1) member handbook to each address
listed for the member’s TennCare case number when there is more than one (1) new
enrollee assigned to the same case number at the time of enrollment and when
subsequent new or updated member handbooks are mailed to members. Should a
single individual be enrolled and be added into an existing case, a member
handbook (new or updated) shall be mailed to that individual regardless of
whether or not a member handbook has been previously mailed to members in the
existing case.
	 
	 	2.17.4.4	 	The CONTRACTOR shall distribute a member handbook to all contract providers
upon initial credentialing, annually thereafter to all contract providers and
the FEA as handbooks are updated, and whenever there are material revisions. For
purposes of providing member handbooks to providers and to the FEA, it shall be
acceptable to provide handbooks in electronic format, including but not limited
to CD or access via a web link.
	 
	 	2.17.4.5	 	The CONTRACTOR shall develop a supplement for the member handbook that includes
information regarding the CHOICES program. The supplement shall include the information
specified in Section 2.17.4.7 that is not currently included in the member handbook, as
determined by TENNCARE.

Page 204 of 374

 

 

	 	2.17.4.5.1	 	The CONTRACTOR shall distribute the supplement to all existing members, contract providers,
and the FEA after TENNCARE has issued member notices regarding CHOICES implementation but prior to the
implementation date of CHOICES in the Grand Region covered by this Agreement, to new members in
accordance with Section 2.17.4.2 above, and to all contract providers and the FEA in accordance with
2.17.4.4 above. The CONTRACTOR shall distribute the supplement until the member handbook is revised to
include the CHOICES program, which shall be no later than the date specified by TENNCARE.
	 
	 	2.17.4.6	 	The CONTRACTOR shall print, disseminate and review with each CHOICES member participating in
consumer direction of HCBS a consumer direction handbook developed by TENNCARE. In the event of
material revisions to the consumer direction handbook, the CONTRACTOR shall immediately disseminate
and review with each CHOICES member participating in consumer direction key changes as reflected in
the new and revised consumer direction handbook.
	 
	 	2.17.4.7	 	Each member handbook shall, at a minimum, be in accordance with the following
guidelines:
	 
	 	2.17.4.7.1	 	Shall be in accordance with all applicable requirements as described in Section 2.17.2
of this Agreement;
	 
	 	2.17.4.7.2	 	Shall include a table of contents;
	 
	 	2.17.4.7.3	 	Shall include an explanation on how members will be notified of member specific
information such as effective date of enrollment, of PCP assignment, and of care coordinator
assignment for CHOICES members;
	 
	 	2.17.4.7.4	 	Shall include an explanation of how members can request to change PCPs;
	 
	 	2.17.4.7.5	 	Shall include a description of services provided including benefit limits, the
consequences of reaching a benefit limit, non-covered services, and use of noncontract
providers, including that members are not entitled to a fair hearing about non-covered
services and that members shall use contract providers except in specified circumstances;
	 
	 	2.17.4.7.6	 	Shall explain that prior authorization is required for some services, including non-
emergency services provided by a non-contract provider, and that service authorization is
required for all long-term care services; that such services will be covered and reimbursed
only if such prior authorization/service authorization is received before the service is
provided; that all prior authorizations/service authorizations are null and void upon
expiration of a member’s TennCare eligibility; and that the member shall be responsible for
payment for any services provided after the member’s eligibility has expired;

Page 205 of 374

 

 

	 	2.17.4.7.7	 	Shall include a statement advising members that the CONTRACTOR may choose to
provide certain non-covered services to a particular member when the CONTRACTOR
determines that such non-covered services are an appropriate and more cost-effective
way of meeting the member’s needs than other covered services that would otherwise be
provided; a member is not entitled to receive these non- covered services; the decision
to provide or not provide these services to a particular member is at the sole
discretion of the CONTRACTOR; and if the CONTRACTOR does not provide one of these
non-covered services to a member, the member is not entitled to a fair hearing
regarding the decision;
	 
	 	2.17.4.7.8	 	Shall include descriptions of the Medicaid Benefits, Standard Benefits, and the covered
long-term care services for CHOICES members, by CHOICES group.
	 
	 	2.17.4.7.9	 	Shall include a description of TennCare cost sharing or patient liability
responsibilities including an explanation that providers and/or the CONTRACTOR may utilize
whatever legal actions are available to collect these amounts. Further, the information shall
specify the instances in which a member may be billed for services, and shall indicate that
the member may not be billed for covered services except for the amounts of the specified
TennCare cost sharing or patient liability responsibilities and explain the member’s right to
appeal in the event that they are billed for amounts other than their TennCare cost sharing or
patient liability responsibilities. The information shall also identify the potential
consequences if the member does not pay his/her patient liability, including loss of the
member’s current nursing facility provider, disenrollment from CHOICES, and, to the extent the
member’s eligibility depends on receipt of long-term care services, loss of eligibility for
TennCare;
	 
	 	2.17.4.7.10	 	Shall include information about preventive services for adults and children, including
TENNderCare, a listing of covered preventive services, and notice that preventive services are
at no cost and without cost sharing responsibilities;
	 
	 	2.17.4.7.11	 	Shall include procedures for obtaining required services, including procedures for
obtaining referrals to specialists as well as procedures for obtaining referrals to
noncontract providers. The handbook shall advise members that if they need a service that is
not available from a contract provider, they will be referred to a non-contract provider and
any copayment requirements would be the same as if this provider were a contract provider;
	 
	 	2.17.4.7.12	 	Shall include information on the CHOICES program, including a description of the
CHOICES groups; eligibility for CHOICES; enrollment in CHOICES, including whom to contact at
the MCO regarding enrollment in CHOICES; enrollment targets for Group 2 and Group 3, including
reserve capacity and administration of waiting lists; and CHOICES benefits, including benefit
limits, the individual cost neutrality cap for Group 2, and the expenditure cap for Group 3;
	 
	 	2.17.4.7.13	 	Shall include information on care coordination for CHOICES members, including but not
limited to the role of the care coordinator, level of care assessment and reassessment, needs
assessment and reassessment, and care planning, including the development of a plan of care
for members in CHOICES Groups 2 and 3;

Page 206 of 374

 

 

	 	2.17.4.7.14	 	Shall include information on the right of CHOICES members to request an
objective review by the State of their needs assessment and/or care planning processes
and how to request such a review;
	 
	 	2.17.4.7.15	 	Shall include information regarding consumer direction of HCBS, including but not
limited to the roles and responsibilities of the member or the member’s representative, the
services that can be directed, the member’s right to participate in or voluntarily withdraw
from consumer direction at any time, the role of and services provided by the FEA, as well as
a statement that voluntary or involuntary withdrawal from consumer direction will not affect a
member’s eligibility for CHOICES;
	 
	 	2.17.4.7.16	 	Shall include an explanation of emergency services and procedures on how to obtain
emergency services both in and out of the CONTRACTOR’s service area, including but not limited
to: an explanation of post-stabilization services, the use of 911, locations of emergency
settings and locations for post-stabilization services;
	 
	 	2.17.4.7.17	 	Shall include information on how to access the primary care provider on a twenty- four
(24) hour basis as well as the twenty-four (24) hour nurse line. The handbook may encourage
members to contact the PCP or twenty-four (24) hour nurse line when they have questions as to
whether they should go to the emergency room;
	 
	 	2.17.4.7.18	 	Shall include information on how to access a care coordinator, including the ability to
access a care coordinator after regular business hours through the twenty-four (24) hour nurse
triage/advice line.
	 
	 	2.17.4.7.19	 	Shall include notice of the right to file a complaint as is provided for by Title VI of
the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, the Omnibus
Budget Reconciliation Act of 1981 (P.L. 97-35) and a complaint form on which to do so;
	 
	 	2.17.4.7.20	 	Shall include information about the Long-Term Care Ombudsman Program;
	 
	 	2.17.4.7.21	 	Shall include information about the CHOICES consumer advocate, including but not
limited to the role of the consumer advocate in the CHOICES program and how to contact the
consumer advocate for assistance;
	 
	 	2.17.4.7.22	 	Shall include information about how to report suspected abuse, neglect, and
exploitation of members who are adults (see TCA 71-6-101 et seq.) and suspected brutality,
abuse, or neglect of members who are children (see TCA 37-1-40 1 et seq. and TCA 37-1-601 et
seq.), including the phone numbers to call to report suspected abuse/neglect;
	 
	 	2.17.4.7.23	 	Shall include complaint and appeal procedures as described in Section 2.19 of this
Agreement;
	 
	 	2.17.4.7.24	 	Shall include notice that in addition to the member’s right to file an appeal directly
to TENNCARE for adverse actions taken by the CONTRACTOR, the member shall have the right to
request reassessment of eligibility related decisions directly to TENNCARE;

Page 207 of 374

 

 

	 	2.17.4.7.25	 	Shall include written policies on member rights and responsibilities,
pursuant to 42 CFR 438.100 and NCQA’s Standards and Guidelines for the Accreditation of
MCOs;
	 
	 	2.17.4.7.26	 	Shall include written information concerning advance directives as described in 42 CFR
489 Subpart I and in accordance with 42 CFR 422.128;
	 
	 	2.17.4.7.27	 	Shall include notice that enrollment in the CONTRACTOR’s MCO invalidates any prior
authorization for services granted by another MCO but not utilized by the member prior to the
member’s enrollment into the CONTRACTOR’s MCO and notice of continuation of care when entering
the CONTRACTOR’s MCO as described in Section 2.9.2 of this Agreement;
	 
	 	2.17.4.7.28	 	Shall include notice to the member that it is the member’s responsibility to notify the
CONTRACTOR, TENNCARE, and DHS (or for SSI eligibles, SSA) each and every time the member moves
to a new address and that failure to notify DHS (or for SSI eligibles, SSA) could result in
the member not receiving important eligibility and/or benefit information;
	 
	 	2.17.4.7.29	 	Shall include notice that a new member may request to change MCOs at anytime during the
forty-five (45) calendar day period immediately following their initial enrollment in an MCO,
subject to the capacity of the selected MCO to accept additional members and any restrictions
limiting enrollment levels established by TENNCARE. This notice shall include instructions on
how to contact TENNCARE to request a change;
	 
	 	2.17.4.7.30	 	Shall include notice that the member may change MCOs at the next choice period as
described in Section 2.4.7.2.2 of this Agreement and shall have a forty-five (45) calendar day
period immediately following the enrollment, as requested during said choice period, in a new
MCO to request to change MCOs, subject to the capacity of the selected MCO to accept
additional enrollees and any restrictions limiting enrollment levels established by TENNCARE.
This notice shall include instructions on how to contact TENNCARE to request a change;
	 
	 	2.17.4.7.31	 	Shall include notice that the member has the right to ask TENNCARE to change MCOs
based on hardship, the circumstances which constitute hardship, explanation of the member’s
right to file an appeal if such request is not granted, and how to do so;
	 
	 	2.17.4.7.32	 	Shall include notice of the enrollee’s right to terminate participation in the TennCare
program at any time with instructions to contact TENNCARE for termination forms and additional
information on termination;
	 
	 	2.17.4.7.33	 	Shall include TENNCARE and MCO member services toll-free telephone numbers, including
the TENNCARE hotline, the CONTRACTOR’s member services information line, and the CONTRACTOR’s
24/7 nurse triage/advice line with a statement that the member may contact the CONTRACTOR or
TENNCARE regarding questions about the TennCare program, including CHOICES, as well as the
service/information that may be obtained from each line;

Page 208 of 374

 

 

	 	2.17.4.7.34	 	Shall include information on how to obtain information in
alternative formats or how to access interpretation services as well as a
statement that interpretation and translation services are free;
	 
	 	2.17.4.7.35	 	Shall include information educating members of their rights and necessary steps
to amend their data in accordance with HIPAA regulations and state law;
	 
	 	2.17.4.7.36	 	Shall include directions on how to request and obtain information regarding the
“structure and operation of the MCO” and “physician incentive plans” (see Section
2.17.8.2);
	 
	 	2.17.4.7.37	 	Shall include information that the member has the right to receive information
on available treatment options and alternatives, presented in a manner appropriate to
the member’s condition and ability to understand;
	 
	 	2.17.4.7.38	 	Shall include information that the member has the right to be free from any form
of restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation;
	 
	 	2.17.4.7.39	 	Shall include information on appropriate prescription drug usage (see Section
2.9.10); and
	 
	 	2.17.4.7.40	 	Shall include any additional information required in accordance with NCQA’s
Standards and Guidelines for the Accreditation of MCOs.

2.17.5 Quarterly Member Newsletter

	 	2.17.5.1	 	General Newsletter
	 
	 	 	 	The CONTRACTOR shall, at a minimum, distribute on a quarterly basis a newsletter
to all members which is intended to educate the enrollee to the managed care
system, proper utilization of services, etc., and encourage utilization of
preventive care services.
	 
	 	2.17.5.2	 	Teen/Adolescent Newsletter
	 
	 	 	 	The CONTRACTOR shall, at a minimum, distribute on a quarterly basis a newsletter
to all enrollees between the ages of 15 and 20 which is intended to educate the
enrollee to the managed care system, proper utilization of services, etc., with
an emphasis on the encouragement to utilize TENNderCare services.
	 
	 	2.17.5.2.1	 	The Teen/Adolescent Newsletter shall be a product of the MCO Adolescent Well-
Care Collaborative. The MCOs will agree on five required topics to include in each
newsletter. MCOs may include additional articles at their discretion; no deviation from
the five agreed upon articles will be allowed unless approved in writing by TENNCARE.
	 
	 	2.17.5.2.1.1	 	The CONTRACTOR shall include the following information in each newsletter:
	 
	 	2.17.5.2.1.1.1	 	Five teen/adolescent specific articles as agreed upon by the MCO Adolescent
Well Care Collaborative; and

Page 209 of 374

 

 

	 	2.17.5.2.1.1.2	 	The procedure on how to obtain information in alternative formats or how to access
interpretation services as well as a statement that interpretation and translation services are
free; and
	 
	 	2.17.5.2.1.1.3	 	TENNderCare information, including but not limited to, encouragement to obtain
screenings and other preventive care services.
	 
	 	2.17.5.3	 	The CONTRACTOR shall include the following information in each newsletter:
	 
	 	2.17.5.3.1	 	Specific articles or other specific information as described when requested by TENNCARE.
Such requests by TENNCARE shall be limited to two hundred (200) words and shall be reasonable
including sufficient notification of information to be included;
	 
	 	2.17.5.3.2	 	At least one specific article targeted to CHOICES members;
	 
	 	2.17.5.3.3	 	Notification regarding the CHOICES program, including a brief description and whom to
contact for additional information;
	 
	 	2.17.5.3.4	 	The procedure on how to obtain information in alternative formats or how to access
interpretation services as well as a statement that interpretation and translation services
are free;
	 
	 	2.17.5.3.5	 	A notice to members of the right to file a complaint, as is provided for by Title VI of
the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title II of the
Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, the Omnibus
Budget Reconciliation Act of 1981 (P.L. 97-35), and a CONTRACTOR phone number for doing so.
The notice shall be in English and Spanish;
	 
	 	2.17.5.3.6	 	TENNderCare information, including but not limited to, encouragement to obtain
screenings and other preventive care services;
	 
	 	2.17.5.3.7	 	Information about appropriate prescription drug usage;
	 
	 	2.17.5.3.8	 	TENNCARE and MCO member services toll-free telephone numbers, including the TENNCARE
hotline, the CONTRACTOR’s member services information line, and the CONTRACTOR’s 24/7 nurse
triage/advice line as well as the service/information that may be obtained from each line; and
	 
	 	2.17.5.3.9	 	The following statement: “To report fraud or abuse to the Office of Inspector General
(OIG) you can call toll-free 1-800-433-3982 or go online to www.state.tn.us/tenncare
and click on ‘Report Fraud’. To report provider fraud or patient abuse to the Medicaid Fraud
Control Unit (MFCU), call toll-free 1-800-433-5454.”

Page 210 of 374

 

 

	 	2.17.5.4	 	The quarterly member newsletters shall be disseminated within thirty (30)
calendar
days of the start of each calendar year quarter. In order to satisfy the
requirement to distribute the quarterly newsletter to all members, it shall be
acceptable to mail one (1) quarterly newsletter to each address associated with
the member’s TennCare case number. In addition to the prior authorization
requirement regarding dissemination of materials to members, the CONTRACTOR
shall also submit to TENNCARE, five (5) final printed originals, unless
otherwise specified by TENNCARE, of the newsletters and documentation from the
MCO’s mail room or outside vendor indicating the quantity and date mailed to
TennCare as proof of compliance by the 30th of the month following each quarter
in accordance with the reporting schedules as described in Section 2.30.1.3 of
this Agreement.

2.17.6 Identification Card

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

	 	2.17.6.1	 	The CONTRACTOR’s name and issuer identifier, with the company logo;
	 
	 	2.17.6.2	 	Phone numbers for information and/or authorizations, including for physical
health,
behavioral health, and long-term care services;

	 
	 	2.17.6.3	 	Descriptions of procedures to be followed for emergency or special services;

	 
	 	2.17.6.4	 	The member’s identification number;
	 
	 	2.17.6.5	 	The member’s name (First, Last and Middle Initial);
	 
	 	2.17.6.6	 	The member’s date of birth;
	 
	 	2.17.6.7	 	The member’s enrollment effective date;
	 
	 	2.17.6.8	 	Co-payment information;
	 
	 	2.17.6.9	 	The Health Insurance Portability and Accountability Act (HIPAA) adopted
identifier;
	 
	 	2.17.6.10	 	The words “Medicaid” or “Standard” based on eligibility; and
	 
	 	2.17.6.11	 	For CHOICES members, the word “CHOICES.”

2.17.7 CHOICES Member Education Materials

	 	2.17.7.1	 	The CONTRACTOR shall explain and provide member education materials to each
CHOICES member (see Section 2.9.6.9.6.4.2).

Page 211 of 374

 

	 	2.17.7.2	 	The CONTRACTOR shall update and re-print the CHOICES member education
materials as specified and with advance notice by TENNCARE. The revised materials shall
be submitted to TENNCARE for review and approval. Upon TENNCARE approval, the
CONTRACTOR shall immediately distribute the updated materials to all CHOICES members.
	 
	 	2.17.7.3	 	The materials shall comply with all state and federal requirements and, at a
minimum, shall include:
	 
	 	2.17.7.3.1	 	A description of the CHOICES program, including the CHOICES Groups;
	 
	 	2.17.7.3.2	 	Information on CHOICES groups and the covered long-term care services for each CHOICES
group, including HCBS benefit limits;
	 
	 	2.17.7.3.3	 	A general description of care coordination and the role of the care coordinator;
	 
	 	2.17.7.3.4	 	Information about contacting and changing the member’s care coordinator, including but
not limited to how to contact the care coordinator, how and when the member will be notified
of who the assigned care coordinator is, and the procedure for making changes to the assigned
care coordinator, whether initiated by the CONTRACTOR or requested by the member;
	 
	 	2.17.7.3.5	 	Information about the CHOICES consumer advocate, including but not limited to the role
of the CHOICES consumer advocate and how to contact the consumer advocate for assistance;
	 
	 	2.17.7.3.6	 	Information and procedures on how to report suspected abuse and neglect (including
abuse, neglect and/or exploitation of members who are adults and suspected brutality, abuse,
or neglect of members who are children), including the phone numbers to call to report
suspected abuse and neglect;
	 
	 	2.17.7.3.7	 	Information about estate recovery;
	 
	 	2.17.7.3.8	 	The procedure on how to obtain member materials in alternative formats for members with
special needs and how to access oral interpretation services and that both alternative formats
and interpretation services are available at no expense to the member;
	 
	 	2.17.7.3.9	 	TENNCARE and MCO member services toll-free telephone numbers, including the TENNCARE
hotline, the CONTRACTOR’s member services information line, and the CONTRACTOR’s 24/7 nurse
triage/advice line as well as the service/information that may be obtained from each line;
	 
	 	2.17.7.3.10	 	Information about the member’s right to choose between nursing facility and HCBS if the
member qualifies for nursing home care and if the member’s needs can be safely and effectively
met in the community and at a cost that does not exceed the member’s cost neutrality cap;
	 
	 	2.17.7.3.11	 	A description of the care coordinator’s role and responsibilities for CHOICES Group 1
members, which at a minimum shall include:

Page 212 of 374

 

	 	2.17.7.3.11.1	 	Performing needs assessments as deemed necessary by the CONTRACTOR;

	 
	 	2.17.7.3.11.2	 	Participating in the nursing facility’s care planning process;
	 
	 	2.17.7.3.11.3	 	Coordinating the member’s physical health, behavioral health, and long-term care
needs;
	 
	 	2.17.7.3.11.4	 	Conducting face-to-face visits every six (6) months;
	 
	 	2.17.7.3.11.5	 	Conducting level of care reassessments; and
	 
	 	2.17.7.3.11.6	 	Determining the member’s interest in transition to the community and facilitating
such transition, as appropriate.
	 
	 	2.17.7.3.12	 	Information for Group 1 members about patient liability responsibilities including the
potential consequences of failure to comply with patient liability requirements, including
loss of the member’s nursing facility provider, disenrollment from CHOICES, and to the extent
that the member’s eligibility depends on receipt of longterm care services, loss of
eligibility for TennCare;
	 
	 	2.17.7.3.13	 	Information for Group 1 members about the CONTRACTOR’s nursing facility transition
process;
	 
	 	2.17.7.3.14	 	A statement advising members in Groups 2 and 3 that the CONTRACTOR may choose to
provide certain non-covered services to a particular member when the CONTRACTOR determines
that such services are an appropriate and more cost- effective way of meeting the member’s
needs than other covered services that would otherwise be provided; a member is not entitled
to receive these non-covered services; the decision to provide or not provide these
non-covered services to a particular member is at the sole discretion of the CONTRACTOR; and
if the CONTRACTOR does not provide one of these non-covered services to a member, the member
is not entitled to a fair hearing regarding the decision;
	 
	 	2.17.7.3.15	 	A statement advising members in Group 2 that the cost of providing HCBS, home health,
and private duty nursing shall not exceed the member’s cost neutrality cap, and that the cost
neutrality cap reflects the projected  cost of providing nursing facility services to
the member;
	 
	 	2.17.7.3.16	 	A statement advising members in Group 3 that the cost of providing HCBS, excluding home
modification, to members in CHOICES Group 3 shall not exceed the expenditure cap;
	 
	 	2.17.7.3.17	 	An explanation for members in Group 2 of what happens when a member is projected to
exceed his/her cost neutrality cap, which shall include the following: The CONTRACTOR will
first work with the member to modify the member’s plan of care to safely and effectively meet
the member’s needs in the community and at a cost that is less than the member’s cost
neutrality cap; if that is not possible, the member will be transitioned to a more appropriate
setting (a nursing facility); and if the member declines to move to a more appropriate
setting, the member may be disenrolled from CHOICES, and to the extent that the member’s
eligibility depends on receipt of long-term care services, may lose eligibility for TennCare;

Page 213 of 374

 

	 	2.17.7.3.18	 	A statement advising CHOICES members in Group 3 that the CONTRACTOR will
deny HCBS in excess of the expenditure cap;
	 
	 	2.17.7.3.19	 	A statement advising members that HCBS provided by the CONTRACTOR to CHOICES members
will build upon and not supplant a member’s existing support system, including but not limited
to informal supports provided by family and other caregivers, services that may be available
at no cost to the member through other entities, and services that are reimbursable through
other public or private funding sources, such as Medicare or long-term care insurance;
	 
	 	2.17.7.3.20	 	A description of the care coordinator’s role and responsibilities for CHOICES Group 2
and 3 members, which at a minimum shall include:
	 
	 	2.17.7.3.20.1	 	Conducting an individualized, comprehensive needs assessment;
	 
	 	2.17.7.3.20.2	 	Coordinating a care plan team and facilitating the development of a plan of care;
	 
	 	2.17.7.3.20.3	 	Coordinating the identification of the member’s physical health, behavioral health
and long-term care needs and coordinating services to meet those needs;
	 
	 	2.17.7.3.20.4	 	Implementing the authorized plan of care, including ensuring the timely delivery of
services in accordance with the plan of care;
	 
	 	2.17.7.3.20.5	 	Providing assistance in resolving any concerns about service delivery or providers;
	 
	 	2.17.7.3.20.6	 	Explanation of the minimum contacts a care coordinator is required to make and a
statement that the care coordinator may be contacted as often as the member needs to contact
the care coordinator;
	 
	 	2.17.7.3.20.7	 	Completing level of care and needs reassessments and updating the plan of care; and
	 
	 	2.17.7.3.20.8	 	Ongoing monitoring of service delivery to ensure that any service gaps are
immediately addressed and that provided services meet the member’s needs;
	 
	 	2.17.7.3.21	 	Information about the right of members in Groups 2 and 3 to request an objective review
by the State of his/her needs assessment and/or care planning processes and how to make such a
request;
	 
	 	2.17.7.3.22	 	Information for members in Groups 2 and 3 on consumer direction of HCBS, including but
not limited to the roles and responsibilities of the member; the ability of the member to
select a representative and who can be a representative; the services that can be directed;
the member’s right to participate in and voluntarily withdraw from consumer direction at any
time; how to choose to participate in consumer direction; the role of the FEA; who can/cannot
be hired by the member to perform the services, and when a family member can be paid to
provide care and applicable limitations thereto; and

Page 214 of 374

 

	 	2.17.7.3.23	 	Information for members in Groups 2 and 3 regarding self-direction
of health care tasks.

2.17.8 Provider Directories

	 	2.17.8.1	 	The CONTRACTOR shall distribute general provider directories
(see Section 2.17.8.5 below) to new members within thirty (30) calendar days of receipt of
notification of enrollment in the CONTRACTOR’s MCO or prior to the member’s
enrollment effective date.
	 
	 	2.17.8.2	 	The CONTRACTOR shall provide the CHOICES provider directory
(see Section 2.17.8.6 below) to each CHOICES member as part of the face-to-face visit (for
members enrolled through the SPOE) or face-to-face intake visit (for current
members) as applicable, but not more than thirty (30) days from notice of
CHOICES enrollment.
	 
	 	2.17.8.3	 	The CONTRACTOR shall also be responsible for redistribution of updated
provider information on a regular basis and shall redistribute a complete and
updated general provider directory to all members and an updated CHOICES provider
directory to CHOICES members at least on an annual basis. In situations where
there is more than one enrollee in a TennCare case, it shall be acceptable for the
CONTRACTOR to mail one (1) general provider directory to each address listed for
the enrollee’s TennCare case number when there is more than one (1) new enrollee
assigned to the same case number at the time of enrollment and when subsequent
updated provider directories are mailed to enrollees. Should a single individual
be enrolled and be added into an existing case, a provider directory shall be
mailed to that individual regardless of whether or not a provider directory has
been previously mailed to enrollees in the existing case.
	 
	 	2.17.8.4	 	Provider directories (including both the general provider directory and the
CHOICES provider directory), and any revisions thereto, shall be submitted to
TENNCARE for written approval prior to distribution to enrollees in accordance
with Section 2.17.1 of this Agreement. The text of the directory shall be in the
format prescribed by TENNCARE. In addition, the provider information used to
populate the provider directory shall be submitted as a TXT file or such format as
otherwise approved in writing by TENNCARE and be produced using the same extract
process as the actual provider directory.
	 
	 	2.17.8.5	 	The CONTRACTOR shall develop and maintain a general provider directory, which
shall be distributed to all members. The general provider directory shall include
the following: names, locations, telephone numbers, office hours, and non-English
languages spoken by contract PCPs and specialists; identification of providers
accepting new patients; and identification of whether or not a provider performs
TENNderCare screens; hospital listings, including locations of emergency settings
and post-stabilization services, with the name, location, and telephone number of
each facility/setting; and a prominent notice that CHOICES members should refer to
the CHOICES provider directory for information on long-term care providers.

Page 215 of 374

 

	 	2.17.8.6	 	The CONTRACTOR shall develop and maintain a CHOICES provider directory
that includes long-term care providers. The CHOICES provider directory, which
shall be provided to all CHOICES members, shall include the following: nursing
facility listings with the name, location, and telephone number of each
facility; community- based residential alternatives, by type, with the name,
location, and telephone number of each facility; and a listing of other
(non-residential) HCBS providers with the name, location, telephone number, and
type of services by county of each provider.

2.17.9 Additional Information Available Upon Request

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

	 	2.17.9.1	 	Information regarding the structure and operation of the CONTRACTOR’s MCO;
and
	 
	 	2.17.9.2	 	Information regarding physician incentive plans, including but not limited to:
	 
	 	2.17.9.2.1	 	Whether the CONTRACTOR uses a physician incentive plan that affects the use of
referral services;
	 
	 	2.17.9.2.2	 	The type of incentive arrangement; and
	 
	 	2.17.9.2.3	 	Whether stop-loss protection is provided.

18. Section 2.18 shall be deleted in its entirety and replaced with the following:

2.18 CUSTOMER SERVICE

2.18.1 Member Services Toll-Free Phone Line

	 	2.18.1.1	 	The CONTRACTOR shall operate a toll-free telephone line (member services
information line) to respond to member questions, concerns, inquiries, and
complaints from the member, the member’s family, or the member’s provider.
	 
	 	2.18.1.2	 	The CONTRACTOR shall develop member services information line policies and
procedures that address staffing, training, hours of operation, access and
response standards, transfers/referrals, including CHOICES referrals from all
sources, monitoring of calls via recording or other means, and compliance with
standards.
	 
	 	2.18.1.3	 	The member services information line shall handle calls from callers with Limited
English Proficiency as well as calls from members who are hearing impaired.
	 
	 	2.18.1.4	 	The CONTRACTOR shall ensure that the member services information line is
staffed adequately to respond to members’ questions, at a minimum, from 8 a.m.
to 5 p.m., in the time zone applicable to the Grand Region being served (for the
Middle Grand Region, the applicable time zone shall be Central Time), Monday
through Friday, except State of Tennessee holidays.
	 
	 	2.18.1.5	 	The member services information line shall be staffed twenty-four (24) hours a day,
seven (7) days a week with qualified nurses to triage urgent care and emergency calls

Page 216 of 374

 

	 	 	 	from members and to facilitate transfer of calls to a care coordinator from or on
behalf of a CHOICES member that require immediate attention by a care coordinator. The
CONTRACTOR may meet this requirement by having a separate nurse triage/nurse advice
line that otherwise meets all of the requirements of this Section, Section 2.18.1.
	 
	 	2.18.1.6	 	The CONTRACTOR shall ensure that all calls from CHOICES members to the nurse triage/nurse
advice line that require immediate attention are immediately addressed or transferred to a
care coordinator. During normal business hours, the transfer shall be a “warm transfer” (see
definition in Section 1). After normal business hours, if the CONTRACTOR cannot transfer the
call as a “warm transfer”, the CONTRACTOR shall ensure that a care coordinator is notified and
returns the member’s call within thirty (30) minutes and that the care coordinator has access
to the necessary information (e.g., the member’s back-up plan) to resolve member issues. The
CONTRACTOR shall implement protocols, prior approved by TENNCARE, that describe how calls to
the nurse triage/nurse advice line from CHOICES members will be handled.
	 
	 	2.18.1.7	 	The member services information line shall be adequately staffed with staff trained
to
accurately respond to member questions regarding the TennCare program and the
CONTRACTOR’s MCO, including but not limited to, covered services, the CHOICES program,
TENNderCare, and the CONTRACTOR’s provider network.
	 
	 	2.18.1.8	 	The CONTRACTOR shall implement protocols, prior approved by TENNCARE, to ensure that calls
to the member services information line that should be transferred/referred to other
CONTRACTOR staff, including but not limited to a member services supervisor or a care
coordinator, or to an external entity, including but not limited to the FEA, are
transferred/referred appropriately.
	 
	 	2.18.1.9	 	The CONTRACTOR shall ensure that calls received during normal
business hours that require immediate attention by a care coordinator are immediately transferred to a
care coordinator as a “warm transfer”; that calls received after normal business hours
that require immediate attention by a care coordinator are transferred to a care
coordinator in accordance with Section 2.18.1.6; that calls for a member’s care
coordinator or care coordination team during normal business hours are handled in
accordance with Section 2.9.6.11.7; that calls transferred to the FEA during business
hours are “warm transfers”; that calls to other CONTRACTOR staff, at a minimum, occur
without the caller having to disconnect or place a second call; and that messages to
care coordinators and other CONTRACTOR are returned by the next business day.
	 
	 	2.18.1.10	 	The CONTRACTOR shall measure and monitor the accuracy of responses and phone etiquette
and take corrective action as necessary to ensure the accuracy of responses and appropriate
phone etiquette by staff.
	 
	 	2.18.1.11	 	The CONTRACTOR shall have an automated system available during non-business hours,
including weekends and holidays. This automated system shall provide callers with operating
instructions on what to do in case of an emergency and shall include, at a minimum, a voice
mailbox for callers to leave messages. The CONTRACTOR shall ensure that the voice mailbox has
adequate capacity to receive all messages. The CONTRACTOR shall return messages on the next
business day.

Page 217 of 374

 

	 	2.18.1.12	 	 Performance Standards for Member Services Line/Queue
	 
	 	2.18.1.12.1	 	The CONTRACTOR shall adequately staff the member services information line to
ensure that the line, including the nurse triage/nurse advice line or queue, meets the
following performance standards: less than five percent (5%) call abandonment rate;
eighty-five percent (85%) of calls are answered by a live voice within thirty (30)
seconds (or the prevailing benchmark established by NCQA); and average wait time for
assistance does not exceed ten (10) minutes.
	 
	 	2.18.1.12.2	 	The CONTRACTOR shall submit the reports required in Section 2.30.12 of this
Agreement.

2.18.2 Interpreter and Translation Services

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

2.18.3 Cultural Competency

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

2.18.4 Provider Services and Toll-Free Telephone Line

	 	2.18.4.1	 	The CONTRACTOR shall establish and maintain a provider
services function to timely and adequately respond to provider questions, comments, and inquiries.
	 
	 	2.18.4.2	 	The CONTRACTOR shall operate a toll-free telephone line (provider service
line) to respond to provider questions, comments, and inquiries.
	 
	 	2.18.4.3	 	The CONTRACTOR shall develop provider service line policies and procedures
that address staffing, training, hours of operation, access and response
standards, monitoring of calls via recording or other means, and compliance with
standards.
	 
	 	2.18.4.4	 	The CONTRACTOR shall ensure that the provider service line is staffed
adequately to respond to providers’ questions at a minimum from 8 a.m. to 5 p.m.,
in the time zone applicable to the Grand Region being served (for the Middle Grand
Region, the applicable time zone shall be Central Time), Monday through Friday,
except State of Tennessee holidays.

Page 218 of 374

 

	 	2.18.4.5	 	The provider service line shall also be adequately staffed to provide
appropriate and timely responses regarding authorization requests as described in
Section 2.14 of this Agreement. The CONTRACTOR may meet this requirement by having
a separate utilization management line.
	 
	 	2.18.4.6	 	The provider service line shall be adequately staffed with staff trained to
accurately respond to questions regarding the TennCare program and the CONTRACTOR’s MCO,
including but not limited to, covered services, the CHOICES program, TENNderCare, prior
authorization and referral requirements, care coordination, and the CONTRACTOR’s provider
network. For a period of at least twelve (12) months following the implementation of
CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR shall maintain a
dedicated queue to assist long-term care providers with enrollment, service
authorization, or reimbursement questions or issues. Such period may be extended as
determined necessary by TENNCARE.
	 
	 	2.18.4.7	 	For hospitals that have elected to refer patients with non-urgent/emergent conditions
to alternative settings for treatment, the CONTRACTOR shall have a specific process in
place whereby the Emergency Department (ED) can contact the CONTRACTOR twenty-four (24)
hours a day, seven (7) days a week (24/7) via a toll free phone line to obtain assistance
for members with non-urgent/emergent conditions who do not require inpatient admission
and who are requesting assistance in scheduling an appointment in an alternate treatment
setting. The CONTRACTOR may use the 24/7 nurse triage line described in Section 2.18.1.5
of this Agreement for this purpose or may use another line the CONTRACTOR designates. The
CONTRACTOR shall submit a description of how it will meet the requirements regarding its
24/7 ED assistance line, which shall provide the telephone number that will be used for
hospitals requiring scheduling assistance and describe the process the CONTRACTOR will
use to assure all requests are responded to appropriately, including a description of the
training provided to staff answering the 24/7 scheduling assistance line. The CONTRACTOR
shall track and report the total number of calls received pertaining to patients in ED’s
needing assistance in accessing care in an alternative setting in accordance with Section
2.30.12.1.3.
	 
	 	2.18.4.8	 	The CONTRACTOR shall measure and monitor the accuracy of responses and phone etiquette and
take corrective action as necessary to ensure the accuracy of responses and appropriate phone
etiquette by staff.
	 
	 	2.18.4.9	 	The CONTRACTOR shall have an automated system available during non-business hours. This
automated system shall include, at a minimum, a voice mailbox for callers to leave messages.
The CONTRACTOR shall ensure that the voice mailbox has adequate capacity to receive all
messages. The CONTRACTOR shall return messages on the next business day.
	 
	 	2.18.4.10	 	 Performance Standards for Provider Service Line
	 
	 	2.18.4.10.1	 	The CONTRACTOR shall adequately staff the provider service line to ensure that the
line, including the utilization management line/queue, meets the following performance
standards: less than five percent (5%) call abandonment rate; eighty-five percent (85%) of
calls are answered by a live voice within thirty (30) seconds (or the prevailing benchmark
established by NCQA); and average wait time for assistance does not exceed ten (10) minutes.

Page 219 of 374

 

	 	2.18.4.10.2	 	The CONTRACTOR shall submit the reports required in Section 2.30.12.1 of this Agreement.

2.18.5 Provider Handbook

	 	2.18.5.1	 	The CONTRACTOR shall issue a provider handbook to all contract providers. The
CONTRACTOR may distribute the provider handbook electronically (e.g., via its
website) as long as providers are notified about how to obtain the electronic
copy and how to request a hard copy at no charge to the provider.
	 
	 	2.18.5.2	 	The CONTRACTOR shall develop a supplement for the provider handbook regarding
CHOICES. This supplement shall include the information in Section 2.18.5.3 relating to
the CHOICES program, as determined by TENNCARE, and the supplement shall be prior
approved by TENNCARE and TDCI. The CONTRACTOR shall distribute the supplement to all
contract providers no later than the end of the quarter prior to implementation of
CHOICES. The CONTRACTOR shall distribute the supplement until the provider handbook is
revised to include the CHOICES program, which shall be no later than the date specified
by TENNCARE.
	 
	 	2.18.5.3	 	At a minimum the provider handbook shall include the following information:
	 
	 	2.18.5.3.1	 	Description of the TennCare program;
	 
	 	2.18.5.3.2	 	Covered services;
	 
	 	2.18.5.3.3	 	Description of the CHOICES program including but not limited to who qualifies for
CHOICES (including the three CHOICES groups and enrollment targets for CHOICES Groups 2
and 3); how to enroll in CHOICES; long-term care services available to each CHOICES
Group (including benefit limits, cost neutrality cap for members in Group 2, and the
expenditure cap for members in Group 3); consumer direction of HCBS; self-direction of
health care tasks; the level of care assessment and reassessment process; the needs
assessment and reassessment processes; requirement to provide services in accordance
with an approved plan of care including the amount, frequency, duration and scope of
each service in accordance with the member’s service schedule; service authorization
requirements and processes; the role of the care coordinator; the role and
responsibilities of long-term care and other providers; requirements regarding the
electronic visit verification system and the provider’s responsibility in monitoring
and immediately addressing service gaps, including back-up staff; how to submit clean
claims; and documentation requirements for HCBS providers;
	 
	 	2.18.5.3.4	 	Emergency service responsibilities;
	 
	 	2.18.5.3.5	 	TENNderCare services and standards;
	 
	 	2.18.5.3.6	 	Information on members’ appeal rights and complaint
processes;

	 
	 	2.18.5.3.7	 	Policies and procedures of the provider complaint
system;

	 
	 	2.18.5.3.8	 	Medical necessity standards and clinical practice
guidelines;

Page 220 of 374

 

	 	2.18.5.3.9	 	PCP responsibilities;
	 
	 	2.18.5.3.10	 	Coordination with other TennCare contractors or MCO subcontractors;
	 
	 	2.18.5.3.11	 	Requirements regarding background checks;
	 
	 	2.18.5.3.12	 	Information on identifying and reporting suspected abuse, neglect, and exploitation of
members who are adults (see TCA 71-6-101 et seq.) and suspected brutality, abuse, or neglect
of members who are children (see TCA 37-1-40 1 et seq. and TCA 37-1-60 1 et seq.), including
reporting to APS, CPS, and the CONTRACTOR;
	 
	 	2.18.5.3.13	 	Requirements for HCBS providers regarding critical incident reporting and management
(see Section 2.15.8);
	 
	 	2.18.5.3.14	 	Requirements for nursing facility providers regarding patient liability (see Sections
2.6.7 and 2.21.5), including the collection of patient liability and the provider’s ability,
if certain conditions are met (including providing notice and required documentation to the
CONTRACTOR and notice to the member), to refuse to provide services if the member does not pay
his/her patient liability, as well as the additional potential consequences to the member of
non-payment of patient liability, including disenrollment from CHOICES, and, to the extent the
member’s eligibility depends on receipt of long-term care services, loss of eligibility for
TennCare;
	 
	 	2.18.5.3.15	 	Requirement to notify the CONTRACTOR of significant changes in a CHOICES member’s
condition or care, hospitalizations, or recommendations for additional services (see Section
2.12.9.3.7);
	 
	 	2.18.5.3.16	 	Prior authorization, referral and other utilization management requirements and
procedures;
	 
	 	2.18.5.3.17	 	Protocol for encounter data element reporting/records;
	 
	 	2.18.5.3.18	 	Medical records standard;
	 
	 	2.18.5.3.19	 	Claims submission protocols and standards, including instructions and all information necessary for a clean claim;

	 
	 	2.18.5.3.20	 	Payment policies;
	 
	 	2.18.5.3.21	 	Member rights and responsibilities;
	 
	 	2.18.5.3.22	 	Important phone numbers of all departments/staff a contract provider may need to reach at the CONTRACTOR’s MCO; and
	 
	 	2.18.5.3.23	 	How to reach the contract provider’s assigned provider relations representative.
	 
	 	2.18.5.4	 	The CONTRACTOR shall disseminate bulletins as needed to incorporate any needed
changes to the provider handbook.

Page 221 of 374

 

2.18.6 Provider Education and Training

	 	2.18.6.1	 	The CONTRACTOR shall develop an education and training plan and materials for
contract providers and provide education and training to contract providers and
their staff regarding key requirements of this Agreement.
	 
	 	2.18.6.2	 	The CONTRACTOR shall conduct initial education and training to contract
providers at least thirty (30) calendar days prior to the start date of
operations
	 
	 	2.18.6.3	 	The CONTRACTOR shall conduct initial education and training for long-term care
providers regarding the CHOICES program no later than thirty (30) days prior to
implementation of CHOICES in the Grand Region covered by this Agreement. This
education and training shall include but not be limited to:
	 
	 	2.18.6.3.1	 	An overview of the CHOICES program;
	 
	 	2.18.6.3.2	 	The three CHOICES groups and the enrollment targets for each (as applicable);
	 
	 	2.18.6.3.3	 	The long-term care services available to each CHOICES group (including benefit
limits, cost neutrality cap for CHOICES Group 2, and the expenditure cap for CHOICES
Group 3);
	 
	 	2.18.6.3.4	 	The level of care assessment and reassessment
processes;
	 
	 	2.18.6.3.5	 	The needs assessment and reassessment
processes;
	 
	 	2.18.6.3.6	 	The CHOICES intake process;
	 
	 	2.18.6.3.7	 	Service authorization requirements and processes;
	 
	 	2.18.6.3.8	 	The role and responsibilities of the care coordinator for members in CHOICES
Group 1;
	 
	 	2.18.6.3.9	 	The role and responsibilities of the care coordinator for members in CHOICES
Groups 2 and 3;
	 
	 	2.18.6.3.10	 	Requirement to provide services in accordance with an approved plan of care
including the amount, frequency, duration and scope of each service in accordance with
the member’s service schedule;
	 
	 	2.18.6.3.11	 	The role and responsibilities of long-term care and other providers;
	 
	 	2.18.6.3.12	 	Requirements regarding the electronic visit verification system and the
provider’s responsibility in monitoring and immediately addressing service gaps,
including back-up staff;
	 
	 	2.18.6.3.13	 	How to submit clean claims;
	 
	 	2.18.6.3.14	 	Background check requirements;

Page 222 of 374

 

	 	2.18.6.3.15	 	Information about abuse/neglect (which includes abuse, neglect and
exploitation of members who are adults and suspected brutality, abuse, or neglect of
members who are children), including how to assess risk for abuse/neglect, how to
identify abuse/neglect, and how to report abuse/neglect to APS and the CONTRACTOR;
	 
	 	2.18.6.3.16	 	Critical incident reporting and management for HCBS providers;
	 
	 	2.18.6.3.17	 	The member complaint and appeal processes; and
	 
	 	2.18.6.3.18	 	The provider complaint system.
	 
	 	2.18.6.4	 	The CONTRACTOR shall provide training and education to long-term care
providers regarding the CONTRACTOR’s enrollment and credentialing requirements and
processes (see Section 2.11.8).
	 
	 	2.18.6.5	 	For a period of at least twelve (12) months following the implementation of
CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR shall conduct
monthly education and training for long-term care providers regarding claims submission
and payment processes, which shall include but not be limited to an explanation of
common claims submission errors and how to avoid those errors. Such period may be
extended as determined necessary by TENNCARE.
	 
	 	2.18.6.6	 	For a period of at least twelve (12) months following the implementation of
CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR shall conduct
monthly education and training for HCBS providers regarding the use of the EVV system.
Such period may be extended as determined necessary by TENNCARE.
	 
	 	2.18.6.7	 	The CONTRACTOR shall provide education and training on documentation requirements for
HCBS.
	 
	 	2.18.6.8	 	The CONTRACTOR shall conduct ongoing provider education, training and
technical assistance as deemed necessary by the CONTRACTOR or TENNCARE in order to
ensure compliance with this Agreement.
	 
	 	2.18.6.9	 	The CONTRACTOR shall inform all contract PCPs, specialists, and hospitals about the
CHOICES program, using a notice developed by TENNCARE, no later than the end of the
calendar quarter prior to implementation of the CHOICES program in the Grand Region
covered by this Agreement.
	 
	 	2.18.6.10	 	The CONTRACTOR shall distribute on a quarterly basis a newsletter to contract providers
to update providers on CONTRACTOR initiatives and communicate pertinent information to
contract providers.
	 
	 	2.18.6.11	 	The CONTRACTOR’s provider relations staff shall contact all contract providers on a
semi-annual basis to update contract providers on CONTRACTOR initiatives and communicate
pertinent information to contract providers. At least one of the two semi-annual contacts made
in a year shall be face-to-face with the provider. Semiannual contacts that are not conducted
face-to-face shall be conducted via a phone conversation with the provider. The CONTRACTOR
shall maintain records that

Page 223 of 374

 

	 	 	 	provide evidence of compliance with the requirement in this Section 2.18.6.5,
including when and how contact is made for each contract provider.

2.18.7 Provider Relations

	 	2.18.7.1	 	The CONTRACTOR shall establish and maintain a formal provider relations
function to provide ongoing troubleshooting and education for contract providers.
	 
	 	2.18.7.2	 	The CONTRACTOR shall provide one-on-one assistance to long-term care providers
as needed to help long-term care providers submit clean and accurate claims and
minimize claim denial. The CONTRACTOR shall develop and implement protocols, prior
approved by TENNCARE, that specify the CONTRACTOR’s criteria for providing
one-on-one assistance to a provider and the type of assistance the CONTRACTOR will
provide. At a minimum, the CONTRACTOR shall contact a provider if, during the
first year after implementation of CHOICES in the Grand Region covered by this
Agreement, the CONTRACTOR has or will deny ten percent (10%) or more of the total
value of the provider’s claims for a rolling thirty (30) day period, and shall, in
addition to issuing a remittance advice, contact the provider to review each of
the error(s)/reason(s) for denial and advise how the provider can correct the
error for resubmission (as applicable) and avoid the error/reason for denial in
the future.
	 
	 	2.18.7.3	 	The CONTRACTOR shall implement policies to monitor and ensure compliance of
providers with the requirements of this Agreement.
	 
	 	2.18.7.4	 	The CONTRACTOR shall conduct an annual survey to assess provider satisfaction,
including satisfaction with provider enrollment, provider communication, provider
education, provider complaints, claims processing, claims reimbursement, care
coordination, and utilization management processes, including medical reviews. The
CONTRACTOR shall include questions specified by TENNCARE. The CONTRACTOR shall
submit an annual report on the survey to TENNCARE as required in Section
2.30.12.4. The CONTRACTOR shall take action to address opportunities for
improvement identified through the survey. The survey shall be structured so that
long-term care provider satisfaction results, behavioral health provider
satisfaction results, and physical health provider satisfaction results can be
separately stratified.

2.18.8 Provider Complaint System

	 	2.18.8.1	 	The CONTRACTOR shall establish and maintain a provider complaint system for
any provider (contract or non-contract) who is not satisfied with the
CONTRACTOR’s policies and procedures or a decision made by the CONTRACTOR that
does not impact the provision of services to members.
	 
	 	2.18.8.2	 	The procedures for resolution of any disputes regarding the payment of claims
shall
comply with TCA 56-32-126(b) (see Section 2.22.5.2).

Page 224 of 374

 

2.18.9 FEA Education and Training

	 	2.18.9.1	 	The CONTRACTOR shall provide education and training to the FEA and its staff
regarding key requirements of this Agreement and the subcontract between the
CONTRACTOR and the FEA.
	 
	 	2.18.9.2	 	The CONTRACTOR shall conduct initial education and training to the FEA and its
staff at least thirty (30) days prior to implementation of CHOICES in the Grand
Region covered by this Agreement. This education and training shall include but
not be limited to:
	 
	 	2.18.9.2.1	 	The roles and responsibilities of the CONTRACTOR and the FEA in implementing and
monitoring consumer direction of HCBS;
	 
	 	2.18.9.2.2	 	The FEA’s responsibilities for communicating with the CONTRACTOR, members and
workers;
	 
	 	2.18.9.2.3	 	Customer service requirements;
	 
	 	2.18.9.2.4	 	Requirements and processes regarding referral to the FEA;
	 
	 	2.18.9.2.5	 	Requirements and processes, including timeframes, for authorization of consumer-
directed HCBS;
	 
	 	2.18.9.2.6	 	Requirements and processes, including timeframes, for claims submission and
payment;
	 
	 	2.18.9.2.7	 	Systems requirements and information exchange requirements;

	 
	 	2.18.9.2.8	 	Requirements regarding the electronic visit verification
system;
	 
	 	2.18.9.2.9	 	Requirements and role and responsibility regarding abuse and neglect plan
protocols (see Section 2.24.4.3) and critical incident reporting and management (see
Section 2.15.8); and
	 
	 	2.18.9.2.10	 	The CONTRACTOR’s member complaint and appeal processes.
	 
	 	2.18.9.3	 	The CONTRACTOR shall conduct ongoing FEA education, training and technical
assistance as deemed necessary by the CONTRACTOR or TENNCARE in order to ensure
compliance with this Agreement and the subcontract between the CONTRACTOR and
the FEA.

2.18.10 Member Involvement with Behavioral Health Services

	 	2.18.10.1	 	The CONTRACTOR shall develop policies and procedures with respect to member,
parent, or legally appointed representative involvement with behavioral health. These
policies and procedures shall include, at a minimum, the following elements:
	 
	 	2.18.10.1.1	 	The requirement that all behavioral health treatment plans document member
involvement. Fulfilling this requirement means that each treatment plan has a
member/family member signature or the signature of a legally appointed

Page 225 of 374

 

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

19. Section 2.19 shall be deleted in its entirety and replaced with the following:

2.19 COMPLAINTS AND APPEALS

2.19.1 General

	 	2.19.1.1	 	Members shall have the right to file appeals regarding adverse actions taken by the
CONTRACTOR. For purposes of this requirement, appeal shall mean a member’s right
to contest verbally or in writing, any adverse action taken by the CONTRACTOR to
deny, reduce, terminate, delay or suspend a covered service as well as any other
acts or omissions of the CONTRACTOR which impair the quality, timeliness, or
availability of such benefits. An appeal may be filed by the member or by a
person authorized by the member to do so, including but not limited to, a
provider or consumer-directed worker with the member’s written consent.
Complaint shall mean a written or verbal expression of dissatisfaction about an
action taken by the CONTRACTOR or service provider other than those that meet
the definition of an adverse action. Examples of complaints include but are not
limited to quality of care or services provided and aspects of interpersonal
relationships such as rudeness

Page 226 of 374

 

	 		 	of a provider or employee. The CONTRACTOR shall inform members of their
complaint and appeal rights in the member handbook in compliance with the
requirements in Section 2.17.4. The CONTRACTOR shall have internal complaint and
appeal procedures for members in accordance with TennCare rules and regulations,
the TennCare waiver, consent decrees, or court orders governing the appeals
process.
	 
	 	2.19.1.2	 	The CONTRACTOR shall devote a portion of its regularly scheduled QM/QI
committee meetings, as described in Section 2.15.2, to the review of member
complaints and appeals that have been received.
	 
	 	2.19.1.3	 	The CONTRACTOR shall ensure that punitive action is not taken against a
provider or worker who files an appeal on behalf of a member with the member’s
written consent, supports a member’s appeal, or certifies that a member’s appeal
is an emergency appeal and requires an expedited resolution in accordance with
TennCare policies and procedures.

2.19.2 Complaints

	 	2.19.2.1	 	The CONTRACTOR’s complaint process shall, at a minimum,
meet the requirements outlined herein.
	 
	 	2.19.2.2	 	The CONTRACTOR’s complaint process shall only be for complaints, as defined in
Sections 1 and 2.19.1.1 of this Agreement. The CONTRACTOR shall ensure that all
appeals, as defined in Sections 1 and 2.19.1.1, are addressed through the appeals
process specified in Section 2.19.3 below.
	 
	 	2.19.2.3	 	The CONTRACTOR shall allow a member to file a complaint either orally or in
writing at any time.
	 
	 	2.19.2.4	 	Within five (5) business days of receipt of the complaint, the CONTRACTOR
shall provide written notice to the member that the complaint has been received and
the expected date of resolution. However, if the CONTRACTOR resolved the
complaint and verbally informed the member of the resolution within five (5)
business days of receipt of the complaint, the CONTRACTOR shall not be required
to provide written acknowledgement of the complaint.
	 
	 	2.19.2.5	 	The CONTRACTOR shall resolve and notify the member in writing of the
resolution of each complaint as expeditiously as possible but no later than thirty
(30) days from the date the complaint is received by the CONTRACTOR. The notice
shall include the resolution and the basis for the resolution. However, if the
CONTRACTOR resolved the complaint and verbally informed the member of the
resolution within five (5) business days of receipt of the complaint, the
CONTRACTOR shall not be required to provide written notice of resolution.
	 
	 	2.19.2.6	 	The CONTRACTOR shall assist members with the complaint process, including but
not limited to completing forms.
	 
	 	2.19.2.7	 	The CONTRACTOR shall track and trend all complaints, timeframes and
resolutions and ensure remediation of individual and/or systemic issues.

Page 227 of 374

 

	 	2.19.2.8	 	The CONTRACTOR shall submit reports regarding member complaints as
specified in Section 2.30.13.

2.19.3 Appeals

	 	2.19.3.1	 	The CONTRACTOR’s appeal process shall, at a minimum, meet the requirements
outlined herein.
	 
	 	2.19.3.2	 	The CONTRACTOR shall have a contact person who is knowledgeable of appeal
procedures and shall direct all appeals, whether the appeal is verbal or the member
chooses to file in writing, to TENNCARE. Should a member choose to appeal in writing,
the member shall be instructed to file via mail or fax to the designated TENNCARE P. O.
Box or fax number for medical appeals.
	 
	 	2.19.3.3	 	The CONTRACTOR shall have sufficient support staff (clerical and professional)
available to process appeals in accordance with TennCare requirements related to
the appeal of adverse actions affecting a TennCare member. The CONTRACTOR shall
notify TENNCARE of the names of appointed staff members and their phone numbers.
Staff shall be knowledgeable about applicable state and federal law, TennCare
rules and regulations, and all court orders and consent decrees governing appeal
procedures, as they become effective.
	 
	 	2.19.3.4	 	The CONTRACTOR shall educate its staff concerning the importance of the
appeals procedure, the rights of the member, and the time frames in which action
shall be taken by the CONTRACTOR regarding the handling and disposition of an
appeal.
	 
	 	2.19.3.5	 	The CONTRACTOR shall identify the appropriate individual or body within the
CONTRACTOR’s MCO having decision-making authority as part of the appeal
procedure.
	 
	 	2.19.3.6	 	The CONTRACTOR shall have the ability to take telephone appeals and
accommodate persons with disabilities during the appeals process. Appeal forms
shall be available at each service site and by contacting the CONTRACTOR.
However, members shall not be required to use a TENNCARE approved appeal form in
order to file an appeal.
	 
	 	2.19.3.7	 	Upon request, the CONTRACTOR shall provide members a TENNCARE approved appeal
form(s).
	 
	 	2.19.3.8	 	The CONTRACTOR shall provide reasonable assistance to all appellants during
the appeal process.
	 
	 	2.19.3.9	 	At any point in the appeal process, TENNCARE shall have the authority to
remove a member from the CONTRACTOR’s MCO when it is determined that such removal
is in the best interest of the member and TENNCARE.
	 
	 	2.19.3.10	 	The CONTRACTOR shall require providers to display notices of members’ right to
appeal adverse actions affecting services in public areas of each facility in
accordance with TennCare rules and regulations. The CONTRACTOR shall ensure that
providers have correct and adequate supply of public notices.

Page 228 of 374

 

	 	2.19.3.11	 	Neither the CONTRACTOR nor TENNCARE shall prohibit or discourage any
individual from testifying on behalf of a member.
	 
	 	2.19.3.12	 	The CONTRACTOR shall ensure compliance with all notice requirements and notice
content requirements specified in applicable state and federal law, TennCare rules and
regulations, and all court orders and consent decrees governing notice and appeal
procedures, as they become effective.
	 
	 	2.19.3.13	 	TENNCARE may develop additional appeal process guidelines or rules, including
requirements as to content and timing of notices to members, which shall be followed by
the CONTRACTOR. However, the CONTRACTOR shall not be precluded from challenging any
judicial requirements and to the extent judicial requirements that are the basis of
such additional guidelines or rules are stayed, reversed or otherwise rendered
inapplicable, the CONTRACTOR shall not be required to comply with such guidelines or
rules during any period of such inapplicability.
	 
	 	2.19.3.14	 	The CONTRACTOR shall provide general and targeted education to providers regarding
expedited appeals (described in TennCare rules and regulations), including when an
expedited appeal is appropriate, and procedures for providing written certification
thereof.
	 
	 	2.19.3.15	 	The CONTRACTOR shall require providers to provide written certification regarding
whether a member’s appeal is an emergency upon request by a member prior to filing such
appeal, or upon reconsideration of such appeal by the CONTRACTOR when requested by
TENNCARE.
	 
	 	2.19.3.16	 	The CONTRACTOR shall provide notice to contract providers regarding provider
responsibility in the appeal process, including but not limited to, the provision of
medical records and/or documentation as described in Section 2.24.6 and 2.14.8.
	 
	 	2.19.3.17	 	The CONTRACTOR shall urge providers who feel they cannot order a drug on the
TennCare Preferred Drug List (PDL) to seek prior authorization in advance, as well as
to take the initiative to seek prior authorization or change or cancel the prescription
when contacted by a member or pharmacy regarding denial of a pharmacy service due to
system edits (e.g., therapeutic duplication, etc.).
	 
	 	2.19.3.18	 	Except for long-term care eligibility and enrollment appeals, which are handled by
TENNCARE, member eligibility and eligibility-related grievances and appeals, including
termination of eligibility, effective dates of coverage, and the determination of
premium, copayment, and patient liability responsibilities shall be directed to the
Department of Human Services.

20. Section 2.21 shall be deleted in its entirety and replaced with the following:

2.21 FINANCIAL MANAGEMENT

The CONTRACTOR shall be responsible for sound financial management of its MCO. The
CONTRACTOR shall adhere to the minimum guidelines outlined below.

Page 229 of 374

 

2.2 1.1 Payments by TENNCARE

The CONTRACTOR shall accept payments remitted by TENNCARE in accordance with Section 3 as
payment in full for all services required pursuant to this Agreement.

2.21.2 Savings/Loss

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

2.21.3 Interest

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

2.2 1.4 Third Party Liability Resources

	 	2.21.4.1	 	The TennCare program shall be the payer of last resort for all covered services in
accordance with federal regulations. The CONTRACTOR shall exercise full
assignment rights as applicable and shall be responsible for making every
reasonable effort to determine the liability of third parties to pay for
services rendered to enrollees under this Agreement and cost avoid and/or
recover any such liability from the third party. The CONTRACTOR shall develop
and implement policies and procedures to meet its obligations regarding third
party liability when the third party (e.g., long-term care insurance) pays a
cash benefit to the member, regardless of services used or does not allow the
member to assign his/her benefits.
	 
	 	2.21.4.1.1	 	If third party liability (TPL) exists for part or all of the services provided
directly by the CONTRACTOR to an enrollee, the CONTRACTOR shall make reasonable efforts
to recover from TPL sources the value of services rendered.
	 
	 	2.21.4.1.2	 	If TPL exists for part or all of the services provided to an enrollee by a
subcontractor or a provider, and the third party will make payment within a reasonable
time, the CONTRACTOR may pay the subcontractor or provider only the amount, if any, by
which the subcontractor’s or provider’s allowable claim exceeds the amount of TPL.
	 
	 	2.21.4.1.3	 	If the probable existence of TPL has been established at the time the claim is
filed, the CONTRACTOR may reject the claim and return it to the provider for a
determination of the amount of any TPL, unless the claim is for one of these services:
	 
	 	2.21.4.1.3.1	 	TENNderCare;
	 
	 	2.21.4.1.3.2	 	Prenatal or preventive pediatric care; or
	 
	 	2.21.4.1.3.3	 	All claims covered by absent parent maintained insurance under Part D of Title
IV of the Social Security Act.

Page 230 of 374

 

	 	2.21.4.1.4	 	The claims specified in Sections 2.21.4.1.3.1, 2.21.4.1.3.2, and 2.21.4.1.3.3 shall be
paid at the time presented for payment by the provider and the CONTRACTOR shall bill the responsible
third party.
	 
	 	2.21.4.2	 	The CONTRACTOR shall deny payment on a claim that has been denied by a third party payer
when the reason for denial is the provider or enrollee’s failure to follow prescribed procedures,
including but not limited to, failure to obtain prior authorization, timely filing, etc.
	 
	 	2.21.4.3	 	The CONTRACTOR shall treat funds recovered from third parties as offsets to
claims payments. The CONTRACTOR shall report all cost avoidance values to TENNCARE in
accordance with federal guidelines and as described in Section 2.2 1.4 of this
Agreement.
	 
	 	2.21.4.4	 	The CONTRACTOR shall post all third party payments to claim level detail by
enrollee.
	 
	 	2.21.4.5	 	Third party resources shall include subrogation recoveries. The CONTRACTOR
shall be required to seek subrogation amounts regardless of the amount believed to be
available as required by federal Medicaid guidelines. The amount of any subrogation
recoveries collected by the CONTRACTOR outside of the claims processing system shall be
treated by the CONTRACTOR as offsets to medical expenses for the purposes of reporting.
	 
	 	2.21.4.6	 	The CONTRACTOR shall conduct diagnosis and trauma code
editing to identify potential subrogation claims. This editing should, at minimum, identify claims with a
diagnosis of 900.00 through 999.99 (excluding 994.6) or claims submitted with an
accident trauma indicator of ‘Y.’
	 
	 	2.21.4.7	 	TennCare cost sharing and patient liability responsibilities permitted pursuant to
Sections 2.6.7 and 2.2 1.5 of this Agreement shall not be considered TPL.
	 
	 	2.21.4.8	 	The CONTRACTOR shall provide TPL data to any provider having a claim denied by the
CONTRACTOR based upon TPL.
	 
	 	2.21.4.9	 	The CONTRACTOR shall provide to TENNCARE any third party resource information necessary in
a format and media described by TENNCARE and shall cooperate in any manner necessary, as
requested by TENNCARE, with TENNCARE and/or a cost recovery vendor at such time that TENNCARE
acquires said services.
	 
	 	2.21.4.10	 	TENNCARE may require a TennCare contracted TPL vendor to review paid claims that are over
ninety (90) calendar days old and pursue TPL (excluding subrogation) for those claims that do
not indicate recovery amounts in the CONTRACTOR’s reported encounter data.
	 
	 	2.21.4.11	 	If the CONTRACTOR operates or administers any non-Medicaid HMO, health plan or other
lines of business, the CONTRACTOR shall assist TENNCARE with the identification of enrollees
with access to other insurance.
	 
	 	2.21.4.12	 	The CONTRACTOR shall demonstrate, upon request, to TENNCARE that reasonable effort has
been made to seek, collect and/or report third party recoveries.

Page 231 of 374

 

	 	 	 	TENNCARE shall have the sole responsibility for determining whether reasonable
efforts have been demonstrated. Said determination shall take into account
reasonable industry standards and practices.
	 
	 	2.21.4.13	 	TENNCARE shall be solely responsible for estate recovery activities and shall
retain any and all funds recovered thorough these activities.

2.2 1.5 Patient Liability

	 	2.21.5.1	 	TENNCARE will notify the CONTRACTOR of any applicable patient liability
amounts for members via the eligibility/enrollment file.
	 
	 	2.21.5.2	 	The CONTRACTOR shall delegate collection of patient liability to the nursing
facility and shall pay the facility net of the applicable patient liability amount.

2.21.6 Solvency Requirements

	 	2.21.6.1	 	 Minimum Net Worth
	 
	 	2.21.6.1.1	 	Until the CONTRACTOR has provided services under this Agreement for a full
calendar year, the CONTRACTOR shall establish and maintain a minimum net worth equal to
the greater of:
	 
	 	2.21.6.1.1.1	 	One million five hundred thousand dollars ($1,500,000); or
	 
	 	2.21.6.1.1.2	 	An amount totaling four percent (4%) of the first one hundred fifty million
dollars ($150,000,000) of the CONTRACTOR’s TennCare revenue which shall be calculated
by: totaling the weighted average capitation rate, as determined by TENNCARE
by multiplying the base capitation rates originally proposed by the
CONTRACTOR and the priority add-on rates effective on the start date of
operations specified by the State by the number of enrollees (for the
appropriate rate cell) assigned to the CONTRACTOR thirty (30) calendar days
prior to the start date of operations for enrollment effective on the start
date of operations.
	 
	 	2.21.6.1.2	 	In the event that actual enrollment as of sixty (60) days after the start date of
operations increased or decreased by more than ten percent (10%) over enrollment as of
thirty (30) calendar days prior to the start date of operations, the minimum net worth
requirement specified in Section 2.21.6.1.1 shall be recalculated to reflect actual
enrollment as of sixty (60) calendar days after the start date of operations.
	 
	 	2.21.6.1.3	 	After the CONTRACTOR has provided services under this Agreement for a full
calendar year, the CONTRACTOR shall establish and maintain the minimum net worth
requirements required by TDCI, including but not limited to
TCA 56-32-112.
	 
	 	2.21.6.1.4	 	Any and all payments made by TENNCARE, including capitation payments, any
payments related to processing claims for services incurred prior to the start date of
operations pursuant to Section 3.7.1.2.1, as well as incentive payments (if applicable)
to the CONTRACTOR shall be considered “Premium revenue” for the purpose of calculating
the minimum net worth required by TCA 56-32-112.

Page 232 of 374

 

	 	2.21.6.1.5	 	The CONTRACTOR shall demonstrate evidence of its compliance with this
provision to TDCI in the financial reports filed with TDCI by the CONTRACTOR. The
CONTRACTOR agrees that failure to maintain any of the financial requirements in
accordance with this Section 2.21.6.1 through 2.21.6.7, as determined by TDCI, shall
constitute hazardous financial conditions as defined by TCA 56-32-112.
	 
	 	2.21.6.2	 	Statutory Net Worth for Enhanced Enrollment

In the event of a significant enrollment expansion as defined in TCA 56-32- 1 03(c)(2):
	 
	 	2.21.6.2.1	 	The CONTRACTOR agrees that in order to maintain the minimum
net worth requirements described in Section 2.21.6.1, the minimum net
worth requirements are to be recalculated.
	 
	 	2.21.6.2.2	 	The calculation of minimum net worth shall be based upon
annual projected premiums including the estimated premiums for the
additional enrollment versus the prior year actual premium revenue.
Estimated premiums will be based on the capitation payment rates in
effect at the time of the calculation and projected future enrollment.
The formula set forth in TCA 56-32-1 12(a)(2) shall then be applied to
the annualized projected premiums to determine the enhanced minimum net
worth requirement.
	 
	 	2.21.6.2.3	 	The CONTRACTOR shall demonstrate to the satisfaction of TDCI
that this enhanced minimum net worth balance has been established prior
to the assignment of additional enrollees to the CONTRACTOR by
TENNCARE.
	 
	 	2.21.6.2.4	 	The CONTRACTOR shall maintain the greater of the enhanced
minimum net worth balance or the minimum net worth balance calculated
pursuant to TCA 56-32-112, until the CONTRACTOR has completed a full
calendar year with the significantly expanded enrollment.
	 
	 	2.21.6.3	 	Statutory Net Worth for CHOICES Implementation
	 
	 	2.21.6.3.1	 	The CONTRACTOR agrees that in order to maintain the minimum net worth requirements
described in Section 2.21.6.1, the minimum net worth requirements are to be recalculated for
the implementation of CHOICES in the Grand Region covered by this Agreement.
	 
	 	2.21.6.3.2	 	The calculation of minimum net worth shall be based upon annual projected premiums
versus the prior year actual premium revenue. Estimated premiums shall be based on the
capitation payment rates for CHOICES and non-CHOICES members to be in effect upon
implementation of CHOICES and projected enrollment as of the date of CHOICES implementation in
the Grand Region covered by this Agreement. The formula set forth in TCA 56-32-1 12(a)(2)
shall then be applied to the annualized projected premiums to determine the enhanced minimum
net worth requirement.
	 
	 	2.21.6.3.3	 	The CONTRACTOR shall demonstrate to the satisfaction of TDCI that this enhanced minimum
net worth balance has been established prior to the implementation of CHOICES in the Grand
Region covered by this Agreement.

Page 233 of 374

 

	 	2.21.6.3.4	 	The CONTRACTOR shall maintain the greater of the enhanced minimum net
worth balance or the minimum net worth balance calculated pursuant to TCA
56-32-112, until the CONTRACTOR has completed a full calendar year with CHOICES.
	 
	 	2.21.6.3.5	 	After the CONTRACTOR has provided services under CHOICES for a full calendar
year, the CONTRACTOR shall establish and maintain the minimum net worth requirements
required by TDCI, including but not limited to
TCA 56-32-112.
	 
	 	2.21.6.4	 	Restricted Deposits

The CONTRACTOR shall achieve and maintain restricted deposits in an amount equal
to the net worth requirement specified in Section 2.21.6.1. TDCI shall calculate
the amount of restricted deposits based on the CONTRACTOR’s TennCare premium
revenue only unless this calculation would result in restricted deposits below
the statutory requirements set forth in TCA 56-32-112 related to restricted
deposits; in which case the required amount would be equal to the statutory
requirement as it is calculated by TDCI. This contractual requirement shall in
no way be construed as a way to circumvent, waive or modify the statutory
requirement.
	 
	 	2.21.6.5	 	Restricted Deposits for Enhanced Enrollment or CHOICES
Implementation

In the event of an increase in the CONTRACTOR’s statutory net worth requirement
as a result of a significant enrollment expansion as defined in TCA
56-32-103(c)(2) or the implementation of CHOICES, the CONTRACTOR shall increase
its restricted deposit to equal its enhanced minimum net worth requirement
required by Section 2.2 1.6.2 or Section 2.2 1.6.3, as applicable. TDCI shall
calculate the amount of the increased restricted deposits based on the
CONTRACTOR’s TennCare premium revenue only unless this calculation would result
in restricted deposits below the statutory requirements set forth in TCA
56-32-112 related to restricted deposits; in which case the required amount
would be equal to the statutory requirement as it is calculated by TDCI. This
contractual requirement shall in no way be construed as a way to circumvent,
waive or modify the statutory requirement. The CONTRACTOR shall demonstrate to
the satisfaction of TDCI that the CONTRACTOR has increased its restricted
deposit in accordance with this Section prior to the assignment of additional
enrollees to the CONTRACTOR by TENNCARE.
	 
	 	2.21.6.6	 	Liquidity Ratio Requirement

In addition to the positive working capital requirement described in TCA
56-32-112, the CONTRACTOR shall maintain a liquidity ratio where admitted assets
consisting of cash, cash equivalents, short-term investments and bonds exceed
total liabilities as reported on the NAIC financial statements.
	 
	 	2.21.6.7	 	If the CONTRACTOR fails to meet the applicable net worth and/or restricted
deposit requirement, said failure shall constitute a hazardous financial condition
and the CONTRACTOR shall be considered to be in breach of the terms of the
Agreement.

2.21.7 Accounting Requirements

	 	2.21.7.1	 	 The CONTRACTOR shall establish and maintain an accounting system in
accordance with generally accepted accounting principles. The accounting system

Page 234 of 374

 

	 	 	 	shall maintain records pertaining to the tasks defined in this Agreement and any
other costs and expenditures made under the Agreement.
	 
	 	2.21.7.2	 	Specific accounting records and procedures are subject to TENNCARE and federal
approval. Accounting procedures, policies, and records shall be completely open
to state and federal personnel at any time during the Agreement period and for
five (5) years thereafter unless otherwise specified elsewhere in this
Agreement.

2.21.8 Insurance

	 	2.21.8.1	 	The CONTRACTOR shall obtain adequate worker’s compensation and general
liability insurance coverage prior to commencing any work in connection with
this Agreement. Additionally, TENNCARE may require, at its sole discretion, the
CONTRACTOR to obtain adequate professional malpractice liability or other forms
of insurance. Any insurance required by TENNCARE shall be in the form and
substance acceptable to TENNCARE.
	 
	 	2.21.8.2	 	Except as otherwise provided in Section 2.12 or in the model subcontract with
the FEA (see Section 2.26.6), the CONTRACTOR shall require that any subcontractors
or contract providers obtain all similar insurance required of it prior to
commencing work.
	 
	 	2.21.8.3	 	The CONTRACTOR shall furnish proof of adequate coverage of insurance by a
certificate of insurance submitted to TENNCARE.
	 
	 	2.21.8.4	 	TENNCARE shall be exempt from and in no way liable for any sums of money that may
represent a deductible in any insurance policy. The payment of such a deductible shall
be the sole responsibility of the CONTRACTOR, subcontractor and/or provider obtaining
such insurance. The same holds true of any premiums paid on any insurance policy
pursuant to this Agreement.
	 
	 	2.21.8.5	 	Failure to provide proof of adequate coverage within the specified time period
may result in this Agreement being terminated.

2.21.9 Ownership and Financial Disclosure

The CONTRACTOR shall disclose, to TENNCARE, the Comptroller General of the United States or
CMS, full and complete information regarding ownership, financial transactions and persons
convicted of criminal activity related to Medicare, Medicaid, or the federal Title XX
programs in accordance with federal and state requirements, including Public Chapter 379 of
the Acts of 1999. The CONTRACTOR shall screen their employees and contractors initially and
on an ongoing monthly basis to determine whether any of them has been excluded from
participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined
in Section 1 128B(f) of the Social Security Act) and not employ or contract with an
individual or entity that has been excluded. This disclosure shall be made in accordance
with the requirements in Section 2.30.15.3.2. The following information shall be disclosed:

	 	2.21.9.1	 	The name and address of each person with an ownership or control interest in
the
disclosing entity or in any provider or subcontractor in which the disclosing entity
has direct or indirect ownership of five percent (5%) or more and whether any of the
persons named pursuant to this requirement is related to another as spouse, parent,

Page 235 of 374

 

	 	 	 	child, or sibling. This disclosure shall include the name of any other disclosing
entity in which a person with an ownership or control interest in the disclosing entity
also has an ownership or control interest;
	 
	 	2.21.9.2	 	The identity of any provider or subcontractor with whom the CONTRACTOR has had significant
business transactions, defined as those totaling more than twenty-five thousand dollars
($25,000) during the twelve (12) month period ending on the date of the disclosure, and any
significant business transactions between the CONTRACTOR, any wholly owned supplier, or
between the CONTRACTOR and any provider or subcontractor, during the five (5) year period
ending on the date of the disclosure;
	 
	 	2.21.9.3	 	The identity of any person who has an ownership or control interest in the
CONTRACTOR, or is an agent or managing employee of the CONTRACTOR and who has been
convicted of a criminal offense related to that person’s involvement in any program
under Medicare, Medicaid, or the federal Title XX services program since the inception
of those programs;
	 
	 	2.21.9.4	 	Disclosure from officials in legislative and executive branches of government as to
possible conflicts of interest;
	 
	 	2.21.9.5	 	If the CONTRACTOR is not a federally qualified HMO, the CONTRACTOR shall disclose certain transactions with
parties in interest to TENNCARE. Transactions shall be reported according to the following guidelines:
	 
	 	2.21.9.5.1	 	The CONTRACTOR shall disclose the following transactions:
	 
	 	2.21.9.5.1.1	 	Any sale, exchange or lease of any property between the HMO and a party in
interest;
	 
	 	2.21.9.5.1.2	 	Any lending of money or other extension of credit between the
HMO and a party in interest; and
	 
	 	2.21.9.5.1.3	 	Any furnishing for consideration of goods, services (including management
services) or facilities between the HMO and the party in interest. This does not
include salaries paid to employees for services provided in the normal course of
their employment.
	 
	 	2.21.9.5.2	 	The information which shall be disclosed in the transactions includes:
	 
	 	2.21.9.5.2.1	 	The name of the party in interest for each transaction;
	 
	 	2.21.9.5.2.2	 	A description of each transaction and the quantity or units involved;
	 
	 	2.21.9.5.2.3	 	The accrued dollar value of each transaction during the fiscal year; and
	 
	 	2.21.9.5.2.4	 	Justification of the reasonableness of each transaction.
	 
	 	2.21.9.5.3	 	If the Agreement is being renewed or extended, the CONTRACTOR shall disclose information
on business transactions which occurred during the prior contract period. If the Agreement is
an initial Agreement with TENNCARE, but the CONTRACTOR

Page 236 of 374

 

	 	 	 	has operated previously in the commercial or Medicare markets, information on
business transactions for the entire year preceding the initial contract period
shall be disclosed. The business transactions which shall be reported are not
limited to transactions related to serving the Medicaid/TennCare enrollment. All
of the CONTRACTOR’s business transactions shall be reported.
	 
	 	2.21.9.5.4	 	A party in interest is:

	 	2.21.9.5.4.1	 	Any director, officer, partner, or employee responsible for management
or administration of an HMO and HIO; any person who is directly or indirectly
the beneficial owner of more than five percent (5%) of the equity of the HMO;
any person who is the beneficial owner of a mortgage, deed of trust, note, or
other interest secured by, and valuing more than five percent (5%) of the HMO;
or, in the case of an HMO organized as a nonprofit corporation, an
incorporator or member of such corporation under applicable state corporation
law;
	 
	 	2.21.9.5.4.2	 	Any organization in which a person described in subsection 1 is
director, officer or partner; has directly or indirectly a beneficial interest
of more than five percent (5%) of the equity of the HMO; or has a mortgage,
deed of trust, note, or other interest valuing more than five percent (5%) of
the assets of the HMO;
	 
	 	2.21.9.5.4.3	 	Any person directly or indirectly controlling, controlled by, or under
common control with an HMO; or
	 
	 	2.21.9.5.4.4	 	Any spouse, child, or parent of an individual described in Sections
2.21.9.5.4.1, 2.2 1.9.5.4.2, or 2.2 1.9.5.4.3

	 	2.21.9.5.5	 	TENNCARE and/or the Secretary of Health and Human Services may request
information to be in the form of a consolidated financial statement.

2.21.10 Internal Audit Function

The CONTRACTOR shall establish and maintain an internal audit function responsible for
providing an independent review and evaluation of the CONTRACTOR’s accuracy of financial
recordkeeping, the reliability and integrity of information, the adequacy of internal
controls, and compliance with applicable laws, policies, procedures, and regulations. The
CONTRACTOR’s internal audit function shall be responsible for performing audits to ensure
the economical and efficient use of resources by all departments to accomplish the
objectives and goals for the operations of the department. Further, the CONTRACTOR’s
internal audit department shall be responsible for performance of the claims payment
accuracy tests as described in Section 2.22.6 of this Agreement.

2.21.11 Audit of Business Transactions

	 	2.21.11.1	 	The CONTRACTOR shall cause an audit of its business transactions to be performed
by a licensed certified public accountant, including but not limited to the financial
transactions made under this Agreement. Such audit shall be performed in accordance
with the requirements in Section 2.30.15.4.3 of this Agreement.

Page 237 of 374

 

	 	2.21.11.2	 	No later than December 1 of each year, the CONTRACTOR shall submit a
copy of the full executed agreement to audit accounts to TENNCARE. Such
agreement shall include the following language:
	 
	 	2.21.11.2.1	 	The auditor agrees to retain working papers for no less than five (5) years and
that all audit working papers shall, upon request, be made available for review by the
Comptroller of the Treasury, the Comptroller’s representatives, agents, and legal
counsel, or the TennCare Division of the Tennessee Department of Commerce and
Insurance, during normal working hours while the audit is in progress and/or subsequent
to the completion of the report. Nothing in this Section shall be construed to modify
or change the obligations of the CONTRACTOR contained in Section 2.23.2 (Data and
Document Management Requirements), 2.23.3 (System and Data Integration Requirements),
or 2.23.6 (Security and Access Management Requirements) of this Agreement.
	 
	 	2.21.11.2.2	 	Any evidence of fraud, such as defalcation, misappropriation, misfeasance,
malfeasance, embezzlement, fraud or other illegal acts shall be reported by the
auditor, in writing immediately upon discovery, to the Comptroller of the Treasury,
State of Tennessee, who shall under all circumstances have the authority, at the
discretion of the Comptroller, to directly investigate such matters. If the
circumstances disclosed by the audit call for a more detailed investigation by the
auditor than necessary under ordinary circumstances, the auditor shall inform the
organization’s governing body in writing of the need for such additional investigation
and the additional compensation required therefore. Upon approval by the Comptroller of
the Treasury, an amendment to this contract may be made by the organization’s governing
body and the auditor for such additional investigation.

21. Section 2.22 shall be deleted in its entirety and replaced with the following:

2.22 CLAIMS MANAGEMENT

2.22.1 General

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

2.22.2 Claims Management System Capabilities

	 	2.22.2.1	 	The CONTRACTOR shall maintain a claims management system that can uniquely
identify the provider of the service, date of receipt (the date the CONTRACTOR
receives the claim as indicated by a date-stamp), real-time-accurate history of
actions taken on each provider claim (i.e., paid, denied, suspended, appealed,
etc.), date of payment (the date of the check or other form of payment) and all
data elements as required by TENNCARE for encounter data submission (see Section
2.23), and can track and report service use against benefit limits in accordance
with a methodology set by TENNCARE.

Page 238 of 374

 

	 	2.22.2.2	 	The CONTRACTOR shall have in place, an electronic claims management
(ECM) capability that can handle online submission of individual claims by
long-term care providers as well as accept and process batches of claims
submitted electronically with the exception of claims that require written
documentation to justify payment (e.g., hysterectomy/sterilization consent
forms, certification for medical necessity for abortion, necessary operative
reports, etc.). The online claims submission capability for long-term care
providers shall be accessible via the World Wide Web or through an alternate,
functionally equivalent medium.
	 
	 	2.22.2.3	 	The ECM capability shall function in accordance with information exchange and
data management requirements specified in Section 2.23 of this Agreement.
	 
	 	2.22.2.4	 	As part of the ECM function, the CONTRACTOR shall also provide on-line and
phone-based capabilities to obtain claims processing status information.
	 
	 	2.22.2.5	 	The CONTRACTOR shall support an automated clearinghouse (ACH) mechanism that allows
providers to request and receive electronic funds transfer (EFT) of claims payments.
	 
	 	2.22.2.6	 	The CONTRACTOR shall not derive financial gain from a provider’s use of
electronic claims filing functionality and/or services offered by the CONTRACTOR
or a third party. However, this provision shall not be construed to imply that
providers may not be responsible for payment of applicable transaction
fees/charges.

2.22.3 Paper Based Claims Formats

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

	 	 	 
	Claim Type	 	Claim Form
	Professional

	 	CMS 1500
	Institutional

	 	CMS 1450/UB04
	Dental

	 	ADA

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

Page 239 of 374

 

	 	2.22.4.1	 	The CONTRACTOR shall comply with prompt pay claims processing requirements
in accordance with TCA 56-32-126.
	 
	 	2.22.4.2	 	The CONTRACTOR shall ensure that ninety percent (90%) of clean claims for
payment for services delivered to a TennCare enrollee are paid within thirty (30)
calendar days of the receipt of such claims.
	 
	 	2.22.4.3	 	The CONTRACTOR shall process, and if appropriate pay, within sixty (60) calendar days
ninety-nine point five percent (99.5%) of all claims for covered services delivered to a
TennCare enrollee. The terms “processed and paid” are synonymous with terms “process and
pay” of TCA 56-32-126(b)(1)(A) and (B).
	 
	 	2.22.4.4	 	Notwithstanding Sections 2.22.4.1 through 2.22.4.3, the CONTRACTOR shall
comply with the following processing requirements for nursing facility claims and for
HCBS claims for services other than PERS, assistive technology, minor home
modifications, and pest control submitted electronically in a HIPAA-compliant format:
	 
	 	2.22.4.4.1	 	Ninety percent (90%) of clean claims for nursing facility services and HCBS excluding
PERS, assistive technology, minor home modifications, and pest control shall be processed and paid
within fourteen (14) calendar days of receipt.

	 
	 	2.22.4.4.2	 	Ninety-nine point five percent (99.5%) of clean claims for nursing facility and HCBS
other than PERS, assistive technology, minor home modifications, and pest control shall be
processed and paid within twenty-one (21) calendar days of receipt.
	 
	 	2.22.4.5	 	The CONTRACTOR shall comply with the requirements in
Sections 2.22.4.2 and 2.22.4.3 above for processing claims for PERS, assistive technology, minor home
modifications, and pest control.
	 
	 	2.22.4.6	 	The CONTRACTOR shall provide claims information and supporting claims documentation as
specified by TENNCARE or TDCI in order for TENNCARE and/or TDCI to verify the CONTRACTOR’s
compliance with prompt payment requirements.
	 
	 	2.22.4.7	 	If a claim is partially or totally denied on the basis the provider did not submit
any required information or documentation with the claim, then the remittance advice or
other appropriate written or electronic notice shall specifically identify all such
information and documentation. Resubmission of a claim with further information and/or
documentation shall constitute a new claim for purposes of establishing the time frame
for claims processing.
	 
	 	2.22.4.8	 	To the extent that the provider agreement requires compensation of a provider on a
monthly fixed fee basis or on any other basis that does not require the submission of a
claim as a condition to payment, such payment shall be made to the provider by no later
than (i) the time period specified in the provider agreement/contract between the
provider and the CONTRACTOR or subcontractor, or if a time period is not specified in
the contract (ii) the tenth (1 0th) day of the calendar month if the payment
is to be made by a subcontractor, or (iii) if the CONTRACTOR is required to

Page 240 of 374

 

	 	 	 	compensate the provider directly, within five (5) calendar days after receipt of
the capitated payment and supporting remittance advice information from
TENNCARE.
	 
	 	2.22.4.9	 	The CONTRACTOR shall not deny provider claims on the basis of untimely filing
in
situations regarding coordination of benefits or subrogation, in which case the
provider is pursuing payment from a third party or if an enrollee is enrolled in
the CONTRACTOR’s MCO with a retroactive eligibility date. In situations of third
party benefits, the time frames for filing a claim shall begin on the date that
the third party documented resolution of the claim. In situations of enrollment
in the CONTRACTOR’s MCO with a retroactive eligibility date, the time frames for
filing a claim shall begin on the date that the CONTRACTOR receives notification
from TENNCARE of the enrollee’s eligibility/enrollment.
	 
	 	2.22.4.10	 	As it relates to MCO Assignment Unknown (see Sections 2.13.10 and 2.13.11), the
CONTRACTOR shall not deny a claim on the basis of the provider’s failure to file a
claim within a specified time period after the date of service when the provider could
not have reasonably known which MCO the member was in during the timely filing period.
However, in such cases the CONTRACTOR may impose timely filing requirements beginning
on the date of notification of the individual’s enrollment.

2.22.5 Claims Dispute Management

	 	2.22.5.1	 	The CONTRACTOR shall have an internal claims dispute procedure that will be
reviewed and approved in writing by TENNCARE prior to its implementation.
	 
	 	2.22.5.2	 	The CONTRACTOR shall contract with independent reviewers to review disputed
claims as provided by TCA 56-32-126.
	 
	 	2.22.5.3	 	The CONTRACTOR shall systematically capture the status and
resolution of all claim disputes, as well as all associated documentation.

2.22.6 Claims Payment Accuracy — Minimum Audit Procedures

	 	2.22.6.1	 	On a monthly basis the CONTRACTOR shall submit claims payment accuracy
percentage reports (see Section 2.30.16.1).
	 
	 	2.22.6.2	 	The report shall be based on an audit conducted by the CONTRACTOR. The audit shall
be conducted by an entity or staff independent of claims management. Requirements for
the internal audit function are outlined in Section 2.21.10 of this Agreement.
	 
	 	2.22.6.3	 	The audit shall utilize a random sample of all “processed or paid” claims upon
initial
submission in each month (the terms “processed and paid” are synonymous with
terms “process and pay” of TCA 56-32- 126(b)(1)(A) and (B)). A minimum sample of
one hundred and sixty (160) claims randomly selected from the entire population
of electronic and paper claims processed or paid upon initial submission for the
month tested is required. Additionally, each monthly sample of one hundred and
sixty (160) claims shall contain a minimum of thirty (30) claims associated with
nursing facility services provided to CHOICES members and thirty (30) claims
associated with HCBS provided to CHOICES members.

Page 241 of 374

 

	 	2.22.6.4	 	The minimum attributes to be tested for each claim selected shall include:
	 
	 	2.22.6.4.1	 	Claim data correctly entered into the claims processing system;
	 
	 	2.22.6.4.2	 	Claim is associated to the correct provider, or if submitted by the FEA, the correct
consumer-directed worker;
	 
	 	2.22.6.4.3	 	Service obtained the proper authorization;
	 
	 	2.22.6.4.4	 	Member eligibility at processing date correctly applied;
	 
	 	2.22.6.4.5	 	Allowed payment amount agrees with contracted rate;
	 
	 	2.22.6.4.6	 	Duplicate payment of the same claim has not occurred;
	 
	 	2.22.6.4.7	 	Denial reason applied appropriately;
	 
	 	2.22.6.4.8	 	Copayment application considered and applied;
	 
	 	2.22.6.4.9	 	Patient liability correctly identified and
applied;
	 
	 	2.22.6.4.10	 	Effect of modifier codes correctly
applied;
	 
	 	2.22.6.4.11	 	Other insurance, including long-term care insurance, properly considered and
applied;
	 
	 	2.22.6.4.12	 	Application of benefit limits;
	 
	 	2.22.6.4.13	 	Whether the processing of the claim correctly considered whether services that
exceeded a benefit limit for HCBS were provided as a cost effective alternative;
	 
	 	2.22.6.4.14	 	Application of the cost neutrality cap for a CHOICES member in Group 2;
	 
	 	2.22.6.4.15	 	Application of the expenditure cap for a CHOICES member in Group 3; and
	 
	 	2.22.6.4.16	 	Proper coding including bundling/unbundling.
	 
	 	2.22.6.5	 	For audit and verification purposes, the population of claims should be maintained.
Additionally, the results of testing at a minimum should be documented to include:
	 
	 	2.22.6.5.1	 	Results for each attribute tested for each claim selected;
	 
	 	2.22.6.5.2	 	Amount of overpayment or underpayment for claims processed or paid in error;
	 
	 	2.22.6.5.3	 	Explanation of the erroneous processing for each claim processed or paid in error;
	 
	 	2.22.6.5.4	 	Determination if the error is the result of keying errors or the result of errors in the
configuration or table maintenance of the claims processing system; and
	 
	 	2.22.6.5.5	 	Claims processed or paid in error have been corrected.

Page 242 of 374

 

	 	2.22.6.6	 	If the CONTRACTOR subcontracts for the provision of any covered
services (see Section 2.26), and the subcontractor is responsible for
processing claims (see Section 2.26.12), then the CONTRACTOR shall submit a
claims payment accuracy percentage report for the claims processed by the
subcontractor. The report shall be based on an audit conducted in compliance
with the requirements of this Section 2.22.6.

2.22.7 Claims Processing Methodology Requirements

	 	2.22.7.1	 	The CONTRACTOR shall perform front end system edits, including but not limited
to:
	 
	 	2.22.7.1.1	 	Confirming eligibility on each enrollee as claims are submitted on the basis of
the eligibility information provided by the State that applies to the period during
which the charges were incurred;
	 
	 	2.22.7.1.2	 	Third party liability (TPL);
	 
	 	2.22.7.1.3	 	Medical necessity (e.g., appropriate age/sex for procedure);
	 
	 	2.22.7.1.4	 	Prior approval: the system shall determine whether a covered service required prior
approval and, if so, whether the CONTRACTOR granted such approval;
	 
	 	2.22.7.1.5	 	Duplicate claims: the system shall in an automated manner flag a claim as being
(1) exactly the same as a previously submitted claim or (2) a possible duplicate and
either deny or pend the claim as needed;
	 
	 	2.22.7.1.6	 	Covered service: the system shall verify that a service is a covered service and
is eligible for payment;
	 
	 	2.22.7.1.7	 	Provider validation: the system shall approve for payment only those claims
received from providers eligible to render services for which the claim was submitted;
and
	 
	 	2.22.7.1.8	 	Benefit limits: the system shall ensure that benefit limit rules set by TENNCARE
are factored into the determination of whether a claim should be adjudicated and paid
and whether HCBS that exceed a benefit limit were approved as a cost effective
alternative.
	 
	 	2.22.7.2	 	The CONTRACTOR shall perform system edits for valid dates of service: the
system
shall assure that dates of service are valid dates, e.g., date of discharge is
later than date of admission; admission or discharge dates are not in the future
or outside of a member’s TennCare eligibility span.
	 
	 	2.22.7.3	 	The CONTRACTOR shall ensure that the cost neutrality cap or expenditure cap
applicable to a particular CHOICES member is not exceeded.
	 
	 	2.22.7.4	 	The CONTRACTOR shall perform post-payment review on a sample of claims to ensure
services provided were medically necessary and were provided in accordance with state
and federal requirements. This shall include, as applicable, review of provider
documentation.

Page 243 of 374

 

	 	2.22.7.5	 	The CONTRACTOR shall have a staff of qualified, medically trained and
appropriately licensed personnel, consistent with NCQA accreditation standards,
whose primary duties are to assist in evaluating claims for medical necessity.

2.22.8 Explanation of Benefits (EOBs) and Related Functions

	 	2.22.8.1	 	The CONTRACTOR shall be responsible for generating and mailing EOBs to
TennCare enrollees in accordance with guidelines described by TENNCARE.
	 
	 	2.22.8.2	 	The CONTRACTOR shall omit any claims in the EOB file that are
associated with sensitive services. The CONTRACTOR, with guidance from TENNCARE, shall develop
“sensitive services” logic to be applied to the handling of said claims for EOB
purposes.
	 
	 	2.22.8.3	 	At a minimum, EOBs shall be designed to address requirements found in 42 CFR
455.20 and 433.116 as well as requirements associated with a change in TennCare
policy and shall include: claims for services with benefit limits, claims with
enrollee cost sharing, denied claims with enrollee responsibility, and a
sampling of paid claims (excluding ancillary and anesthesia services).
	 
	 	2.22.8.4	 	On a monthly basis, the CONTRACTOR shall sample a minimum of one hundred (100)
claims and associated EOBs. The sample shall be based on a minimum of twenty-five (25)
claims per check run. The EOBs shall be examined for correctness based on how the
associated claim was processed and for adherence to the requirements outlined in
Section 2.22.8. The CONTRACTOR shall ensure that the examined EOBs constitute a
representative sample of EOBs from all types of services and provider types. To the
extent that the CONTRACTOR and/or TENNCARE considers a particular type of service or
provider to warrant closer scrutiny, the CONTRACTOR shall over sample as needed.
	 
	 	2.22.8.5	 	Based on the EOBs sent to TennCare enrollees, the CONTRACTOR shall track any
complaints received from enrollees and resolve the complaints according to its
established policies and procedures. The resolution may be enrollee education,
provider education, or referral to TBI/OIG. The CONTRACTOR shall use the
feedback received to modify or enhance the EOB sampling methodology.

2.22.9 Remittance Advices and Related Functions

	 	2.22.9.1	 	In concert with its claims payment cycle the CONTRACTOR shall provide an
electronic status report indicating the disposition for every adjudicated claim
for each claim type submitted by providers seeking payment as well as capitated
payments generated and paid by the CONTRACTOR.
	 
	 	2.22.9.2	 	The status report shall contain appropriate explanatory remarks related to
payment or denial of the claim, including but not limited to TPL data.
	 
	 	2.22.9.3	 	If a claim is partially or totally denied on the basis the provider did not
submit any required information or documentation with the claim, then the
remittance advice shall specifically identify all such information and
documentation.

Page 244 of 374

 

	 	2.22.9.4	 	In accordance with 42 CFR 455.18 and 455.19, the following statement shall be
included on each remittance advice sent to providers: “I understand that payment
and satisfaction of this claim will be from federal and state funds, and that
any false claims, statements, documents, or concealment of a material fact, may
be prosecuted under applicable federal and/or state laws.”

2.22.10 Processing of Payment Errors

The CONTRACTOR shall not employ off-system or gross adjustments when processing corrections
to payment errors, unless it requests and receives prior written authorization from
TENNCARE.

2.22.11 Notification to Providers

For purposes of network management, the CONTRACTOR shall, at a minimum, notify all contract
providers to file claims associated with covered services directly with the CONTRACTOR, or
its subcontractors, on behalf of TennCare enrollees.

2.22.12 Payment Cycle

At a minimum, the CONTRACTOR shall run one (1) provider payment cycle per week, on the same
day each week, as determined by the CONTRACTOR and approved in writing by TENNCARE.

2.22.13 Excluded Providers

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

22. Section 2.24 shall be deleted in its entirety and replaced with the following:

2.24 ADMINISTRATIVE REQUIREMENTS

2.24.1 General Responsibilities

	 	2.24.1.1	 	TENNCARE shall be responsible for management of this Agreement. Management
shall be conducted in good faith with the best interest of the State and the
citizens it serves being the prime consideration. Management of TennCare shall
be conducted in a manner consistent with simplicity of administration and the
best interests of enrollees, as required by 42 USC 1396a(a)(19).
	 
	 	2.24.1.2	 	The CONTRACTOR shall be responsible for complying with the requirements of
this Agreement and shall act in good faith in the performance of the
requirements of this Agreement.

Page 245 of 374

 

	 	2.24.1.3	 	The CONTRACTOR shall develop policies and procedures that describe, in detail,
how the CONTRACTOR will comply with the requirements of this Agreement and, as
applicable, are specific to the Grand Region covered by this Agreement, and the
CONTRACTOR shall administer this Agreement in accordance with those policies and
procedures unless otherwise directed or approved in writing by TENNCARE.
	 
	 	2.24.1.4	 	The CONTRACTOR shall submit policies and procedures and other deliverables
specified by TENNCARE to TENNCARE for review and/or written approval in the
format and within the time frames specified by TENNCARE. The CONTRACTOR shall
make any changes requested by TENNCARE to policies and procedures or other
deliverables and in the time frames specified by TENNCARE.
	 
	 	2.24.1.5	 	As provided in Section 4.10 of this Agreement, should the CONTRACTOR have a
question on policy determinations, benefits, or operating guidelines required
for proper performance of the CONTRACTOR’s responsibilities, the CONTRACTOR
shall request a determination from TENNCARE in writing.

2.24.2 Behavioral Health Advisory Committee

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

	 	2.24.2.1	 	The CONTRACTOR’s behavioral health advisory committee shall be comprised of
at least fifty-one percent (51%) consumer and family representatives, of which
the majority shall include families of adults with serious and/or persistent
mental illness (SPMI) and families of children with serious emotional
disturbance (SED);
	 
	 	2.24.2.2	 	There shall be geographic diversity;
	 
	 	2.24.2.3	 	There shall be cultural and racial diversity;
	 
	 	2.24.2.4	 	There shall be representation by providers and consumers (or family members of
consumers) of substance abuse services;
	 
	 	2.24.2.5	 	At a minimum, the CONTRACTOR’s behavioral health advisory committee shall have
input into policy development, planning for services, service evaluation, and member,
family member and provider education;
	 
	 	2.24.2.6	 	Meetings shall be held at least quarterly;
	 
	 	2.24.2.7	 	Travel costs shall be paid by the CONTRACTOR;
	 
	 	2.24.2.8	 	The CONTRACTOR shall report on the activities of the CONTRACTOR’s
behavioral health advisory committee as required in Section 2.30.18.1; and
	 
	 	2.24.2.9	 	The CONTRACTOR, as membership changes, shall submit current membership lists to the
State.

Page 246 of 374

 

2.24.3 CHOICES Advisory Group

	 	2.24.3.1	 	To promote a collaborative effort to enhance the long-term care service
delivery
system in the Grand Region covered by this Agreement while maintaining a member-
centered focus, the CONTRACTOR shall establish a CHOICES advisory group that is
accountable to the CONTRACTOR’s governing body to provide input and advice
regarding the CONTRACTOR’s CHOICES program and policies.
	 
	 	2.24.3.2	 	The CONTRACTOR’s CHOICES advisory group shall include CHOICES members, member’s
representatives, advocates, and providers. At least fifty-one percent (51%) of the
group shall be CHOICES members and/or their representatives (e.g., family members or
caregivers). The advisory group shall include representatives from nursing facility and
HCBS providers, including community-based residential alternative providers. The group
shall reflect the geographic, cultural and racial diversity of the Grand Region covered
by this Agreement.
	 
	 	2.24.3.3	 	At a minimum, the CONTRACTOR’s CHOICES advisory group shall have input into the
CONTRACTOR’s planning and delivery of long-term care services, CHOICES QM/QI
activities, program monitoring and evaluation, and member, family and provider
education.
	 
	 	2.24.3.4	 	The CONTRACTOR shall provide an orientation and ongoing training for advisory
group members so they have sufficient information and understanding of the
CHOICES program to fulfill their responsibilities.
	 
	 	2.24.3.5	 	The CONTRACTOR’s CHOICES advisory group shall meet at least quarterly, and the
CONTRACTOR shall keep a written record of meetings.
	 
	 	2.24.3.6	 	The CONTRACTOR shall pay travel costs for advisory group members who are CHOICES
members or their representatives.
	 
	 	2.24.3.7	 	The CONTRACTOR shall report on the activities of the CONTRACTOR’s CHOICES advisory
group as required in Section 2.30.18.2.
	 
	 	2.24.3.8	 	As advisory group membership changes, the CONTRACTOR shall submit current
membership lists to TENNCARE.

2.24.4 Abuse and Neglect Plan

	 	2.24.4.1	 	The CONTRACTOR shall develop and implement an abuse and
neglect plan that includes protocols for preventing, identifying, and reporting suspected abuse,
neglect, and exploitation of CHOICES members who are adults (see TCA 71-6-101 et
seq.) and suspected brutality, abuse, or neglect of CHOICES members who are
children (see TCA 37-1-40 1 et seq. and TCA 37-1-60 1 et seq.); a plan for
educating and training providers, subcontractors, care coordinators, and other
CONTRACTOR staff regarding the protocols; and a plan for training members,
representatives, and caregivers regarding identification and reporting of
suspected abuse and/or neglect.
	 
	 	2.24.4.2	 	The CONTRACTOR’s abuse and neglect protocols shall include, but not be limited
to the following:

Page 247 of 374

 

	 	2.24.4.2.1	 	Protocols for assessing risk for abuse and/or neglect, including
factors that may indicate the potential for abuse and/or neglect;
	 
	 	2.24.4.2.2	 	Protocols for reducing a member’s risk of abuse and/or neglect (e.g., frequency of
care coordinator home visits, referrals to non-covered support services);
	 
	 	2.24.4.2.3	 	Indicators for identifying suspected abuse and/or neglect;
	 
	 	2.24.4.2.4	 	Requirements for reporting suspected abuse and/or neglect, including reporting
suspected abuse and/or neglect of a child pursuant to TCA 37-1-403, reporting suspected
abuse and/or neglect of an adult to APS pursuant to TCA 7 1-6-103, and reporting
suspected abuse and/or neglect to the CONTRACTOR pursuant to Section 2.15.8.4;
	 
	 	2.24.4.2.5	 	Steps for protecting a member if abuse and/or neglect is suspected (e.g.,
removing a staff person suspected of committing the abuse and/or neglect, making
referrals for members to support services); and
	 
	 	2.24.4.2.6	 	Requirements regarding coordination and cooperation with APS/CPS
investigations and remediations.
	 
	 	2.24.4.3	 	The CONTRACTOR’s abuse and neglect plan shall also define the role and
responsibilities of the fiscal employer agent (see definition in Section 1) in
assessing and reducing a member’s risk of abuse and neglect, identifying and
reporting abuse and neglect, protecting a member if abuse and/or neglect is
suspected; training employees, contractors of the FEA (including supports
brokers), and consumer- directed workers regarding the protocols identified in
Sections 2.24.4.2.1 through 2.24.4.2.6 above; and training members and
caregivers regarding identification and reporting of suspected abuse and/or
neglect. Such role and responsibilities shall be defined in a manner that is
consistent with requirements in this Section 2.24.4 as well as TENNCARE’s
contract with the fiscal employer agent and the model subcontract between the
CONTRACTOR and the FEA.

2.24.5 Performance Standards

The CONTRACTOR agrees TENNCARE may assess liquidated damages for failure to meet the
performance standards specified in Attachment VII.

2.24.6 Medical Records Requirements

	 	2.24.6.1	 	The CONTRACTOR shall maintain, and shall require contract providers and
subcontractors to maintain, medical records (as defined in Section 1) in a
manner that is current, detailed and organized, and which permits effective and
confidential patient care and quality review, administrative, civil and/or
criminal investigations and/or prosecutions.
	 
	 	2.24.6.2	 	The CONTRACTOR shall have medical record keeping policies and practices which
are consistent with 42 CFR Part 456 and current NCQA standards for medical record
documentation. The CONTRACTOR shall distribute these policies to practice sites.
At a minimum, the policies and procedures shall address:

Page 248 of 374

 

	 	2.24.6.2.1	 	Confidentiality of medical records;
	 
	 	2.24.6.2.2	 	Medical record documentation standards; and
	 
	 	2.24.6.2.3	 	The medical record keeping system and standards for the availability of medical
records. At a minimum the following shall apply:
	 
	 	2.24.6.2.3.1	 	As applicable, medical records shall be maintained or available at the site where
covered services are rendered;
	 
	 	2.24.6.2.3.2	 	Enrollees (for purposes of behavioral health records, enrollee includes an
individual who is age sixteen (16) or over) and their legally appointed
representatives shall be given access to the enrollees’ medical records, to
the extent and in the manner provided by TCA 63-2-101, 63-2-102 and 33-3-104
et seq., and, subject to reasonable charges, (except as provided in Section
2.24.6.2.3.3 below) be given copies thereof upon request;
	 
	 	2.24.6.2.3.3	 	Provisions for ensuring that, in the event a patient-provider relationship with
a
TennCare primary care provider ends and the enrollee requests that medical
records be sent to a second TennCare provider who will be the enrollee’s
primary care provider, the first provider does not charge the enrollee or the
second provider for providing the medical records; and
	 
	 	2.24.6.2.3.4	 	Performance goals to assess the quality of medical record keeping.
	 
	 	2.24.6.2.4	 	The CONTRACTOR shall maintain and require contract behavioral health providers to
maintain medical records in conformity with TCA 33-3-10 1 et seq. for persons with
serious emotional disturbance or mental illness.
	 
	 	2.24.6.2.5	 	The CONTRACTOR shall maintain and require contract behavioral health providers to
maintain medical records of persons whose confidentiality is protected by 42 CFR Part 2
in conformity with that rule or TCA 33-3-103, whichever is more stringent.

23. Section 2.25 shall be deleted in its entirety and replaced with the following:

2.25 MONITORING

2.25.1 General

	 	2.25.1.1	 	TENNCARE, in its daily activities, shall monitor the CONTRACTOR for
compliance with the provisions of this Agreement.
	 
	 	2.25.1.2	 	TENNCARE, CMS, or their representatives shall at least annually monitor the
operation of the CONTRACTOR for compliance with the provisions of this Agreement
and applicable federal and state laws and regulations. Monitoring activities
shall include, but not be limited to, inspection of the CONTRACTOR’s facilities,
auditing and/or review of all records developed under this Agreement including
periodic medical audits, appeals, enrollments, disenrollments, termination of
providers, utilization and financial records, reviewing management systems and
procedures developed under this Agreement and review of any other areas or
materials relevant to or pertaining to this Agreement. TENNCARE will emphasize

Page 249 of 374

 

	 	 	 	case record validation because of the importance of having accurate service
utilization data for program management, utilization review and evaluation
purposes.
	 
	 	2.25.1.3	 	TENNCARE shall prepare a report of its findings and recommendations and
require the CONTRACTOR to develop corrective action plans as appropriate.

2.25.2 Facility Inspection

TENNCARE, CMS, or their representatives may conduct on-site inspections of all health
facilities and service delivery sites to be utilized by the CONTRACTOR in fulfilling the
obligations under this Agreement. Inspections may be made at anytime during the Agreement
period and without prior notice.

2.25.3 Inspection of Work Performed

TENNCARE, CMS, or their representatives shall, at all reasonable times, have the right to
enter into the CONTRACTOR’s premises, or such other places where duties of this Agreement
are being performed, to inspect, monitor, or otherwise evaluate including periodic audits of
the work being performed. The CONTRACTOR and all other subcontractors or providers shall
supply reasonable access to all facilities and assistance for TENNCARE’s representatives.
All inspections and evaluations shall be performed in such a manner as to minimize
disruption of normal business.

2.25.4 Approval Process

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

2.25.5 Availability of Records

	 	2.25.5.1	 	The CONTRACTOR shall ensure within its own organization and pursuant to any
agreement the CONTRACTOR may have with any other providers of service,
including, but not limited to providers, subcontractors or any person or entity
receiving monies directly or indirectly by or through TennCare, that TENNCARE
representatives and authorized federal, state and Office of the Comptroller of
the

Page 250 of 374

 

	 	 	 	Treasury personnel, including, but not limited to TENNCARE, the Office of the Inspector
General (OIG), the Tennessee Bureau of Investigations, Medicaid Fraud Control Unit (TBI
MFCU), the Department of Health and Human Services, Office of Inspector General (DHHS
OIG) and the Department of Justice (DOJ), and any other duly authorized state or
federal agency shall have immediate and complete access to all records pertaining to
services provided to TennCare enrollees.
	 
	 	2.25.5.2	 	The CONTRACTOR and its subcontractors and any providers of service, including, but
not limited to providers or any person or entity receiving monies directly or indirectly
by or through TennCare shall make all records (including but not limited to, financial
and medical records) available at the CONTRACTOR’s, provider’s, and/or the
subcontractor’s expense for administrative, civil and/or criminal review, audit, or
evaluation, inspection, investigation and/or prosecution by authorized federal, state,
and Office of the Comptroller of the Treasury personnel, including representatives from
the OIG, the TBI MFCU, DOJ and the DHHS OIG, TENNCARE or any duly authorized state or
federal agency. Access will be either through on-site review of records or through the
mail at the government agency’s discretion and during normal business hours, unless there
are exigent circumstances, in which case access will be at any time. The CONTRACTOR shall
send all records to be sent by mail to TENNCARE within twenty (20) business days of
request unless otherwise specified by TENNCARE or TennCare rules and regulations.
Requested records shall be provided at no expense to TENNCARE, authorized federal, state,
and Office of the Comptroller of the Treasury personnel, including representatives from
the OIG, the TBI MFCU, DOJ and the DHHS OIG, or any duly authorized state or federal
agency. Records related to appeals shall be forwarded within the time frames specified in
the appeal process portion of this Agreement. Such requests made by TENNCARE shall not be
unreasonable.
	 
	 	2.25.5.3	 	The CONTRACTOR and any of its subcontractors, providers or any entity or person
directly or indirectly receiving monies originating from TennCare, shall make all
records, including, but not limited to, financial, administrative and medical records
available to any duly authorized government agency, including but not limited to
TENNCARE, OIG, TBI MFCU, DHHS OIG and DOJ, upon any authorized government agency’s
request. Any authorized government agency, including but not limited to OIG, TBI MFCU,
DHHS OIG and DOJ, may use these records to carry out their authorized duties, reviews,
audits, administrative, civil and/or criminal investigations and/or prosecutions.
	 
	 	2.25.5.4	 	The CONTRACTOR, any CONTRACTOR’s management company and any CONTRACTOR’s claims processing
subcontractor shall cooperate with the State, or any of the State’s contractors and agents,
including, but not limited to TENNCARE, OIG, TBI MFCU, DOJ and the DHHS OIG, and the Office of
the Comptroller of the Treasury, and any duly authorized governmental agency, during the
course of any claims processing, financial or operational examinations or during any
administrative, civil or criminal investigation, hearing or prosecution. This cooperation
shall include, but shall not be limited to the following:
	 
	 	2.25.5.4.1	 	Providing full cooperation and direct and unrestricted access to facilities,
information, and staff, including facilities, information and staff of any management company
or subcontractor, to the State or any of the State’s contractors and agents, which includes,
but is not limited to TENNCARE, OIG, TBI MFCU, DOJ and the

Page 251 of 374

 

	 	 	 	DHHS OIG, and the Office of the Comptroller of the Treasury and any duly
authorized governmental agency, including federal agencies; and
	 
	 	2.25.5.4.2	 	Maintaining full cooperation and open authority for claims processing systems
access and mailroom visits by TDCI or designated representatives or any authorized
entity of the state or federal government, and to cooperate fully with detail claims
testing for claims processing system compliance.
	 
	 	2.25.5.5	 	The CONTRACTOR shall cooperate fully with audits the State may conduct of
medical management to include clinical processes and outcomes, internal audits,
provider networks, and any other aspect of the program the State deems
appropriate. The State may select any qualified person or organization to
conduct the audits.

2.25.6 Audit Requirements

The CONTRACTOR and its providers, subcontractors and other entities receiving monies
originating by or through TennCare shall maintain books, records, documents, and other
evidence pertaining to services rendered, equipment, staff, financial records, medical
records, and the administrative costs and expenses incurred pursuant to this Agreement as
well as medical information relating to the individual enrollees as required for the
purposes of audit, or administrative, civil and/or criminal investigations and/or
prosecution or for the purposes of complying with the requirements set forth in Section 2.20
of this Agreement. Records other than medical records may be kept in an original paper state
or preserved on micromedia or electronic format. Medical records shall be maintained in
their original form or may be converted to electronic format as long as the records are
readable and/or legible. These records, books, documents, etc., shall be available for any
authorized federal, state, including, but not limited to TENNCARE, OIG, TBI MFCU, DOJ and
the DHHS OIG, and Office of the Comptroller of the Treasury personnel during the Agreement
period and five (5) years thereafter, unless an audit, administrative, civil or criminal
investigation or prosecution is in progress or audit findings or administrative, civil or
criminal investigations or prosecutions are yet unresolved in which case records shall be
kept until all tasks or proceedings are completed. During the Agreement period, these
records shall be available at the CONTRACTOR’s chosen location in Tennessee subject to the
written approval of TENNCARE. If the records need to be sent to TENNCARE, the CONTRACTOR
shall bear the expense of delivery. Prior approval of the disposition of CONTRACTOR,
subcontractor or provider records must be requested and approved by TENNCARE in writing.
Nothing in this Section shall be construed to modify or change the obligations of the
CONTRACTOR contained in Section 2.23.2 (Data and Document Management Requirements), 2.23.3
(System and Data Integration Requirements), or 2.23.6 (Security and Access Management
Requirements) of this Agreement.

2.25.7 Independent Review of the CONTRACTOR

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

Page 252 of 374

 

2.25.8 Accessibility for Monitoring

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

2.25.9 CHOICES Consumer/Family Surveys

	 	2.25.9.1	 	The EQRO will administer an annual survey to a representative sample of
CHOICES members to assess members’ quality of life and members’ and/or caregivers’
satisfaction with the CHOICES program. The CONTRACTOR shall cooperate fully with
the EQRO in conducting the survey. The EQRO will provide a copy of its findings to
the CONTRACTOR.
	 
	 	2.25.9.2	 	As specified in Section 2.15.7, the CONTRACTOR shall
administer the Health Outcomes Survey and submit survey data files to TENNCARE. The EQRO will test,
clean, and score the data, develop reports, and provide relevant reports to the
CONTRACTOR.
	 
	 	2.25.9.3	 	TENNCARE or its designee will conduct a post-transition survey of a
representative sample of CHOICES members following discharge from a nursing
facility to an HCBS delivery setting (including the member’s home or
community-based residential alternatives setting) to assess the quality of the
care transition. The CONTRACTOR shall cooperate fully with TENNCARE or its
designee in conducting these surveys. TENNCARE or its designee will provide a copy
of its findings to the CONTRACTOR.
	 
	 	2.25.9.4	 	TENNCARE or its designee will conduct a survey of a
representative sample of CHOICES members following the CONTRACTOR’s needs assessment and care planning
processes to assess members’ and/or caregivers’ satisfaction with these
processes. The CONTRACTOR shall cooperate fully with TENNCARE or its designee in
conducting the survey. TENNCARE or its designee will provide a copy of the
survey findings to the CONTRACTOR.

2.25.10 Monitoring Quality of Care for CHOICES

In addition to any other monitoring activities conducted by TENNCARE, the CONTRACTOR shall
cooperate fully with any monitoring activities conducted by TENNCARE regarding the CHOICES
program. These activities will include but not be limited to the following:

	 	2.25.10.1	 	Quarterly and annual monitoring to ensure that CHOICES members receive disease
management interventions and the adequacy and appropriateness of these interventions
(see Sections 2.30.5.3 through 2.30.5.5).
	 
	 	2.25.10.2	 	For the first six (6) months after implementation of CHOICES in the Grand Region
covered by this Agreement, or as long as determined necessary by TENNCARE, monthly
monitoring of the CONTRACTOR’s performance regarding transitioning CHOICES members.
TENNCARE will review the Status of Transitioning CHOICES

Page 253 of 374

 

	 	 	 	Members report submitted by the CONTRACTOR (see Section 2.30.6.2) to determine the
CONTRACTOR’s performance on specified measures. TENNCARE may validate the report and
may conduct a more in-depth review and/or request additional information for instances
where the CONTRACTOR does not adhere to required timeframes. TENNCARE may require a
corrective action plan and/or impose sanctions to address non-compliance issues and to
improve CONTRACTOR performance.
	 
	 	2.25.10.3	 	Quarterly monitoring to determine the CONTRACTOR’s adherence to the requirements in this
Agreement regarding timeframes for assessments, care planning, and implementation of services
for members who are enrolled through the SPOE. TENNCARE will review the New Member Assessment
and Care Planning and Initiation of Services reports submitted by the CONTRACTOR (see Section
2.30.6.3) to determine the CONTRACTOR’s performance on specified measures. In the event the
CONTRACTOR’s performance on a measure is less than one hundred percent (100%), TENNCARE will
evaluate the adequacy and appropriateness of the CONTRACTOR’s remediation and improvement
activities. TENNCARE may validate the report and may conduct a more in-depth review and/or
request additional information for instances where the CONTRACTOR does not adhere to required
timeframes. TENNCARE may require a performance improvement plan, a corrective action plan
and/or impose sanctions to address non-compliance issues and to improve CONTRACTOR
performance.
	 
	 	2.25.10.4	 	Quarterly monitoring to determine the CONTRACTOR’s adherence to the timelines in this
Agreement regarding CHOICES intake of members who may be eligible for CHOICES. TENNCARE will
review the CHOICES Intake, Enrollment and Service Initiation reports submitted by the
CONTRACTOR (see Section 2.30.6.4) to determine the CONTRACTOR’s performance on specified
measures. In the event the CONTRACTOR’s performance on a measure is less than one hundred
percent (100%), TENNCARE will evaluate the adequacy and appropriateness of the CONTRACTOR’s
remediation and improvement activities. TENNCARE may validate the report and may conduct a
more in-depth review and/or request additional information for instances where the CONTRACTOR
does not adhere to required timeframes. TENNCARE may require a performance improvement plan, a
corrective action plan and/or impose sanctions to address non-compliance issues and to improve
CONTRACTOR performance.
	 
	 	2.25.10.5	 	Quarterly monitoring to determine the CONTRACTOR’s adherence to the requirements in this
Agreement regarding ongoing assessment and care planning and service initiation timeframes.
TENNCARE will review the Ongoing Assessment and Care Planning and Service Initiation reports
submitted by the CONTRACTOR (see Section 2.30.6.5) to determine the CONTRACTOR’s performance
on specified measures. In the event the CONTRACTOR’s performance on a measure is less than one
hundred percent (100%), TENNCARE will evaluate the adequacy and appropriateness of the
CONTRACTOR’s remediation and improvement activities. TENNCARE may validate the report and may
conduct a more in-depth review and/or request additional information for instances where the
CONTRACTOR does not adhere to required timeframes. TENNCARE may require a performance
improvement plan, a corrective action plan and/or impose sanctions to address noncompliance
issues and to improve CONTRACTOR performance.

Page 254 of 374

 

	 	2.25.10.6	 	Quarterly monitoring to determine the CONTRACTOR’s adherence to the
requirements in this Agreement regarding care coordinator contacts for CHOICES members
following enrollment into CHOICES. TENNCARE will review the Post-Enrollment Care
Coordination Contact reports submitted by the CONTRACTOR (see Section 2.30.6.6) to
determine the CONTRACTOR’s performance on specified measures. In the event the
CONTRACTOR’s performance on a measure is less than one hundred percent (100%), TENNCARE
will evaluate the adequacy and appropriateness of the CONTRACTOR’s remediation and
improvement activities. TENNCARE may validate the report and may conduct a more
in-depth review and/or request additional information for instances where the
CONTRACTOR does not adhere to required timeframes. TENNCARE may require a performance
improvement plan, a corrective action plan and/or impose sanctions to address
noncompliance issues and to improve CONTRACTOR performance.
	 
	 	2.25.10.7	 	Quarterly monitoring to determine the CONTRACTOR’s adherence to the requirements in this
Agreement regarding processes for identifying, assessing, and transitioning CHOICES who may
have the ability and/or desire to transition from a nursing facility to the community.
TENNCARE will review the Nursing Facility to Community Transition reports submitted by the
CONTRACTOR (see Section 2.30.6.8) to determine the CONTRACTOR’s performance on specified
measures. In the event the CONTRACTOR’s performance on a measure is less than one hundred
percent (100%), TENNCARE will evaluate the adequacy and appropriateness of the CONTRACTOR’s
remediation and improvement activities. TENNCARE may validate the report and may conduct a
more in-depth review and/or request additional information for instances where the CONTRACTOR
does not adhere to prescribed requirements. TENNCARE may require a performance improvement
plan, a corrective action plan and/or impose sanctions to address non-compliance issues and to
improve CONTRACTOR performance.
	 
	 	2.25.10.8	 	Monthly monitoring regarding missed and late visits. TENNCARE will review the HCBS Missed
Visits reports submitted by the CONTRACTOR (see Section 2.30.6.9) to determine the
CONTRACTOR’s performance on specified measures. TENNCARE will evaluate the adequacy and
appropriateness of the CONTRACTOR’s remediation and improvement activities. TENNCARE may
validate the report and may conduct a more in-depth review and/or request additional
information. TENNCARE may require a performance improvement plan, a corrective action plan
and/or impose sanctions to address non-compliance issues and to improve CONTRACTOR
performance.
	 
	 	2.25.10.9	 	For CHOICES members identified by TENNCARE, monthly case reviews to monitor the
objectivity of the CONTRACTOR’s needs assessment and care planning processes and to ensure
consistent and reliable outcomes.
	 
	 	2.25.10.10	 	Quarterly monitoring of the CONTRACTOR’s provider network file (see Section 2.30.7) to
ensure that CHOICES provider network requirements are met (see Section 2.11.6).
	 
	 	2.25.10.11	 	Annual monitoring of the CONTRACTOR’s long-term care provider network development plan
to ensure that the CONTRACTOR is making sufficient progress towards meeting its network
development and expansion goals (see Section 2.11.6.6).

Page 255 of 374

 

	 	 	 	TENNCARE will review the plan provided by the CONTRACTOR (see Section 2.30.7.6)
and will evaluate the adequacy of the CONTRACTOR’s long-term care network and
the CONTRACTOR’s efforts to improve the network where deficiencies exist.
	 
	 	2.25.10.12	 	Quarterly monitoring of critical incidents. TENNCARE will review the Critical
Incidents reports submitted by the CONTRACTOR (see Section 2.30.11.7) to identify
potential performance improvement activities and the adequacy of the CONTRACTOR’s
action steps to reduce the number of critical incidents and improve the critical
incidents reporting and management process. TENNCARE may conduct a more in-depth review
and/or request additional information.
	 
	 	2.25.10.13	 	Quarterly monitoring of the CONTRACTOR’s member complaints process to determine
compliance with timeframes prescribed in Section 2.19.2 of this Agreement and
appropriateness of resolutions. TENNCARE will review the Member Complaints reports
submitted by the CONTRACTOR (see Section 2.30.13), to determine the CONTRACTOR’s
performance on specified measures. In the event the CONTRACTOR’s performance on a
measure is less than one hundred percent (100%), TENNCARE will evaluate the adequacy
and appropriateness of the CONTRACTOR’s remediation and improvement activities.
TENNCARE may validate the report and may conduct a more in-depth review and/or request
additional information for instances where the CONTRACTOR does not adhere to required
timeframes. TENNCARE may require a performance improvement plan, a corrective action
plan and/or impose sanctions to address non-compliance issues and to improve CONTRACTOR
performance.
	 
	 	2.25.10.14	 	Review of all reports from the CONTRACTOR (see Section 2.30) and any related
follow-up activities.

2.25.11 Corrective Action Requirements

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

Page 256 of 374

 

24. Section 2.26 shall be deleted in its entirety and replaced with the following:

2.26 SUBCONTRACTS

2.26.1 Subcontract Relationships and Delegation

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

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

2.26.2 Legal Responsibility

The CONTRACTOR shall be responsible for the administration and management of all aspects of
this Agreement including all subcontracts/subcontractors. The CONTRACTOR shall ensure that
the subcontractor shall not enter into any subsequent agreements or subcontracts for any of
the work contemplated under the subcontractor for purposes of this Agreement without prior
written approval of the CONTRACTOR. No subcontract, provider agreement or other delegation
of responsibility terminates or reduces the legal responsibility of the CONTRACTOR to
TENNCARE to ensure that all activities under this Agreement are carried out in compliance
with the Agreement.

2.26.3 Prior Approval

All subcontracts, as defined in Section 1 of this Agreement, and revisions thereto shall be
approved in advance in writing by TENNCARE. The CONTRACTOR shall revise subcontracts as
directed by TENNCARE. Approval of subcontracts shall not be considered granted unless
TENNCARE issues its approval in writing. Once a subcontract has been executed by all of the
participating parties, a copy of the fully executed subcontract shall be sent to TENNCARE
within thirty (30) calendar days of execution. This written prior approval requirement does
not relieve the CONTRACTOR of any responsibilities to submit all proposed material
modifications of the

Page 257 of 374

 

CONTRACTOR’s MCO operations to TDCI for prior review and approval as required by Title 56,
Chapter 32, Part 1.

2.26.4 Subcontracts for Behavioral Health Services

If the CONTRACTOR subcontracts for the provision or management of behavioral health
services, the subcontract shall be specific to the TennCare program, and the CONTRACTOR
shall comply with the requirements in Section 2.6.1.2 regarding integration of physical
health and behavioral health services.

2.26.5 Subcontracts for Assessments and Plans of Care

If the CONTRACTOR subcontracts with an entity to conduct level of care or needs assessments
or reassessments and/or develop or authorize plans of care (see Section 2.9.6), such
subcontractor shall not provide any direct long-term care services.

2.26.6 Subcontract with Fiscal Employer Agent (FEA)

As required in Section 2.9.7.3, the CONTRACTOR shall contract with TENNCARE’s designated FEA
to provide assistance to members choosing consumer direction of HCBS. This subcontract shall
include the provisions specified by TENNCARE in the model FEA subcontract provided to the
CONTRACTOR. The CONTRACTOR shall not be liable for any failure, error, or omission by the
FEA related to the FEA’s verification of worker qualifications.

2.26.7 Standards

The CONTRACTOR shall require and ensure that the subcontractor complies with all applicable
requirements in this Agreement. This includes, but is not limited to, Sections 2.19, 2.2
1.7, 2.25.5, 2.25.6, 2.25.8, 2.25.9, 4.3, 4.19, 4.31, and 4.32 of this Agreement.

2.26.8 Quality of Care

If the subcontract is for the purpose of securing the provision of covered services, the
subcontract shall specify that the subcontractor adhere to the quality requirements the
CONTRACTOR is held to.

2.26.9 Interpretation/Translation Services and Limited English Proficiency (LEP) Provisions

The CONTRACTOR shall provide instruction for all direct service subcontractors regarding the
CONTRACTOR’s written procedure for the provision of language interpretation and translation
services for any member who needs such services, including but not limited to, enrollees
with Limited English Proficiency.

2.26.10 Children in State Custody

The CONTRACTOR shall include in its subcontracts a provision stating that subcontractors are
not permitted to encourage or suggest, in any way, that TennCare children be placed into
state custody in order to receive medical or behavioral health services covered by TENNCARE.

Page 258 of 374

 

2.26.11 Assignability

Transportation and claims processing subcontracts shall include language requiring that the
subcontract agreement shall be assignable from the CONTRACTOR to the State, or its designee:
i) at the State’s discretion upon written notice to the CONTRACTOR and the affected
subcontractor; or ii) upon CONTRACTOR’s request and written approval by the State. Further,
the subcontract agreement shall include language by which the subcontractor agrees to be
bound by any such assignment, and that the State, or its designee, shall not be responsible
for past obligations of the CONTRACTOR.

2.26.12 Claims Processing

	 	2.26.12.1	 	All claims for services furnished to a TennCare enrollee filed with a CONTRACTOR
shall be processed by either the CONTRACTOR or by one (1) subcontractor retained by the
organization for the purpose of processing claims. However, another entity can process
claims related to behavioral health, vision, lab, transportation, or consumer- directed
HCBS if that entity has been retained by the CONTRACTOR to arrange and provide for the
delivery of said services. However, all claims processed by any subcontractor shall be
maintained and submitted by the CONTRACTOR.
	 
	 	2.26.12.2	 	As required in Section 2.30.19 of this Agreement, where the CONTRACTOR has
subcontracted claims processing for TennCare claims, the CONTRACTOR shall provide to
TENNCARE a Type II examination based on the Statement on Auditing Standards (SAS) No.
70, Service Organizations.

2.26.13 HIPAA Requirements

The CONTRACTOR shall require all its subcontractors to adhere to HIPAA requirements.

2.26.14 Compensation for Utilization Management Activities

Should the CONTRACTOR have a subcontract arrangement for utilization management activities,
the CONTRACTOR shall ensure, consistent with 42 CFR 438.210(e) that compensation to
individuals or entities that conduct utilization management activities is not structured so
as to provide incentives for the individual or entity to deny, limit, or discontinue
medically necessary services to any enrollee, as provided by the Balanced Budget Act of 1997
and the provisions of 42 CFR 438.210(e).

2.26.15 Notice of Subcontractor Termination

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

Page 259 of 374

 

25. Section 2.29 shall be deleted in its entirety and replaced with the following:

2.29 PERSONNEL REQUIREMENTS

2.29.1 Staffing Requirements

	 	2.29.1.1	 	The CONTRACTOR shall have sufficient staffing capable of fulfilling the
requirements of this Agreement.
	 
	 	2.29.1.2	 	The CONTRACTOR shall submit to TENNCARE the names, resumes and contact information
of the key staff identified below. In the event of a change to any of the key staff
identified in Section 2.29.1.3, the CONTRACTOR shall notify TENNCARE within ten (10)
business days of the change.
	 
	 	2.29.1.3	 	The minimum key staff requirements are listed below. If a full-time staff person is
required, that means that one person shall perform that function (as opposed to
multiple persons equaling a full-time equivalent). If a full-time staff person
is not specified, the position does not require a full-time staff person.
	 
	 	2.29.1.3.1	 	A full-time administrator/project director dedicated to the TennCare program who
has clear authority over the general administration and day-to-day business activities
of this Agreement;
	 
	 	2.29.1.3.2	 	[Left blank intentionally];
	 
	 	2.29.1.3.3	 	A full-time Medical Director dedicated to the TennCare program who is a licensed
physician in the State of Tennessee to oversee and be responsible for all clinical
activities, including but not limited to the proper provision of covered services to
members, developing clinical practice standards and clinical policies and procedures;
	 
	 	2.29.1.3.4	 	A full-time senior executive dedicated to the TennCare program who is a board
certified psychiatrist in the State of Tennessee and has at least five (5) years
combined experience in mental health and substance abuse services. This person shall
oversee and be responsible for all behavioral health activities;
	 
	 	2.29.1.3.5	 	A full-time senior executive dedicated to the TennCare CHOICES program who has at
least five (5) years of experience administering managed long-term care programs. On a
case-by-case basis, equivalent experience in administering long-term care programs and
services, including HCBS, or in managed care may be substituted, subject to the prior
approval of TENNCARE This person shall oversee and be responsible for all CHOICES
activities;
	 
	 	2.29.1.3.5.1	 	The CONTRACTOR shall ensure that this position is filled at least one hundred
and twenty (120) days prior to the scheduled implementation of CHOICES in the
Grand Region covered by this Agreement;
	 
	 	2.29.1.3.5.2	 	If the CONTRACTOR has not filled this position one hundred and eighty (180)
days prior to the scheduled implementation of CHOICES in the Grand Region
covered by this Agreement, the CONTRACTOR shall designate another senior
executive dedicated to the TennCare program to temporarily oversee CHOICES
implementation activities, as prior approved by TENNCARE, until this position

Page 260 of 374

 

	 	 	 	is filled (which, as specified in Section 2.29.1.3.5.1 above, shall be at least
one hundred and twenty (120) days prior to the scheduled implementation of CHOICES).
Should another senior executive be temporarily designated to oversee CHOICES
implementation activities, upon filling the full-time position as specified in
Section 2.29.1.3.5.1 above, the CONTRACTOR shall ensure the effective transition of
all CHOICES implementation activities, including a minimum transition period of
ninety (90) days;
	 
	 	2.29.1.3.6	 	A full-time chief financial officer dedicated to the TennCare program responsible for
accounting and finance operations, including all audit activities;
	 
	 	2.29.1.3.7	 	A full-time staff information systems director/manager dedicated to the TennCare program
responsible for all CONTRACTOR information systems supporting this Agreement who is trained
and experienced in information systems, data processing and data reporting as required to
oversee all information systems functions supporting this Agreement including, but not limited
to, establishing and maintaining connectivity with TennCare information systems and providing
necessary and timely reports to TENNCARE;
	 
	 	2.29.1.3.8	 	A staff person designated as the contact available after hours for the “on-call”
TennCare Solutions staff to contact with service issues;
	 
	 	2.29.1.3.9	 	A staff person to serve as the CONTRACTOR’s Non-discrimination Compliance Coordinator.
This person shall be responsible for compliance with Title VI of the Civil Rights Act of 1964,
Section 504 of the Rehabilitation Act of 1973, Title II of the Americans with Disabilities Act
of 1990, the Age Discrimination Act of 1975 and the Omnibus Budget Reconciliation Act of 1981
(P.L. 97-35) on behalf of the CONTRACTOR. The CONTRACTOR shall report to TENNCARE in writing,
to the attention of the Director of Non-Discrimination Compliance/Health Care Disparities,
within ten (10) calendar days of the commencement of any period of time that the CONTRACTOR
does not have a designated staff person for non-discrimination compliance. The CONTRACTOR
shall report to TENNCARE at such time that the function is redirected as required in Section
2.29.1.2;
	 
	 	2.29.1.3.10	 	A full-time staff person dedicated to the TennCare program responsible for member
services, who shall communicate with TENNCARE regarding member service activities;
	 
	 	2.29.1.3.11	 	A full-time staff person dedicated to the TennCare program responsible for provider
services and provider relations, including all network development and management issues. This
person shall be responsible for appropriate education regarding provider participation in the
TennCare (including CHOICES) program; communications between the CONTRACTOR and its contract
providers; and ensuring that providers receive prompt resolution of problems or inquiries.
This person shall also be responsible for communicating with TENNCARE regarding provider
service and provider relations activities. The FEA shall be responsible for education of and
communication with consumer-directed workers, resolution of problems or inquiries from
workers, and communication with TENNCARE regarding workers;
	 
	 	2.29.1.3.12	 	A full-time staff person dedicated to the TennCare CHOICES program responsible for
educating and assisting long-term care providers and the FEA regarding

Page 261 of 374

 

	 	 	 	appropriate claims submission processes and requirements, coding updates, electronic
claims transactions and electronic funds transfer; for the development and maintenance
of CONTRACTOR resources such as CHOICES provider manuals, website, fee schedules, etc.;
for technical assistance regarding long-term care claims submission and resolution
processes; and for prompt resolution of long-term care claims issues or inquiries as
specified in Section 2.22.5. This person shall develop strategies to assess the
effectiveness of the CONTRACTOR’S claims education and technical assistance activities,
gather feedback regarding the extent to which CHOICES providers are informed about
appropriate claims submission processes and practices, and identify trends and guide the
development of strategies to improve the efficiency of long-term care claims submission
and resolution processes, as well as CHOICES provider satisfaction;

	 	2.29.1.3.13	 	A staff person responsible for all fraud and abuse detection activities, including the
fraud and abuse compliance plan, as set forth in Section 2.20 of this Agreement;
	 
	 	2.29.1.3.14	 	A staff person responsible for all UM activities, including but not limited to
overseeing prior authorizations. This person shall be a physician licensed in the State of
Tennessee and shall ensure that UM staff have appropriate clinical backgrounds in order to
make utilization management decisions;
	 
	 	2.29.1.3.15	 	A staff person responsible for all quality management activities. This person shall be
a physician or registered nurse licensed in the State of Tennessee;
	 
	 	2.29.1.3.16	 	A staff person responsible for all appeal system resolution issues;

	 
	 	2.29.1.3.17	 	A staff person responsible for all claims management activities;
	 
	 	2.29.1.3.18	 	A staff person assigned to provide legal and technical assistance for and coordination
with the legal system for court ordered services;
	 
	 	2.29.1.3.19	 	A staff person responsible for all MCO case management and related issues, including
but not limited to, disease management activities and coordination between physical and
behavioral health services;
	 
	 	2.29.1.3.20	 	A full-time staff person dedicated to the TennCare CHOICES program who is a registered
nurse and has at least three (3) years experience providing care coordination to persons
receiving long-term care services and an additional two (2) years work experience in managed
and/or long-term care. This person shall oversee and be responsible for all care coordination
activities.
	 
	 	2.29.1.3.21	 	A sufficient number of CHOICES care coordinators that meet the qualifications in
Section 2.9.6.11 to conduct all required activities as specified herein;
	 
	 	2.29.1.3.22	 	A consumer advocate for members receiving, or in need of, behavioral health services.
This person shall be responsible for internal representation of members’ interests including
but not limited to: ensuring input in policy development, planning, decision making, and
oversight as well as coordination of recovery and resilience activities;

Page 262 of 374

 

	 	2.29.1.3.23	 	A consumer advocate for CHOICES members. This person shall be responsible for internal
representation of CHOICES members’ interests including but not limited to input into planning
and delivery of long-term care services, CHOICES QM/QI activities, program monitoring and
evaluation, and member, family, and provider education. The consumer advocate shall also
assist CHOICES members in navigating the CONTRACTOR’s system (e.g., how to file a complaint,
how to change care coordinators). This shall include, but not be limited to, helping members
understand and use the CONTRACTOR’s system, e.g., being a resource for members, providing
information, making referrals to appropriate CONTRACTOR staff, and facilitating resolution of
any issues. The consumer advocate shall also make recommendations to the CONTRACTOR on any
changes needed to improve the CONTRACTOR’s system for CHOICES members, make recommendations to
TENNCARE regarding improvements for the CHOICES program, and participate as an ex officio
member of the CHOICES Advisory Group required in Section 2.24.3;
	 
	 	2.29.1.3.24	 	A staff person responsible for TENNderCare services;
	 
	 	2.29.1.3.25	 	A staff person responsible for working with the Department of Children’s Services;
	 
	 	2.29.1.3.26	 	A senior executive responsible for overseeing all subcontractor activities, if the
subcontract is for the provision of covered benefits;
	 
	 	2.29.1.3.27	 	A staff person responsible for coordinating all activities and resolving issues related
to CONTRACTOR/DBM coordination. This person shall be responsible for overseeing the work of
the DBM Care Coordination Committee and the DBM Claims Coordination Committee as described in
Section 2.9.11;
	 
	 	2.29.1.3.28	 	A staff person responsible for coordinating all activities and resolving issues related
to CONTRACTOR/PBM coordination; and
	 
	 	2.29.1.3.29	 	A staff person designated for interfacing and coordinating with the TDMHDD Planning and
Policy Council.
	 
	 	2.29.1.4	 	In addition to the key staff requirements described above, the CONTRACTOR shall have
sufficient full-time clinical and support staff to conduct daily business in an orderly
manner. This includes but is not limited to functions and services in the following areas:
administration, accounting and finance, fraud and abuse, utilization management including
prior authorizations, MCO case management, disease management, care coordination, quality
management, member education and outreach, appeal system resolution, member services,
provider services, provider relations, claims processing, and reporting.
	 
	 	2.29.1.5	 	The CONTRACTOR shall have a sufficient number of DBM care coordinators and claims coordinators to
conduct all required activities, including but not limited to collaboration with the DBM and coordination
with various state agencies.
	 
	 	2.29.1.6	 	The CONTRACTOR shall appoint specific staff to an internal audit function as
specified in Section 2.2 1.10.
	 
	 	2.29.1.7	 	At least one hundred and twenty (120) days prior to the scheduled implementation of
CHOICES in the Grand Region covered by this Agreement, the CONTRACTOR

Page 263 of 374

 

	 	 	 	shall establish a team dedicated to the implementation of the CHOICES program.
This team shall be responsible for directing and overseeing all aspects of the
implementation of CHOICES. The team shall be led by the full-time senior
executive referenced in Section 2.29.1.3.5 above and shall include, at a
minimum, a staff person with responsibility for developing and implementing the
CONTRACTOR’s care coordination program, a staff person responsible for long-term
care provider network development and provider relations, a staff person
responsible for CHOICES provider claims education and assistance, a staff person
responsible for long-term care QM/QI, a staff person responsible for IS issues
related to CHOICES, and other staff as necessary to ensure the successful
implementation of the CHOICES program and the seamless transition of members
currently receiving long-term care services. The team shall report directly to
the CONTRACTOR’s senior management and shall interface with all of the
CONTRACTOR’s departments/business units as necessary to ensure the CONTRACTOR’s
readiness to provide services to CHOICES members in compliance with the
requirements of this Agreement.
	 
	 	2.29.1.8	 	The CONTRACTOR is not required to report to TENNCARE the names of staff not
identified as key staff in Section 2.29.1.3. However, the CONTRACTOR shall provide its
staffing plan to TENNCARE.
	 
	 	2.29.1.9	 	The CONTRACTOR’s project director, transition staff person, Medical Director,
psychiatrist, CHOICES senior executive, financial staff, member services staff,
provider services staff, provider relations staff, CHOICES provider claims
education and assistance staff, UM staff, appeals staff, MCO case management
staff, care coordination staff, consumer advocate, and TENNderCare staff person
shall be located in the State of Tennessee. However, TENNCARE may authorize
exceptions to this requirement. The CONTRACTOR shall seek TENNCARE’s written
prior approval to locate any of these staff outside of the State of Tennessee.
The CONTRACTOR’s request to locate required in-state staff to an out-of-state
location shall include a justification of the request and an explanation of how
services will be coordinated. If financial staff are not located in Tennessee
the CONTRACTOR shall have the ability to issue a check within five (5) calendar
days of a payment directive from TENNCARE.
	 
	 	2.29.1.10	 	The CONTRACTOR shall conduct training of staff in all departments to ensure
appropriate functioning in all areas. This training shall be provided to all new staff
members and on an ongoing basis for current staff.

2.29.2 Licensure and Background Checks

	 	2.29.2.1	 	Except as specified in this Section 2.29.2.1 regarding the FEA, the CONTRACTOR
is responsible for ensuring that all persons, whether they are employees,
agents, subcontractors, providers or anyone acting for or on behalf of the
CONTRACTOR, are legally authorized to render services under applicable state
law. The FEA shall be responsible for ensuring that consumer-directed workers
are qualified to provide HCBS in accordance with TENNCARE requirements.
	 
	 	2.29.2.2	 	Except as specified in this Section 2.29.2.2 regarding the FEA, the CONTRACTOR
is responsible for conducting background checks in accordance with state law and
TennCare policy and ensuring that all employees, agents, subcontractors, providers
or anyone acting for or on behalf of the CONTRACTOR conducts background checks in
accordance with state law and TennCare policy. The FEA shall be responsible for
conducting background checks

Page 264 of 374

 

	 	 	 	on its staff, its subcontractors, and consumer-directed workers.

2.29.3 Board of Directors

	 	 	 	The CONTRACTOR shall provide to TENNCARE, in writing, a list of all officers and members of
the CONTRACTOR’s Board of Directors. The CONTRACTOR shall notify TENNCARE, in writing,
within ten (10) business days of any change thereto.

2.29.4 Employment and Contracting Restrictions

	 	 	 	The CONTRACTOR shall not knowingly have a director, officer, partner, or person with
beneficial ownership of more than five percent (5%) of the entity’s equity who has been
debarred or suspended by any federal agency. The CONTRACTOR may not have an employment,
consulting, or any other agreement with a person that has been debarred or suspended by any
federal agency for the provision of items or services that are significant and material to
the entity’s contractual obligation with the State. To the best of its knowledge and belief,
the CONTRACTOR certifies by its signature to this Agreement that the CONTRACTOR and its
principals:

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

26. Section 2.30 shall be deleted in its entirety and replaced with the following:

2.30 REPORTING REQUIREMENTS

2.30.1 General Requirements

	 	2.30.1.1	 	The CONTRACTOR shall comply with all the reporting requirements established by
TENNCARE. TENNCARE shall provide the CONTRACTOR with the appropriate reporting
formats, instructions, submission timetables, and technical assistance as
required. TENNCARE may, at its discretion, change the content, format or
frequency of reports.

Page 265 of 374

 

	 	2.30.1.2	 	TENNCARE may, at its discretion, require the CONTRACTOR to submit additional reports both
ad hoc and recurring. If TENNCARE requests any revisions to the reports already submitted, the
CONTRACTOR shall make the changes and re-submit the reports, according to the time period and
format required by TENNCARE.
	 
	 	2.30.1.3	 	The CONTRACTOR shall submit all reports to TENNCARE, unless indicated
otherwise in this Agreement, according to the schedule below:

	 	 	 
	DELIVERABLES	 	DUE DATE
	Daily Reports

	 	Within two (2) business days.
	 
	 	 
	Weekly Reports

	 	Wednesday of the following week.
	 
	 	 
	Monthly Reports

	 	20th of the following month.
	 
	 	 
	Quarterly Reports

	 	30th of the following month.
	 
	 	 
	Semi-Annual Reports

	 	January 31 and July 31.
	 
	 	 
	Annual Reports

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

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

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

	 	2.30.1.4	 	The CONTRACTOR shall submit all reports electronically and in the manner and
format prescribed by TENNCARE. Except as otherwise specified by TENNCARE, all reports
shall be specific to the Grand Region covered by this Agreement.
	 
	 	2.30.1.5	 	Except as otherwise provided in this Agreement, the CONTRACTOR shall submit all
reports to the Bureau of TennCare.
	 
	 	2.30.1.6	 	The CONTRACTOR shall transmit to and receive from TENNCARE all transactions and code sets
in the appropriate standard formats as specified under HIPAA and as directed by TENNCARE, so
long as TENNCARE direction does not conflict with the law.
	 
	 	2.30.1.7	 	As part of its QM/QI program, the CONTRACTOR shall review all reports submitted to
TENNCARE to identify instances and/or patterns of non-compliance, determine and analyze
the reasons for non-compliance, identify and implement actions to correct instances of
non-compliance and to address patterns of non-compliance, and identify and implement
quality improvement activities to improve performance and ensure compliance going forward.

Page 266 of 374

 

2.30.2 Eligibility, Enrollment and Disenrollment Reports

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

2.30.3 LEFT BLANK INTENTIONALLY

2.30.4 Specialized Service Reports

	 	2.30.4.1	 	The CONTRACTOR shall submit a quarterly Psychiatric Hospital/RTF Readmission
Report that provides: the percentage of members readmitted to the facility within
seven (7) calendar days of discharge (the number of members readmitted divided by
the total number of discharges); the percent of members readmitted within thirty
(30) calendar days of discharge (the number of members readmitted divided by the
total number of discharges); and an analysis of the findings with any actions or
follow-up planned. The information shall be reported separately for members age
eighteen (18) and over and under eighteen (18).
	 
	 	2.30.4.2	 	The CONTRACTOR shall submit a quarterly Mental Health Case Management Report that
provides information on mental health case management appointments and refusals (see
Section 2.7.2.6). The minimum data elements required are identified in Attachment IX,
Exhibit B.
	 
	 	2.30.4.3	 	The CONTRACTOR shall submit an annual Supported Employment Report that
reports on the percent of SPMI adults receiving supported employment services that

Page 267 of 374

 

	 	 	 	are gainfully employed in either part-time or full-time capacity for a continuous ninety
(90) day period (defined as the number of adults receiving supported employment for a
continuous ninety (90) day period divided by the number of SPMI adults receiving
supported employment services during the year) and an analysis of the findings with any
action or follow-up planned as a result of the findings.

	 	2.30.4.4	 	The CONTRACTOR shall submit a quarterly Behavioral Health Crisis Response Report that
provides information on behavioral health crisis services (see Section 2.7.2.8) including the
data elements listed in Attachment IX, Exhibit C. Specified data elements shall be reported
separately for members ages eighteen (18) years and over and those under eighteen (18) years and
all data elements shall be reported for each individual crisis service provider.
	 
	 	2.30.4.5	 	The CONTRACTOR shall submit a weekly Member CRG/TPG Assessment Report that contains
information regarding the CRG assessments and TPG assessments (see Section 2.7.2.9) of members
who have presented for mental health or substance abuse services or who have received CRG
assessments and TPG assessments prior to obtaining such services. For purposes of this weekly
Member CRG/TPG Assessment Report, the weekly report shall be due no later than 12:00 Noon, each
Tuesday. The minimum data elements required are identified in Attachment IX, Exhibit D of this
Agreement.
	 
	 	2.30.4.6	 	On a quarterly basis the CONTRACTOR shall submit a Rejected CRG/TPG Assessments Report
that provides, by agency, the number of rejected CRG/TPG assessments and the unduplicated number
of and identifying information for the unapproved raters who completed the rejected assessments.
	 
	 	2.30.4.7	 	The CONTRACTOR shall submit an annual CRG/TPG Assessments Audit Report. The report
shall contain the results of the CONTRACTOR’s audits for the prior year of CRG/TPG assessments
for accuracy and conformity to state policies and procedures.
	 
	 	2.30.4.8	 	The CONTRACTOR shall annually submit to TENNCARE its methodology for conducting the
CRG/TPG assessment audits on March 1.
	 
	 	2.30.4.9	 	The CONTRACTOR shall submit a quarterly Adverse Occurrences Report that
summarizes all adverse occurrences and their resolutions as reported to the CONTRACTOR
by its providers.
	 
	 	2.30.4.10	 	The CONTRACTOR shall submit a quarterly TENNderCare Report.
	 
	 	2.30.4.11	 	The CONTRACTOR shall submit a quarterly Self-Directed Health Care Tasks Report. The
report shall include current and cumulative information, by month, on various measures.
Initially the performance measure will be the following:

	 	(1)	 	Number and percent of CHOICES members self-directing health care tasks

	 	 	 	Upon expansion of self-directed health care tasks to include additional tasks, the
performances measures shall also include but not be limited to the following:

Page 268 of 374

 

	 	(1)	 	Of CHOICES members self-directing health care tasks,
the number and percent by type of health care task that is self-directed
	 
	 	(2)	 	Of CHOICES members self-directing health care tasks,
the number and percent who, overall and by task, use:

	 	(a)	 	A community-based residential
alternative provider, other than a companion care model
	 
	 	(b)	 	A companion care model
	 
	 	(c)	 	A non-residential provider
	 
	 	(d)	 	A consumer-directed worker
	 
	 	(e)	 	Both a non-residential provider and a
consumer-directed worker

	 	 	 	The cumulative information shall include information on each of the measures by
and across previous months on a rolling twelve (12) month basis, and the
CONTRACTOR shall provide a graphical (as well as numeric) representation of
current and cumulative information.
	 
	 	 	 	The CONTRACTOR shall submit its first report following the first calendar
quarter after CHOICES implementation, and that report shall include information
for the period from CHOICES implementation through the first calendar quarter.

2.30.5 Disease Management Reports

	 	2.30.5.1	 	The CONTRACTOR shall submit a quarterly Disease Management Update Report
that includes, for each disease management program (see Section 2.8), a brief
narrative description of the program, the total number of members in the
program, the total number of members enrolled and disenrolled during the
quarter, and a description of the specific provider and member interventions
performed during the quarter.
	 
	 	2.30.5.2	 	The CONTRACTOR shall submit on July 1 an annual Disease Management Report that
includes, for each disease management programs, a narrative description of the
eligibility criteria and the method used to identify and enroll eligible members, the
passive participation rate as defined by NCQA (the percentage of identified eligible
members who have received an intervention divided by the total population who meet the
criteria for eligibility), the total number of active members having one or more of the
diagnosis codes (ICD-9 Codes) relating to each of the disease management programs, a
description of stratification levels for each DM program including member criteria and
associated interventions, a discussion of barriers and challenges to include resources,
program structure, member involvement and provider participation, a summary of member
satisfaction with the DM program, a written analysis of the data presented, a
description of proposed changes to program, and information on the programs’
activities, benchmarks and goals as described in Section 2.8.7.
	 
	 	2.30.5.3	 	The CONTRACTOR shall submit a quarterly Disease Management for CHOICES Update
Report.
	 
	 	2.30.5.3.1	 	The first report shall be submitted after the first calendar quarter after
CHOICES implementation in the Grand Region covered by this Agreement and shall provide
a narrative description of the CONTRACTOR’s proposed approach to disease

Page 269 of 374

 

	 	 	 	management for CHOICES members for four of the six disease management (DM) conditions
listed in Sections 2.8.1.1.2, 2.8.1.1.3, 2.8.1.1.5, 2.8.1.1.6, 2.8.1.1.8, and 2.8.8).
This shall include but not be limited to identifying the four DM conditions that will be
targeted for the next six months, the proposed stratification levels including member
criteria and the proposed associated member/caregiver and provider interventions for
each DM condition, which shall include targeted interventions based on the setting in
which the member resides.

	 	2.30.5.3.2	 	The report for the second calendar quarter after CHOICES implementation shall provide an
update regarding the CONTRACTOR’s progress in implementing the four disease management
programs identified by the CONTRACTOR in the first report, including the stratification levels
including member criteria and proposed associated member/caregiver and provider interventions
for each DM condition; number of members who have been identified, by stratification level and
associated proposed member/caregiver and provider interventions; and any other disease
management activities that have been conducted for the population.
	 
	 	2.30.5.3.3	 	The report for the third calendar quarter after CHOICES implementation shall include,
for each of the four disease management programs identified by the CONTRACTOR in the first
report, a brief narrative description of any changes, opportunities or barriers regarding
these DM programs; the total number of CHOICES members receiving DM interventions for the four
selected conditions, by DM condition; the total number of CHOICES members starting and
terminating DM interventions during the quarter, a description of the specific provider and
member interventions that were new during the quarter, the number of member and provider
activities/interventions conducted, by activity/intervention, and a written analysis of data
provided.
	 
	 	2.30.5.3.4	 	The report for the fourth calendar quarter after CHOICES implementation shall include
the same type of information as in the report for the third quarter (see Section 2.30.5.3.3)
as well as the CONTRACTOR’s proposed approach to disease management for CHOICES members for
the two DM conditions listed in Sections 2.8.1.1.2, 2.8.1.1.3, 2.8.1.1.5, 2.8.1.1.6,
2.8.1.1.8, 2.8.8) for which the CONTRACTOR has not developed a DM program for CHOICES members.
This shall include but not be limited to the elements listed in Section 2.30.5.3.2 for each of
the two DM programs.
	 
	 	2.30.5.3.5	 	The report for the fifth calendar quarter after CHOICES implementation shall include the
same type of information as in the report for the third quarter (see Section 2.30.5.3.3) for
each of the six DM programs implemented by the CONTRACTOR for CHOICES members.
	 
	 	2.30.5.3.6	 	The report for the sixth calendar quarter after CHOICES implementation shall include the
same type of information as in the fifth calendar quarter report (see Section 2.30.5.3.5) as
well as the CONTRACTOR’s proposed approach to disease management for CHOICES members for the
three DM conditions listed in Sections 2.8.1.1.4, 2.8.1.1.7, and 2.8.1.1.9.
	 
	 	2.30.5.3.7	 	The report for the seventh calendar quarter after CHOICES implementation shall include
the same type of information as in the report for the third quarter (see Section

Page 270 of 374

 

	 	 	 	2.30.5.3.3) for each of the nine DM programs implemented by the CONTRACTOR for
CHOICES members.

	 	2.30.5.4	 	The CONTRACTOR shall submit on July 1 an annual Disease Management for CHOICES
Report that includes, for each disease management program implemented by the CONTRACTOR
(see Section 2.8.1.7), a narrative description of the eligibility criteria and the
method used to identify and enroll eligible CHOICES members; a description of
stratification levels including member criteria and associated member and provider
interventions, which shall include targeted interventions based on the setting in which
the member resides; total number of CHOICES members identified as having a DM
condition, total number of members receiving DM activities/interventions, and the
passive participation rate of CHOICES members; number of CHOICES members by level of
stratification and intervention; outcome measures; a discussion of barriers and
challenges to include resources, program structure, member involvement and provider
participation; evaluation of member satisfaction with activities/interventions; and a
description of proposed changes.
	 
	 	2.30.5.5	 	The CONTRACTOR shall submit annually an updated Disease Management Program
Description to include at a minimum the disease management components listed in
Sections 2.8.1.4 through 2.8.1.5 of this Agreement and an updated Disease Management
Program Description for CHOICES to include at a minimum the disease management
components listed in Section 2.8.1.6 of this Agreement.

2.30.6 Service Coordination Reports

	 	2.30.6.1	 	MCO Case Management Reports
	 
	 	2.30.6.1.1	 	The CONTRACTOR shall submit annually an updated MCO Case Management Program
Description to TENNCARE describing the CONTRACTOR’s MCO case management services. The
report shall include a description of the criteria and process the CONTRACTOR uses to
identify members for MCO case management, the process the CONTRACTOR uses to inform
members and providers of the availability of MCO case management, a description of the
MCO case management services provided by the CONTRACTOR and the methods used by the
CONTRACTOR to evaluate its MCO case management program.
	 
	 	2.30.6.1.2	 	The CONTRACTOR shall submit an annual MCO Case Management Services Report that
addresses the activities in Section 2.9.5 of this Agreement by July 1 of each year.
	 
	 	2.30.6.1.3	 	The CONTRACTOR shall submit a quarterly MCO Case Management Update Report.
Enrollees who are enrolled in Disease Management need not be included in this report
unless they are also receiving case management.
	 
	 	2.30.6.2	 	For the first six (6) months after implementation of CHOICES in the Grand
Region
covered by this Agreement, or as long as determined necessary by TENNCARE, the
CONTRACTOR shall submit a monthly Status of Transitioning CHOICES Members Report
that provides information regarding transitioning CHOICES members (see Section
2.9.3). The report shall include information on the CONTRACTOR’s current and
cumulative performance on various measures.

Page 271 of 374

 

	 	 	 	The performance measures shall include but not be limited to the following:

	 	(1)	 	Of CHOICES Group 1 members who were enrolled in CHOICES as of the
CHOICES implementation date, the number and percent for whom the CONTRACTOR
has/has not conducted a face-to-face visit (see Section 2.9.3.7)
	 
	 	(2)	 	Of CHOICES Group 2 members who were enrolled in CHOICES as of the
CHOICES implementation date, the number and percent for whom the CONTRACTOR
has/has not conducted face-to-face visit and a comprehensive needs assessment and
developed and authorized a new plan of care

	 	 	 	If, at the expiration of any one of the timeframes specified in Section 2.9.3, the
CONTRACTOR’s performance for the measure is less than one hundred percent (100%), the
CONTRACTOR shall provide an exceptions report for that measure. The report shall
identify the number and percent of members for whom the CONTRACTOR did not meet the
specified timeframe and provide detail information regarding each instance in which the
CONTRACTOR did not meet the applicable timeframe. The detail information shall include
but not be limited to for each member: the date the applicable activity should have
occurred, the date that the applicable activity will/did occur, and why the CONTRACTOR
exceeded the timeframe. The CONTRACTOR shall submit a follow-up exceptions report until
the CONTRACTOR has conducted the required activities for each member.
	 
	 	2.30.6.3	 	The CONTRACTOR shall submit a quarterly New Member Assessment and Care Planning and
Initiation of Services Report that provides information regarding assessment, care planning,
and initiation of services for CHOICES members who are enrolled through the SPOE. The report
shall include information on the CONTRACTOR’s performance, by month, on various measures; an
exceptions report (as applicable); a cumulative report; and a performance improvement plan (as
applicable).
	 
	 	 	 	The performance measures shall include but not be limited to the following:

	 	(1)	 	Of CHOICES Group 1 members enrolled through the SPOE who, at the time
of CHOICES enrollment, had been residing in a nursing facility for ninety (90)
days or more and are due for a face-to-face visit in the month, the number and
percent for whom the CONTRACTOR met/did not meet the specified timeframe for a
face-to-face visit (see Section 2.9.6.2.4.2)
	 
	 	(2)	 	Of CHOICES Group 1 members enrolled through the SPOE who, at the time
of CHOICES enrollment, were recently admitted to a nursing facility and are due
for a face-to-face visit in the month, the number and percent for whom the
CONTRACTOR met/did not meet the specified timeframe for a face-to- face visit (see
Section 2.9.6.2.4.3)
	 
	 	(3)	 	Of CHOICES Group 1 members enrolled through the SPOE who will be
admitted to a nursing facility and are due for a face-to-face visit in the month,
the number and percent for whom the CONTRACTOR met /did not meet the

Page 272 of 374

 

	 	 	 	specified timeframe for a face-to-face visit and initiation of nursing facility
services (see Section 2.9.6.2.4.4)
	 
	 	(4)	 	Of CHOICES Group 2 and Group 3 members enrolled through the SPOE
who are due for a face-to-face visit in the month, the number and percent for
whom the CONTRACTOR met/did not meet the specified timeframe for conducting a
face-to-face visit and initiating ongoing HCBS (as defined in Section 1)
identified in the member’s plan of care (see Section 2.9.6.2.5)

	 	 	 	If the CONTRACTOR’s performance for the reporting period for any one of the timeframe
measures is less than one hundred percent (100%), the CONTRACTOR shall provide an
exceptions report for that measure. The report shall identify the number and percent of
members for whom the CONTRACTOR did not meet the specified timeframe and provide detail
information regarding each instance in which the CONTRACTOR did not meet the applicable
timeframe. The detail information shall include but not be limited to for each member:
the date the applicable activity should have occurred, the actual date that the
applicable activity occurred (if it occurred within the reporting period), the date that
the applicable activity will occur (if it did not occur within the reporting period),
and why the CONTRACTOR exceeded the timeframe.
	 
	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a
follow-up exceptions report that provides updated information on the exceptions reported
in the previous report that identifies any members for whom the CONTRACTOR did not
remediate on the date specified in the previous exceptions report; (2) for each month in
the previous twelve (12) months, for each timeframe measure, the CONTRACTOR’s
performance; and (3) over the previous months on a rolling twelve (12) month basis, for
each timeframe measure, the minimum, maximum, median, and average amount of time that it
took the CONTRACTOR to complete the applicable activity, which shall include instances
where the activity was completed after the specified timeframe, as compared to the
timeframe specified in this Agreement for that measure. The report shall include a
graphical representation of current and cumulative information.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the
CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance improvement plan that
includes an analysis of the reasons for noncompliance, actions taken/to be taken by the
CONTRACTOR to ensure compliance, the timeframes for these actions, who is responsible
for the actions, and any related quality improvement activities, including timeframes.
	 
	 	2.30.6.4	 	The CONTRACTOR shall submit a quarterly CHOICES Intake, Enrollment, and Service Initiation
Report regarding the CONTRACTOR’s CHOICES intake process for current members who may be
eligible for CHOICES. The report shall include information on the CONTRACTOR’s performance, by
month, on various measures; an exceptions report (as applicable); a cumulative report; and a
performance improvement plan (as applicable).
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

Page 273 of 374

 

	 	(1)	 	Number of members identified as potentially eligible for CHOICES
	 
	 	(2)	 	Of members due for a CHOICES intake visit, the number and percent for
whom the CONTRACTOR met/did not meet the specified timeframe for conducting a CHOICES intake
visit (see Section 2.9.6.3)
	 
	 	(3)	 	Of the members identified for whom the CONTRACTOR conducted a
telephone screening process, the number and percent who:

	 	(a)	 	Met the screening criteria
	 
	 	(b)	 	Did not meet the screening criteria, by reason
	 
	 	(c)	 	Did not meet the screening criteria and submitted a written request to
proceed with CHOICES intake
	 
	 	(d)	 	Did not meet the screening criteria, submitted a written request to proceed
with CHOICES intake, and were enrolled in CHOICES (or put on the waiting list if not
enrolled in Group 2 as a CEA)

	 	(4)	 	Of the members identified, the number and percent who were enrolled in
CHOICES or put on the waiting list, overall and by CHOICES Group
	 
	 	(5)	 	Of members for whom the CONTRACTOR conducted CHOICES intake and
due for initiation of services, the number and percent for whom the CONTRACTOR met/did not
meet the specified timeframe for initiating nursing facility or ongoing HCBS, as applicable
(see Section 2.9.6.3.17)
	 
	 	Starting the thirteenth month after CHOICES implementation, the performance shall include but not
be limited to the following:
	 
	 	(1)	 	Number of members identified as potentially eligible for CHOICES in each
month, the number and percent identified through:

	 	(a)	 	Referrals by referral source, including each designee agency
	 
	 	(b)	 	Notice of hospital admission
	 
	 	(c)	 	Data review (not referral or hospital admission)

	 	(2)	 	Of members identified as potentially eligible for CHOICES in each month,
the number and percent for whom the CONTRACTOR conducted a telephone screening in the
reporting quarter, overall and by:

	 	(a)	 	Members referred
	 
	 	(b)	 	Members identified by data review (not referral or hospital admission)

	 	(3)	 	Of members identified through referral due for a CHOICES intake visit, the
number and percent for whom the CONTRACTOR met/did not meet the specified timeframe for
conducting a CHOICES intake visit (see Section 2.9.6.3.10)
	 
	 	(4)	 	Of members identified by data review (not referral or hospital admission) due
for a CHOICES intake visit, the number and percent for whom the CONTRACTOR met/did not meet
the specified timeframe for conducting a CHOICES intake visit (see Section 2.9.6.3.11)

Page 274 of 374

 

	 	(5)	 	Of members for whom the CONTRACTOR conducted a telephone screening
process, the number and percent, overall and by type of identification (referral, hospital
admission, or data analysis), who:

	 	(a)	 	Met the screening criteria
	 
	 	(b)	 	Did not meet the screening criteria, by reason
	 
	 	(c)	 	Did not meet the screening criteria and submitted a written request to
proceed with CHOICES intake
	 
	 	(d)	 	Did not meet the screening criteria, submitted a written request to proceed
with CHOICES intake, and were enrolled in CHOICES (or put on a waiting list)

	 	(6)	 	Of the members who submitted a written request to proceed with CHOICES
intake and due for a CHOICES intake visit, the number and percent for whom the CONTRACTOR
met/did not meet the specified timeframe for conducting a CHOICES intake visit (see Section
2.9.6.3.7)
	 
	 	(7)	 	Of members identified by referral, the number and percent who were
enrolled in CHOICES or put on a waiting list, overall and by CHOICES Group and by referral
source
	 
	 	(8)	 	Of members identified through notice of hospital admission, the number and
percent who were enrolled in CHOICES or put on a waiting list, overall and by CHOICES Group
	 
	 	(9)	 	Of members identified by data review (not referral or hospital admission),
the number and percent who were enrolled in CHOICES or put on a waiting list, overall and by
CHOICES Group
	 
	 	(10)	 	Of members in Group 1 for whom the CONTRACTOR conducted CHOICES intake and were due for
initiation of services, the number and percent for whom, the CONTRACTOR met/did not meet the
specified timeframe for initiating nursing facility services (see Section 2.9.6.3.17)
	 
	 	(11)	 	Of CHOICES members in Group 2 or 3 for whom the CONTRACTOR conducted CHOICES intake and were
due for initiation of services, the number and percent for whom, overall and by service, the
CONTRACTOR met/did not meet the specified timeframe for initiating ongoing HCBS identified in
the member’s plan of care (see Section 2.9.6.3.17)
	 
	 	(12)	 	Of CHOICES members in Group 2 or 3 for whom the CONTRACTOR conducted CHOICES intake and were
due for initiation of services, the number and percent for whom, overall and by service, the
CONTRACTOR met/did not meet the specified timeframe for initiating one-time HCBS (as defined
in Section 1) identified in the member’s plan of care (see Section 2.9.6.3.17)

	 	 	 	If the CONTRACTOR’s performance for any one of the timeframe measures is less than one hundred
percent (100%), the CONTRACTOR shall provide an exceptions report for that measure. The report
shall identify the number and percent of members for whom the CONTRACTOR did not meet the specified
timeframe and provide detail information regarding each instance in which the CONTRACTOR did not
meet

Page 275 of 374

 

	 	 	 	the applicable timeframe. The detail information shall include but not be limited to for
each member: the date the applicable activity should have occurred, the actual date that
the applicable activity occurred (if it occurred within the reporting period), the date
that the applicable activity will occur (if it did not occur within the reporting
period), and why the CONTRACTOR exceeded the timeframe.

	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a
follow-up exceptions report that provides updated information on the exceptions reported
in the previous report that identifies any members for whom the CONTRACTOR did not
remediate on the date specified in the previous exceptions report; (2) for each month in
the previous twelve (12) months, for each timeframe measure, the CONTRACTOR’s
performance; (3) over the previous months on a rolling twelve (12) month basis, for each
timeframe measure, the minimum, maximum, median, and average amount of time that it took
the CONTRACTOR to complete the applicable activity, which shall include instances where
the activity was completed after the specified timeframe, as compared to the timeframe
specified in this Agreement for that measure; and (4) for any non-timeframe measures,
the information by and across previous months on a rolling twelve (12) month basis. The
report shall include a graphical representation of current and cumulative information.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the
CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance improvement plan that
includes an analysis of the reasons for noncompliance, actions taken/to be taken by the
CONTRACTOR to ensure compliance, the timeframes for these actions, who is responsible
for the actions, and any related quality improvement activities, including timeframes.
	 
	 	2.30.6.5	 	The CONTRACTOR shall submit a quarterly Ongoing Assessment and Care Planning and Service
Initiation Report that provides information regarding ongoing assessment and care planning and
service initiation timeframes. The report shall include information on the CONTRACTOR’s
performance, by month, on various measures; an exceptions report (as applicable); a cumulative
report; and a performance improvement plan (as applicable).
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

	 	(1)	 	Of CHOICES members due for an annual level of care assessment, the
number and percent for whom the CONTRACTOR conducted/did not conduct an annual
level of care assessment, overall and by CHOICES Group
	 
	 	(2)	 	Of CHOICES members in Group 2 due for an annual needs assessment, the
number and percent for whom the CONTRACTOR conducted/did not conduct an annual
needs reassessment and an annual plan of care update
	 
	 	Starting the thirteenth month following CHOICES implementation, the performance shall
include but not be limited to the following:
	 
	 	(1)	 	Of CHOICES Group 2 and 3 members due for inclusion of the additional
elements in their plan of care, the number and percent for whom the

Page 276 of 374

 

	 	 	 	CONTRACTOR met/did not meet the specified timeframe for including additional elements in the
member’s plan of care (see Section 2.9.6.6.2.5)

	 	(2)	 	Of CHOICES members due for an annual level of care assessment, the number and percent for
whom the CONTRACTOR conducted/did not conduct an annual level of care assessment, overall and
by CHOICES Group
	 
	 	(3)	 	Of CHOICES Group 1 members, the number and percent with a supplemental plan of care
	 
	 	(4)	 	Of CHOICES members in Group 2 and 3 due for an annual needs assessment, the number and
percent for whom the CONTRACTOR conducted/did not conduct an annual needs reassessment and an
annual plan of care update, overall and by CHOICES Group
	 
	 	(5)	 	Of CHOICES members in Groups 2 and 3 whose plan of care was updated and due and were due for
initiation of services, the number and percent for whom, overall and by service, the
CONTRACTOR met the specified timeframe for initiating ongoing HCBS in the updated of plan of
care (see Section 2.9.6.6.2.8)
	 
	 	(6)	 	Of CHOICES members in Groups 2 and 3 whose plan of care was updated and due and were due for
initiation of services, the number and percent for whom, overall and by service, the
CONTRACTOR met the specified timeframe for initiating one-time HCBS (as defined in Section 1)
in the updated of plan of care (see Section 2.9.6.6.2.8)

	 	 	 	If the CONTRACTOR’s performance for the reporting period for any one of the timeframe measures is
less than one hundred percent (100%), the CONTRACTOR shall provide an exceptions report for that
measure. The report shall identify the number and percent of members for whom the CONTRACTOR did
not meet the specified timeframe and provide detail information regarding each instance in which
the CONTRACTOR did not meet the applicable timeframe. The detail information shall include but not
be limited to for each member: the date the applicable activity should have occurred, the actual
date that the applicable activity occurred (if it occurred within the reporting period), the date
that the applicable activity will occur (if it did not occur within the reporting period), and why
the CONTRACTOR exceeded the timeframe.
	 
	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a follow-up
exceptions report that provides updated information on the exceptions reported in the previous
report that identifies any members for whom the CONTRACTOR did not remediate on the date specified
in the previous exceptions report; (2) for each month in the previous twelve (12) months, for each
timeframe measure, the CONTRACTOR’s performance; (3) over the previous months on a rolling twelve
(12) month basis, for each timeframe measure, the minimum, maximum, median, and average amount of
time that it took the CONTRACTOR to complete the applicable activity, which shall include instances
where the activity was completed after the specified timeframe, as compared to the timeframe
specified in this Agreement for that measure; and (4) for any non-timeframe measures, the

Page 277 of 374

 

	 	 	 	information by and across previous months on a rolling twelve (12) month basis. The
report shall include a graphical representation of current and cumulative information.

	 	 	 	The CONTRACTOR shall submit its first report following the second calendar quarter after
CHOICES implementation, and that report shall include information for the period from
CHOICES implementation through the second calendar quarter after CHOICES implementation.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the
CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance improvement plan that
includes an analysis of the reasons for noncompliance, actions taken/to be taken by the
CONTRACTOR to ensure compliance, the timeframes for these actions, who is responsible
for the actions, and any related quality improvement activities, including timeframes.
	 
	 	2.30.6.6	 	The CONTRACTOR shall submit a quarterly Post-Enrollment Care Coordinator Contact Report
that provides information on care coordinator contacts with CHOICES members occurring after
the member’s enrollment in CHOICES. The report shall include information on the CONTRACTOR’s
performance, by month, on various measures; an exceptions report (as applicable); a cumulative
report; and a performance improvement plan (as applicable).
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

	 	(1)	 	Of members in Group 1 due for a face-to-face visit in the month, the
number and percent for whom the care coordinator did/did not conduct a
face-to-face visit
	 
	 	(2)	 	Of members in Group 2 due for a face-to-face contact in the month,
the number and percent for whom the care coordinator did/did not conduct a
face-to-face visit
	 
	 	Starting the thirteenth month following CHOICES implementation, in addition to the
performance measures for the first twelve (12) months, the performance measures shall
include but not be limited to the following:
	 
	 	(1)	 	Of new members in Group 2 and 3 due for contact after initiation of
HCBS, the number and percent for whom, the CONTRACTOR met/did not meet the
specified timeframe for contacting the member after initiation of HCBS (see
Section 2.9.6.9.4.3.4)
	 
	 	(2)	 	Of members in Group 2 and 3 admitted to a nursing facility where the
admission was not authorized by the CONTRACTOR and due for a face-to- face visit,
the number and percent for whom the CONTRACTOR met/did not meet the specified
timeframe for contacting the member after notice of admission (see Section
2.9.6.9.4.3.2)
	 
	 	(3)	 	Of members in Group 2, the number and percent the care coordinator
did/did not contact, overall and by type of contact (phone or face-to-face)

Page 278 of 374

 

	 	(4)	 	Of members in Group 3 due for a contact in the month, the number and
percent the care coordinator did/did not contact, overall and by type of contact
	 
	 	(5)	 	Of members in Group 3 due for a face-to-face contact in the month,
the number and percent the care coordinator did/did not conduct a face-to-face
visit
	 
	 	(6)	 	For members in Groups 2 and 3 due for a contact after initiation of
HCBS in an updated plan of care, the number and percent for whom, the CONTRACTOR
met/did not meet the specified timeframe for contacting the member after
initiating HCBS in the updated plan of care (see Section 2.9.6.4.3.5)

	 	 	 	If the CONTRACTOR’s performance for any one of these measures is less than one hundred
percent (100%), the CONTRACTOR shall provide an exceptions report for that measure. The
report shall identify the number and percent of members for whom the CONTRACTOR did not
meet the specified timeframe and provide detail information regarding each instance in
which the CONTRACTOR did not meet the applicable timeframe. The detail information shall
include but not be limited to for each member: the date the applicable activity should
have occurred, the actual date that the applicable activity occurred (if it occurred
within the reporting period), the date that the applicable activity will occur (if it
did not occur within the reporting period), and why the CONTRACTOR exceeded the
timeframe.
	 
	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a
follow-up exceptions report that provides updated information on the exceptions reported
in the previous report that identifies any members for whom the CONTRACTOR did not
remediate on the date specified in the previous exceptions report; (2) for each month in
the previous twelve (12) months, for each timeframe measure, the CONTRACTOR’s
performance; (3) over the previous months on a rolling twelve (12) month basis, for each
timeframe measure, the minimum, maximum, median, and average amount of time that it took
the CONTRACTOR to complete the applicable activity, which shall include instances where
the activity was completed after the specified timeframe, as compared to the timeframe
specified in this Agreement for that measure; and (4) for any non-timeframe measures,
the information by and across previous months on a rolling twelve (12) month basis. The
report shall include a graphical representation of current and cumulative information.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the
CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance improvement plan that
includes an analysis of the reasons for noncompliance, actions taken/to be taken by the
CONTRACTOR to ensure compliance, the timeframes for these actions, who is responsible
for the actions, and any related quality improvement activities, including timeframes.
	 
	 	2.30.6.7	 	The CONTRACTOR shall submit a semi-annual Nursing Facility Diversion Report regarding
CHOICES members who have been diverted from a nursing facility to the community. The report
shall describe the CONTRACTOR’s nursing facility diversion activities by each of the groups
identified in Section 2.9.6.7, the CONTRACTOR’s success in identifying and diverting members
and maintaining

Page 279 of 374

 

	 	 	 	members in the community and lessons learned, including factors affecting the
CONTRACTOR’s ability to divert members, identified issues, strategies to address
identified issues, and opportunities for systemic improvements in the CONTRACTOR’s
nursing facility diversion process.

	 	2.30.6.8	 	The CONTRACTOR shall submit a quarterly Nursing Facility to Community Transition Report
regarding CHOICES members who have been identified as potentially eligible for transition from
a nursing facility setting to the community. The report shall include information, by month,
on various performance measures; as applicable, an exceptions report, a follow-up exceptions
report, and a performance improvement plan; and a cumulative report.
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

	 	(1)	 	Number of CHOICES members in Group 1 identified as potential candidates
for transition
	 
	 	(2)	 	Number of Group 1 members identified as candidates for transition
	 
	 	(3)	 	Number of transition assessments conducted
	 
	 	(4)	 	Number of members identified as candidates for transition who were
transitioned/not transitioned to the community within ninety (90) days
	 
	 	(5)	 	Of members who transitioned to the community, the number and percent of
members who transitioned to:

	 	(a)	 	A community-based residential alternative facility (by
type)
	 
	 	(b)	 	A residential setting where the member will be living independently
	 
	 	(c)	 	A residential setting other than (a) or (b) (i.e.,
where the member will be living with a relative or other caregiver)

	 	(6)	 	Of CHOICES members who transitioned to live independently in the community or whose on-site visit during transition planning indicated an
elevated risk and were due for the applicable contact, the number and percent
for whom:

	 	(a)	 	The CONTRACTOR met/did not meet the timeframe for
contact within twenty-four (24) hours after transition
	 
	 	(b)	 	The CONTRACTOR met/did not meet the timeframe for
contact within the first month of transition
	 
	 	(c)	 	The CONTRACTOR met/did not meet the timeframe for
contact in the second month of transition
	 
	 	(d)	 	The CONTRACTOR met/did not meet the timeframe for
contact in the third month of transition

	 	(7)	 	Of CHOICES members who transitioned to a community-based residential
alternative setting or to live with a relative or other caregiver and were due
for the applicable contact, the number and percent for whom:

	 	(a)	 	The CONTRACTOR met/did not meet the timeframe for
contact within twenty-four (24) hours after transition

Page 280 of 374

 

	 	(b)	 	The CONTRACTOR met/did not meet the timeframe for contact within the first
seven days of transition
	 
	 	(c)	 	The CONTRACTOR met/did not meet the timeframe for contact within the first
month of transition
	 
	 	(d)	 	The CONTRACTOR met/did not meet the timeframe for contact in the second month
of transition
	 
	 	(e)	 	The CONTRACTOR met/did not meet the timeframe for contact in the third month
of transition

	 	(8)	 	Number of members transitioned to the community who were re-admitted to a nursing facility in
ninety (90) days or less
	 
	 	(9)	 	Number of members transitioned to the community who were re-admitted to a nursing facility in
greater than ninety (90) days

	 	 	 	Starting the thirteenth month following CHOICES implementation, in addition to performance measures
(5) through (7) identified above for the first twelve months, the performance measures shall
include but not be limited to the following:

	 	(1)	 	Number of CHOICES members in Group 1 identified as potential candidates
for transition in the month, overall and the:

	 	(a)	 	Number and percent of potential candidates who were referred to the
CONTRACTOR
	 
	 	(b)	 	Number and percent of potential candidates who were identified from the MDS
	 
	 	(c)	 	Number and percent of potential candidates whom the CONTRACTOR identified
through the care coordination process
	 
	 	(d)	 	Number and percent of potential candidates whom the CONTRACTOR identified
other than through referral, MDS, or the care coordination process (and an explanation
of how these members were identified)

	 	(2)	 	Of members identified by the CONTRACTOR as potential candidates for
transition, overall and by source of identification:

	 	(a)	 	Of those who had an initial visit, the number and percent who indicated that
they wanted/did not want to pursue transition
	 
	 	(b)	 	Of those for whom the CONTRACTOR conducted a transition assessment, the
number and percent whom the CONTRACTOR determined were/were not candidates for
transition, overall and by reason
	 
	 	(c)	 	Number and percent who (i) were transitioned to the community or (ii) are
still in the transitioning process

	 	(3)	 	Of CHOICES members transitioned from a nursing facility who were
subsequently re-admitted to a nursing facility, the number and percent, overall and by
Group, who remained in the community before nursing facility admission for:

	 	(a)	 	<30 days
	 
	 	(b)	 	30-89 days
	 
	 	(c)	 	90-179 days
	 
	 	(d)	 	180 or more days

	 	(4)	 	The fourth quarter report shall include:

Page 281 of 374

 

	 	(a)	 	Of members transitioned from a nursing facility, the number and percent who
received a transition allowance
	 
	 	(b)	 	The minimum, maximum, median, and average transition allowance amount per
member
	 
	 	(c)	 	The minimum, maximum, median, and average transition allowance amount per
transition item
	 
	 	(d)	 	The frequency with which a transition allowance is authorized per item

	 	 	 	If the CONTRACTOR’s performance for any one of the timeframe measures is less than one hundred
percent (100%), the CONTRACTOR shall provide an exceptions report for that measure. The report
shall identify the number and percent of members for whom the CONTRACTOR did not meet the specified
timeframe and provide detail information regarding each instance in which the CONTRACTOR did not
meet the applicable timeframe. The detail information shall include but not be limited to for each
member: the date the applicable activity should have occurred, the actual date that the applicable
activity occurred (if it occurred within the reporting period), the date that the applicable
activity will occur (if it did not occur within the reporting period), and why the CONTRACTOR
exceeded the timeframe.
	 
	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a follow-up
exceptions report that provides updated information on the exceptions reported in the previous
report that identifies any members for whom the CONTRACTOR did not remediate on the date specified
in the previous exceptions report; (2) for each month in the previous twelve (12) months, for each
timeframe measure, the CONTRACTOR’s performance; (3) over the previous months on a rolling twelve
(12) month basis, for each timeframe measure, the minimum, maximum, median, and average amount of
time that it took the CONTRACTOR to complete the applicable activity, which shall include instances
where the activity was completed after the specified timeframe, as compared to the timeframe
specified in this Agreement for that measure; and (4) for any non-timeframe measures, the
information by and across previous months on a rolling twelve (12) month basis. The report shall
include a graphical representation of current and cumulative information.
	 
	 	 	 	The CONTRACTOR shall submit its first report following the second calendar quarter after CHOICES
implementation, and that report shall include information for the period from CHOICES
implementation through the second calendar quarter after CHOICES implementation.
	 
	 	 	 	Each year, with the fourth quarter report, the CONTRACTOR shall submit a narrative that describes
the CONTRACTOR’s nursing facility transition activities and the CONTRACTOR’s success in identifying
and transitioning members and maintaining members in the community and lessons learned, including
factors affecting the CONTRACTOR’s ability to transition members, identified issues, strategies to
address identified issues, and opportunities for systemic improvements in the CONTRACTOR’s nursing
facility transition process.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the CONTRACTOR or
TENNCARE, the CONTRACTOR shall submit a performance improvement plan that includes an analysis of
the reasons for noncompliance, actions taken/to be taken by the CONTRACTOR to ensure compliance,

Page 282 of 374

 

	 	 	 	the timeframes for these actions, who is responsible for the actions, and any related
quality improvement activities, including timeframes.

	 	2.30.6.9	 	The CONTRACTOR shall submit a monthly HCBS Missed Visits Report for CHOICES members
regarding the following HCBS services: personal care, attendant care, homemaker services, and
home-delivered meals. The report shall include current and cumulative information on various
performance measures, a summary report, and, as applicable, a performance improvement plan.
	 
	 	 	 	The performance measures shall include but not be limited to the following:

	 	(1)	 	The number and percent of members in Groups 2 and 3, by Group, who had:

	 	(a)	 	A late visit (for any reason)
	 
	 	(b)	 	A missed visit by type of reason (member initiated,
provider initiated, or severe inclement weather)

	 	(2)	 	The number and percent of visits, overall, by service, and by type of provider
(agency or worker), that were:

	 	(a)	 	Late, by type of reason
	 
	 	(b)	 	Missed, by type of reason

	 	(3)	 	The minimum, maximum, median, and average number and percent of visits
by member that were late for a provider initiated reason, overall and by:

	 	(a)	 	Service type
	 
	 	(b)	 	Type of provider (agency or worker)

	 	(4)	 	The minimum, maximum, median, and average number and percent of visits
by member that were missed for a provider initiated reason, overall and by:

	 	(a)	 	Service type
	 
	 	(b)	 	Type of provider (agency or worker)

	 	(5)	 	Of members in Groups 2 and 3 (by Group), the number and percent who had:

	 	(a)	 	One missed visit that was provider initiated
	 
	 	(b)	 	Two missed visits that were provider initiated
	 
	 	(c)	 	Etc.

	 	(6)	 	Of all agency HCBS providers, the number and percent with:

	 	(a)	 	5% of visits missed (provider initiated)
	 
	 	(b)	 	10% of visits missed (provider initiated)
	 
	 	(c)	 	Etc.

	 	(7)	 	Of consumer-directed workers, the number and percent with:

	 	(a)	 	5% of visits missed (provider initiated)
	 
	 	(b)	 	10% of visits missed (provider initiated)
	 
	 	(c)	 	Etc.

	 	(8)	 	Number and percent of missed visits that were remediated before the next
scheduled visit, overall and by service

Page 283 of 374

 

	 	 	 	The CONTRACTOR shall provide information on each of these measures by and across
previous months on a twelve (12) month rolling basis and shall include a graphical
representation of current and cumulative information.
	 
	 	 	 	The summary report shall analyze the reasons for late and missed visits and identify
strategies to reduce late and minimize missed visits that are not member initiated going
forward, including provider interventions.
	 
	 	 	 	If the CONTRACTOR’s number of late and/or missed visits indicates a systemic failure, as
determined by the CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance
improvement plan that includes an analysis of the reasons for missed visits, actions
taken/to be taken by the CONTRACTOR to ensure compliance, the timeframes for these
actions, who is responsible for the actions, and any related quality improvement
activities, including timeframes.
	 
	 	2.30.6.10	 	The CONTRACTOR shall submit a semi-annual Care Coordinator Staffing Report. The report
shall include current information, by month, as well as cumulative information on key
performance measures and, as applicable, a performance improvement plan.
	 
	 	 	 	The performance measures shall include but not be limited to the following:

	 	(1)	 	Care coordinator turnover rate (number of care coordinators
separating during the time period divided by the number of care coordinators)
	 
	 	(2)	 	Minimum, maximum, median, and average months of employment (or
contract service) for care coordinators
	 
	 	(3)	 	The care coordinator to CHOICES member ratio overall, for Group 1,
and for members receiving HCBS (Groups 2 and 3)

	 	2.30.6.11	 	The CONTRACTOR shall submit an annual Care Coordination Quality Assurance Plan that
describes the monitoring activities that will be conducted by the CONTRACTOR specific to care coordination (including those specified in Section 2.9.6.12) and shall submit a quarterly Care
Coordination Quality Assurance Plan Report that summarizes the CONTRACTOR’s monitoring
activities and identifies findings, remediation activities, opportunities for systemic
improvement, proposed QI activities, and the timeframe for remediation and QI activities. The
CONTRACTOR shall submit its first quarterly report at the end of the second calendar quarter
after CHOICES implementation, and that report shall include information for the period from
CHOICES implementation through the second calendar quarter.
	 
	 	2.30.6.12	 	The CONTRACTOR shall submit a quarterly Consumer Direction of HCBS Report. The report
shall include current information, by month, as well as cumulative information on various
measures.
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

Page 284 of 374

 

	 	(1)	 	Number and percent of CHOICES members using consumer direction of
HCBS overall and by eligible service
	 
	 	(2)	 	Number and percent of CHOICES members using consumer direction who
have a representative to direct services on their behalf
	 
	 	(3)	 	Number and percent of CHOICES members who withdrew from consumer
direction for all HCBS, overall and by reason
	 
	 	(4)	 	Minimum, maximum, median, and average timeframe from the date of
member’s written confirmation of his/her decision to participate in consumer
direction of HCBS and the date consumer-directed HCBS were initiated
	 
	 	Starting the thirteenth month after CHOICES implementation, the performance measures
shall include but not be limited to the performance measures from the first twelve (12)
month as well as the following performance measure:
	 
	 	(1)	 	Minimum, maximum, median, and average timeframe from the date of
member’s written confirmation of his/her decision to participate in consumer
direction of HCBS and the date of the CONTRACTOR’s referral to the FEA

	 	 	 	The CONTRACTOR shall provide information on each of these measures by and across
previous months on a rolling twelve (12) month basis. The report shall include a
graphical representation of current and cumulative information.
	 
	 	 	 	The CONTRACTOR shall submit its first report following the second calendar quarter after
CHOICES implementation, and that report shall include information for the period from
CHOICES implementation through the second calendar quarter.
	 
	 	2.30.6.13	 	As necessary, the CONTRACTOR shall submit a listing of members identified as potential
pharmacy lock-in candidates (see Section 2.9.10.3.2).
	 
	 	2.30.6.14	 	The CONTRACTOR shall submit a quarterly Pharmacy Services Report that includes a list of
the providers and information on the interventions the CONTRACTOR has taken with the providers
who appear to be operating outside industry or peer norms as defined by TENNCARE, have been
identified as noncompliant as it relates to adherence to the PDL and/or generic prescribing
patterns and/or are failing to follow required prior authorization processes and procedures
the steps the CONTRACTOR has taken to personally contact each one as well as the outcome of
these personal contacts.
	 
	 	2.30.6.15	 	The CONTRACTOR shall submit a Pharmacy Services Report, On Request when TENNCARE requires
assistance in identifying and working with providers for any reason. These reports shall
provide information on the activities the CONTRACTOR undertook to comply with TENNCARE’s
request for assistance, outcomes (if applicable) and shall be submitted in the format and
within the time frame prescribed by TENNCARE.

Page 285 of 374

 

2.30.7 Provider Network Reports

	 	2.30.7.1	 	The CONTRACTOR shall submit a monthly Provider Enrollment File that includes
information on all providers of TennCare health services, including physical,
behavioral health, and long-term care providers (see Section 2.11). This includes
but is not limited to, PCPs, physician specialists, hospitals, home health
agencies, CMHAs, nursing facilities, HCBS providers, and emergency and
non-emergency transportation providers. For HCBS providers, the Provider
Enrollment File shall identify the type(s) of HCBS the provider is contracted to
provide and the specific counties in which the provider is contracted to deliver
HCBS, by service type. The report shall include contract providers as well as all
non-contract providers with whom the CONTRACTOR has a relationship. The report
shall be sorted by provider type. The CONTRACTOR shall submit this report during
readiness review, by the 5th of each month, and upon TENNCARE request.
Each monthly Provider Enrollment File shall include information on all providers
of covered services and shall provide a complete replacement for any previous
Provider Enrollment File submission. Any changes in a provider’s contract status
from the previous submission shall be indicated in the file generated in the month
the change became effective and shall be submitted in the next monthly file.
	 
	 	2.30.7.2	 	The CONTRACTOR shall submit an annual Provider Compliance with Access Requirements
Report that summarizes the CONTRACTOR’s monitoring activities, findings, and
opportunities for improvement regarding provider compliance with applicable access
standards. (See Section 2.11.1.10.)
	 
	 	2.30.7.3	 	The CONTRACTOR shall submit a quarterly PCP Assignment Report that provides the
following information for non-dual members: Provider Name, Provider Medicaid I.D.
Number, NPI Number, Number of Enrollees assigned by Enrollee Age Category. The enrollee
age categories shall be consistent with the following: Age Under 1, Age 1-13, Age 14-20, Age 21-44, Age 45-4, Age 65 +. This report shall be submitted using the
format provided in Attachment IX, Exhibit F. (See Section 2.11.2.)
	 
	 	2.30.7.4	 	The CONTRACTOR shall submit an annual Report of Essential Hospital Services by
September 1 of each year. The CONTRACTOR shall use the format in Attachment IX, Exhibit
G.
	 
	 	2.30.7.5	 	The CONTRACTOR shall submit a quarterly Behavioral Health Initial Appointment
Timeliness Report that shall include the average time between the intake
assessment appointment and the member’s next scheduled appointment or admission.
The report shall provide this information by type of service and shall include an
analysis of the findings and any actions or follow-up planned as a result of the
findings.
	 
	 	2.30.7.6	 	The CONTRACTOR shall submit an annual Long-Term Care Provider Network
Development Plan that includes all of the elements specified in Section 2.11.6.6 of
this Agreement.
	 
	 	2.30.7.7	 	The CONTRACTOR shall submit a quarterly Long-Term Care Provider Capacity
Performance Report that provides information on the CONTRACTOR’s performance with
respect to the performance standards and benchmarks established by TENNCARE pursuant to
Section 2.11.6.5.

Page 286 of 374

 

	 	2.30.7.8	 	The CONTRACTOR shall submit an annual Qualified Workforce Strategies
Report that includes, at a minimum, a brief description of each of the CONTRACTOR’s
strategies and associated activities, including partnerships in implementing each
strategy/activity; timeframes for implementing each strategy/activity; and the status
of each strategy/activity (see Section 2.11.6.7).
	 
	 	2.30.7.9	 	The CONTRACTOR shall submit an annual FQHC Report by January 1 of each year. The
CONTRACTOR shall use the form provided in Attachment IX, Exhibit H.
	 
	 	2.30.7.10	 	The CONTRACTOR shall submit a monthly Institutions for Mental Diseases (IMD)
Out-of-State Report on the use of IMDs utilized outside of the State of Tennessee. The
report shall be submitted by the 5th of each month for the previous month.

2.30.8 Provider Agreement Report

	 	 	 	The CONTRACTOR shall submit a monthly Single Case Agreements Report using the format
provided in Attachment IX, Exhibit I. (See Section 2.12.4.)

2.30.9 Provider Payment Reports

	 	2.30.9.1	 	The CONTRACTOR shall submit a quarterly Related Provider Payment Report that
lists all related providers and subcontractors to whom the CONTRACTOR has made
payments during the previous quarter and the payment amounts. (See Section
2.13.18.)
	 
	 	2.30.9.2	 	The CONTRACTOR shall submit Check Run Summaries on at least a monthly basis. The
summaries should be submitted for the relevant adjudication cycle(s) during the
reporting period.
	 
	 	2.30.9.3	 	The CONTRACTOR shall submit a Claims Data Extract that shall be due at least on
a monthly basis along with the Check Run Summaries and shall be submitted for
the relevant adjudication cycle(s) during the reporting period.
	 
	 	2.30.9.4	 	 The CONTRACTOR shall provide a Reconciliation Report for the total paid amounts
between the funds released for payment to providers and the FEA (for consumer-
directed workers), the supporting claims data extract, and the encounter data
submissions for the relevant adjudication cycle. The reconciliation should be
submitted within fourteen (14) days of the claims data extract

2.30.10 Utilization Management Reports

	 	2.30.10.1	 	The CONTRACTOR shall annually submit, by July 30th of each year, a UM
program description and an associated work plan and evaluation. These documents must be
prior approved by the CONTRACTOR’s oversight committee prior to submission to TENNCARE.
The annual evaluation shall include an analysis of findings and actions taken.
	 
	 	2.30.10.2	 	The CONTRACTOR shall submit quarterly Cost and Utilization Reports. These reports
shall be in an Excel spreadsheet format and submitted with a ninety (90) day lag and
shall be due to TENNCARE one hundred five (105) calendar days following

Page 287 of 374

 

	 	 	 	the quarter for which the CONTRACTOR is reporting. These reports shall be
submitted on both a cumulative year basis and on a rolling twelve (12) month
basis.

	 	2.30.10.3	 	The CONTRACTOR shall provide quarterly Cost and Utilization Summaries. These
summaries shall report on services paid during the previous quarter. The summaries
shall include all data elements listed in Attachment IX, Exhibit K.
	 
	 	2.30.10.4	 	The CONTRACTOR shall identify and report the number of members who incurred
non-nursing facility claims in excess of twenty-five thousand dollars ($25,000) on a
rolling quarterly basis (high-cost claimants). The CONTRACTOR shall report the member’s
age, sex, primary diagnosis, and amount paid by claim type for each member. The name,
and other identifying information of the member shall be blinded in order to maintain
confidentiality.
	 
	 	2.30.10.5	 	The CONTRACTOR shall submit a monthly CHOICES Utilization Report that identifies
each CHOICES member who has not received any long-term care services within thirty
(30), sixty (60), or ninety (90) days; identifies the reason why the member has not
received long-term care services; and states whether/when long-term care services will
resume.
	 
	 	2.30.10.6	 	The CONTRACTOR shall submit quarterly Prior Authorization Reports that include
information, by service and separately for adults and children, on the number of
requests received, number processed, number approved, number denied, and denial reason.
	 
	 	2.30.10.7	 	The CONTRACTOR shall submit a copy of the Referral Provider Listing (see Section
2.14.3.5), a data file of the provider information used to create the listing, and
documentation from the CONTRACTOR’s mail room or outside vendor indicating the quantity
of the referral provider listings mailed to providers, the date mailed, and to whom.
The CONTRACTOR shall submit this information at the same time it is sent to the
providers as required in Section 2.14.3.5.
	 
	 	2.30.10.8	 	The CONTRACTOR shall submit a semi-annual Emergency Department Threshold Report to
TENNCARE no later than February 28th and August 31st each year
identifying interventions initiated for members who exceeded the defined threshold for
ED usage.

2.30.11 Quality Management/Quality Improvement Reports

	 	2.30.11.1	 	The CONTRACTOR shall annually submit, by July 30, an approved (by the CONTRACTOR’s
QM/QI Committee) QM/QI Program Description, Associated Work Plan, and Annual
Evaluation.
	 
	 	2.30.11.2	 	The CONTRACTOR shall submit an annual Report on Performance Improvement Projects
that includes the information specified in Section 2.15.3. The report shall be
submitted annually on July 30.
	 
	 	2.30.11.3	 	The CONTRACTOR shall submit its NCQA Accreditation Report (the final bound copy
from NCQA) immediately upon receipt, but not to exceed ten (10) calendar days from
notification by NCQA.

Page 288 of 374

 

	 	2.30.11.4	 	The CONTRACTOR shall submit its annual reevaluation of accreditation status based on
HEDIS scores immediately upon receipt, but not to exceed ten (10) calendar days from
notification by NCQA.
	 
	 	2.30.11.5	 	The CONTRACTOR shall submit an annual Report of Audited CAHPS Results and Audited HEDIS
Results by June 15 of each year (see Sections 2.15.6 and 2.15.7). This shall include the
results for the CAHPS survey for CHOICES members, which shall include the Medicare CAHPS
questions specified by TENNCARE (see Section 2.15.6).
	 
	 	2.30.11.6	 	The CONTRACTOR shall submit survey data files for the Health Outcomes Survey (HOS) (see
Section 2.15.7).
	 
	 	2.30.11.7	 	The CONTRACTOR shall submit a quarterly Critical Incidents Report (see Section 2.15.8)
that provides current information, by month, as well as cumulative information regarding
specified measures and a summary report.
	 
	 	 	 	The performance measures shall include but not be limited to the following:

	 	(1)	 	The number of critical incidents, overall and by:

	 	(a)	 	Type
	 
	 	(b)	 	CHOICES Group
	 
	 	(c)	 	Setting
	 
	 	(d)	 	Type of provider (agency or worker)
	 
	 	(e)	 	Provider

	 	(2)	 	Of all critical incidents, the percent that were reported to the CONTRACTOR
within the specified timeframes
	 
	 	(3)	 	The number of investigations conducted by a provider agency, overall and by
type of incident
	 
	 	(4)	 	The number of investigation reports reviewed by the CONTRACTOR, overall
and by type of incident
	 
	 	(5)	 	The number of incidents reported to APS/CPS
	 
	 	(6)	 	The number of investigations conducted by APS/CPS (to the extent this
information is available)
	 
	 	(7)	 	The number of investigations conducted by the FEA
	 
	 	(8)	 	The number of investigations conducted by an entity other than the provider,
FEA, or APS/CPS, and the name of that entity

	 	 	 	The CONTRACTOR shall provide information on each of these measures by and across
previous quarters on a rolling twelve (12) month basis. The report shall include a
graphical representation of current and cumulative information.

Page 289 of 374

 

	 	 	 	The summary report shall include identification of any trends and any action
steps to reduce the number of critical incidents and improve the critical
incident reporting and management process.

2.30.12 Customer Service Reports/Provider Service Reports

	 	2.30.12.1	 	Member Services/Provider Services/ED Phone Line Reports
	 
	 	2.30.12.1.1	 	The CONTRACTOR shall submit a quarterly Member Services and Provider Services
Phone Line Report. The data in the report shall be recorded by month and shall include
the detailed rate calculations. The CONTRACTOR shall submit the report in the format
specified in Attachment IX, Exhibit M.
	 
	 	2.30.12.1.2	 	The CONTRACTOR shall submit a quarterly 24/7 Nurse Triage Line Report that lists
the total calls received by the 24/7 nurse triage line, including the number of calls
from CHOICES members, including the ultimate disposition of the call (e.g. education
only, no referral for care; referred to primary care provider for care, referred to
emergency department for care, transfers to a care coordinator (for CHOICES members).
If the CONTRACTOR uses the 24/7 nurse line to fulfill the requirements set forth in
Section 2.18.4.7 of this Agreement, such calls shall be separately delineated in the
report in accordance with the requirements described in Section 2.30.12.1.3 of this
Agreement.
	 
	 	2.30.12.1.3	 	The CONTRACTOR shall submit a quarterly ED Assistance Tracking Report that
provides the total number of calls received pertaining to patients in EDs needing
assistance in accessing care in an alternative setting. Such report shall include the
date and time of the call, identifying information for the member, the name and
location of the hospital, the ultimate response to the call (e.g. appointment made with
PCP) and the elapsed time from ED visit until appointment in alternative setting. If
the CONTRACTOR uses the nurse triage line to provide appointment assistance to
non-emergency ED patients, the aforementioned information may be provided in
conjunction with the report discussed at Section 2.30.12.1.2.
	 
	 	2.30.12.2	 	The CONTRACTOR shall report separately any member services or utilization
management phone lines operated by subcontractors.
	 
	 	2.30.12.3	 	The CONTRACTOR shall submit a quarterly Translation/Interpretation Services
Report. The report shall list each request and include the name and member
identification number for each member to whom translation/interpretation service was
provided, the date of the request, the date provided, and the identification of the
translator/interpreter.
	 
	 	2.30.12.4	 	The CONTRACTOR shall submit an annual Provider Satisfaction Survey Report that
summarizes the provider survey methods and findings and provides analysis of
opportunities for improvement (see Section 2.18.7.4).
	 
	 	2.30.12.5	 	The CONTRACTOR shall submit a quarterly Provider Complaints Report that provides
information on the number and type of provider complaints received, either in writing
or by phone, by type of provider, and the disposition/resolution of those complaints.
The data shall be reported by month.

Page 290 of 374

 

2.30.13 Member Complaints

	 	 	 	The CONTRACTOR shall submit a quarterly Member Complaints Report (see Section 2.19.2) that
includes current information, by month, as well as cumulative information regarding
specified measures, an exceptions report (as needed), a cumulative report, a summary
report, and a performance improvement plan (as applicable).
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following:

	 	(1)	 	The number of complaints received in the month, overall, by type, and
by CHOICES Group (if the member is a CHOICES member)
	 
	 	(2)	 	The number and percent of complaints received in the month, overall
and by CHOICES Group (if applicable), that were/were not resolved within five (5)
business days via a call with the member (see Section 2.19.2)
	 
	 	(3)	 	Of complaints that were not resolved within five (5) business days
via a call with the member and for which resolution is due, the number and percent
of complaints for which the CONTRACTOR met/did not meet the specified timeframe
for resolution and notice of resolution (see Section 2.19.2.5)
	 
	 	(4)	 	Of complaints that were not resolved within five (5) business days
via a call with the member, the minimum, maximum, median, and average amount of
time that the CONTRACTOR took to resolve complaints and notify members of
resolution

	 	 	 	Starting the thirteenth month after CHOICES implementation, the performance measures shall
include but not be limited to the performance measures from the first twelve (12) month as
well as the following performance measure:

	 	(1)	 	Of complaints that were not resolved within five (5) business days via a call with
the
member and for which acknowledgement is due, the number and percent for which
the CONTRACTOR met/did not meet the specified timeframe for sending a notice of
acknowledgement (see Section 2.19.2.5)

	 	 	 	If the CONTRACTOR’s performance for any one of the timeframe measures is less than one
hundred percent (100%), the CONTRACTOR shall provide an exceptions report for that measure.
The report shall identify the number and percent of members for whom the CONTRACTOR did not
meet the specified timeframe and provide detail information regarding each instance in which
the CONTRACTOR did not meet the applicable timeframe. The detail information shall include
but not be limited to for each member: the date the applicable activity should have
occurred, the actual date that the applicable activity occurred (if it occurred within the
reporting period), the date that the applicable activity will occur (if it did not occur
within the reporting period), and why the CONTRACTOR exceeded the timeframe.
	 
	 	 	 	Each quarterly report shall also include a cumulative report that includes: (1) a follow-up
exceptions report that provides updated information on the exceptions reported in the
previous report that identifies any members for whom the CONTRACTOR did not remediate on the
date specified in the previous exceptions report; (2) for each month in the previous twelve
(12) months, for each timeframe measure, the CONTRACTOR’s performance; (3) over the previous
months, on a rolling twelve (12) month basis, for each timeframe measure, the minimum,

Page 291 of 374

 

	 	 	 	maximum, median, and average amount of time that it took the CONTRACTOR to complete the
applicable activity, which shall include instances where the activity was completed after
the specified timeframe, as compared to the timeframe specified in this Agreement for that
measure; and (4) for any non-timeframe measures, the information by and across previous
months on a rolling twelve (12) month basis. The report shall include a graphical
representation of current and cumulative information.

	 	 	 	The summary report shall also include identification of any trends regarding complaints
(e.g., the
type or number of complaints) and any action steps to address these trends,
including quality improvement activities.
	 
	 	 	 	The CONTRACTOR shall submit its first report following the second calendar quarter after
CHOICES implementation, and that report shall include information for the period from
CHOICES implementation through the second calendar quarter after CHOICES implementation.
	 
	 	 	 	If the CONTRACTOR’s failure to meet the timeframes is systemic, as determined by the
CONTRACTOR or TENNCARE, the CONTRACTOR shall submit a performance improvement plan that
includes an analysis of the reasons for non-compliance, actions taken/to be taken by the
CONTRACTOR to ensure compliance, the timeframes for these actions, who is responsible for
the actions, and any related quality improvement activities, including timeframes.

2.30.14 Fraud and Abuse Reports

	 	2.30.14.1	 	The CONTRACTOR shall submit an annual Fraud and Abuse Activities Report. This
report shall summarize the results of its fraud and abuse compliance plan (see Section
2.20) and other fraud and abuse prevention, detection, reporting, and investigation
measures, and should cover results for the fiscal year ending June 30. The report shall
be submitted by September 30 of each year in the format reviewed and approved by
TENNCARE (as part of the CONTRACTOR’s compliance plan).
	 
	 	2.30.14.2	 	The CONTRACTOR shall submit an annual fraud and abuse compliance plan (see Section
2.20.3 of this Agreement).
	 
	 	2.30.14.3	 	On an annual basis the CONTRACTOR shall submit its policies for employees,
contractors, and agents that comply with Section 1902(a)(68) of the Social Security
Act. These policies shall be submitted by July 1 of each year.

2.30.15 Financial Management Reports

	 	2.30.15.1	 	Third Party Liability (TPL) Resources Reports
	 
	 	2.30.15.1.1	 	The CONTRACTOR shall submit a monthly, quarterly and annual Recovery and Cost
Avoidance Report that includes any recoveries for third party resources as well funds
for which the CONTRACTOR does not pay a claim due to TPL coverage or Medicare coverage.
This CONTRACTOR shall calculate cost savings in categories described by TENNCARE.
	 
	 	2.30.15.1.2	 	The CONTRACTOR shall submit an Other Insurance Report that provides information
on any members who have other insurance, including long-term care insurance. This
report shall be submitted in a format and frequency described by TENNCARE.

Page 292 of 374

 

	 	2.30.15.2	 	Patient Liability Reports
	 
	 	 	 	The CONTRACTOR shall submit a quarterly CHOICES Patient Liability Report that provides,
for any members for whom the CONTRACTOR is aware that the full patient liability amount
was not collected by a nursing facility provider, the efforts taken by the
CONTRACTOR/nursing facility to collect any unpaid amounts, identified issues, and
strategies to address issues, both on an individual basis for those members who have not
paid their complete patient liability amount and systemically.
	 
	 	2.30.15.3	 	Financial Reports to TENNCARE
	 
	 	2.30.15.3.1	 	The CONTRACTOR shall submit a Medical Loss Ratio Report monthly with cumulative year to
date calculation. The CONTRACTOR shall report all medical expenses and complete the supporting
claims lag tables. This report shall be accompanied by a letter from an actuary, who may be an
employee of the CONTRACTOR, indicating that the reports, including the estimate for incurred
but not reported expenses, has been reviewed for accuracy. The CONTRACTOR shall also file this
report with its NAIC filings due in March and September of each year using an accrual basis
that includes incurred but not reported amounts by calendar service period that have been
certified by an actuary. This report shall reconcile to NAIC filings including the
supplemental TennCare income statement. The CONTRACTOR shall also reconcile the amount paid
reported on the supporting claims lag tables to the amount paid for the corresponding period
as reported on the CONTRACTOR’s encounter file submission as specified in Sections 2.30.16.3
and 2.23.4.
	 
	 	2.30.15.3.2	 	The CONTRACTOR shall submit an annual Ownership and Financial Disclosure Report to
TENNCARE. This report shall include full and complete information regarding ownership,
financial transactions and persons as described in Section 2.21.9 and shall be submitted March
1 of each calendar year and at other times as required by TENNCARE.
	 
	 	2.30.15.3.3	 	The CONTRACTOR shall submit its annual audit plan on March 1 of each year (see Section
2.30.48).
	 
	 	2.30.15.4	 	TDCI Financial Reports
	 
	 	2.30.15.4.1	 	By no later than December 31 of each year, the CONTRACTOR shall submit to TDCI an
annual Financial Plan and Projection of Operating Results Report. This submission shall
include the CONTRACTOR’s budget projecting revenues earned and expenses incurred on a calendar
year basis through the term of this Agreement. This budget shall be prepared in accordance
with the form prescribed by TDCI and shall include narratives explaining the assumptions and
calculations utilized in the projections of operating results.
	 
	 	2.30.15.4.2	 	By no later than July 31 of each year, the CONTRACTOR shall submit to TDCI a mid-year
Comparison of Actual Revenues and Expenses to Budgeted Amounts Report. If necessary, the
CONTRACTOR shall revise the calendar year budget based

Page 293 of 374

 

	 	 	 	on its actual results of operations. Any revisions to the budget shall include
narratives explaining the assumptions and calculations utilized in making the revisions.

	 	2.30.15.4.3	 	The CONTRACTOR shall submit to TDCI an Annual Financial Report required to be filed by
all licensed health maintenance organizations pursuant to TCA 56-32-208. This report shall be
on the form prescribed by the National Association of Insurance Commissioners (NAIC) for
health maintenance organizations and shall be submitted to TDCI on or before March 1 of each
calendar year. It shall contain an income statement detailing the CONTRACTOR’s fourth quarter
and year-to-date revenues earned and expenses incurred as a result of the CONTRACTOR’s
participation in the TennCare program. The CONTRACTOR in preparing this annual report shall
comply with any and all rules and regulations of TDCI related to the preparation and filing of
this report. This Annual Report shall also be accompanied by the Medical Loss Ratio report,
where applicable, completed on a calendar year basis. The CONTRACTOR shall submit a
reconciliation of the Medical Loss Ratio report to the annual NAIC filing using an accrual
basis that includes an actuarial certification of the claims payable (reported and
unreported).
	 
	 	2.30.15.4.4	 	The CONTRACTOR shall file with TDCI, a Quarterly Financial Report. These reports shall
be on the form prescribed by the National Association of Insurance Commissioners for health
maintenance organizations and shall be submitted to TDCI on or before May 15 (covering first
quarter of current year), August 15 (covering second quarter of current year) and November 15
(covering third quarter of current year). Each quarterly report shall also contain an income
statement detailing the CONTRACTOR’s quarterly and year-to-date revenues earned and expenses
incurred as a result of the CONTRACTOR’s participation in the TennCare program. The second
quarterly report (submitted on September 1) shall include the Medical Loss Ratio report
completed on an accrual basis that includes an actuarial certification of the claims payable
(reported and unreported) and, if any, other actuarial liabilities reported. The actuarial
certification shall be prepared in accordance with National Association of Insurance
Commissioners guidelines. The CONTRACTOR shall also submit a reconciliation of the Medical
Loss Ratio report to the second quarterly NAIC report.
	 
	 	2.30.15.4.5	 	The CONTRACTOR shall submit to TDCI annual Audited Financial Statements. Such audit
shall be performed in accordance with NAIC Annual Statement Instructions regarding the annual
audited financial statements. There are three (3) exceptions to the NAIC statement
instructions:
	 
	 	2.30.15.4.5.1	 	The CONTRACTOR shall submit the audited financial statements covering the previous
calendar year by May 1 of each calendar year.
	 
	 	2.30.15.4.5.2	 	Any requests for extension of the May 1 submission date must be granted by the Office
of the Comptroller of the Treasury pursuant to the “Contract to Audit Accounts.”
	 
	 	2.30.15.4.5.3	 	The report shall include an income statement addressing the TENNCARE operations of
the CONTRACTOR.

Page 294 of 374

 

2.30.16 Claims Management Reports

	 	2.30.16.1	 	The CONTRACTOR shall submit a monthly Claims Payment Accuracy Report. The report
shall include the results of the internal audit of the random sample of all “processed
or paid” claims (described in Section 2.22.6) and shall report on the number and
percent of claims that are paid accurately. As provided in Section 2.22.6.6, if the
CONTRACTOR subcontracts for the provision of any covered services, and the
subcontractor is responsible for processing claims, then the CONTRACTOR shall submit a
claims payment accuracy percentage report for the claims processed by the
subcontractor. The report for each subcontractor shall include the results of the
internal audit conducted in compliance with Section 2.22.6 and shall report on the
number and percent of claims that are paid accurately.
	 
	 	2.30.16.2	 	The CONTRACTOR shall submit a quarterly Explanation of Benefits (EOB) Report. This
report shall summarize the number of EOBs sent by category, member complaints, and
complaint resolution (including referral to TBI/OIG). (See Section 2.22.8.)
	 
	 	2.30.16.3	 	The CONTRACTOR shall submit a weekly Claims Activity Report. This report shall
identify the number of claims received, number of claims denied (by reason), number of
claims paid, and total amount paid by the categories of service specified by TENNCARE.
	 
	 	2.30.16.4	 	The CONTRACTOR shall submit a quarterly HCBS Annual Benefit Limits Report that
provides information on CHOICES members in Group 2 or 3 who are approaching or have met
an annual benefit limit for HCBS. The report shall provide current and cumulative
information regarding specified measures, including but not limited to the following:

	 	(1)	 	The number and percent of members in Group 2 who are
within specified percentages of an annual benefit limit, by service
	 
	 	(2)	 	The number and percent of members in Group 2 who have
met an annual benefit limit, by specified timeframes, overall and by
service
	 
	 	In addition, upon implementation of Group 3, the performance measures shall
include but not be limited to the following:

	 	(1)	 	The number and percent of members in Group 3 who are
within specified percentages of an annual benefit limit, by service
	 
	 	(2)	 	The number and percent of members in Group 3 who have
met an annual benefit limit, overall and by service
	 
	 	The report shall also include assurance to TENNCARE that the CONTRACTOR (a) has
notified each member who is approaching an annual HCBS benefit limit that he/she
is approaching the limit and (b) has sent a notice to each member (pursuant to
TennCare rules and regulations) who has requested services in excess of a
specified annual benefit limit and for whom the CONTRACTOR will not provide
services in excess of the limit as a CEA.

Page 295 of 374

 

	 	 	 	The CONTRACTOR shall submit its first report following the third calendar quarter after
CHOICES implementation, and that report shall include information from the date of
CHOICES implementation through the third calendar quarter.
	 
	 	2.30.16.5	 	The CONTRACTOR shall submit a quarterly Cost Neutrality Report that provides information,
by month, on members in CHOICES Group 2 who are approaching or have met the cost neutrality
cap for CHOICES members in Group 2. The report shall provide current information, by month, as
well as cumulative information regarding specified measures.
	 
	 	 	 	The performance measures for the first twelve (12) months after CHOICES implementation
shall include but not be limited to the following

	 	(1)	 	The number and percent of members in Group 2 who are within specified
percentages of the member’s cost neutrality cap, on a monthly and/or annual basis
	 
	 	(2)	 	The number and percent of members in Group 2 who are projected to
exceed their cost neutrality cap, on a monthly and/or annual basis, by specified
timeframes
	 
	 	Starting the thirteenth month after CHOICES implementation, the performance measures
shall include but not be limited to the performance measures from the first twelve (12)
month as well as the following performance measure:
	 
	 	(1)	 	Of the members in Group 2 who were projected to exceed their cost
neutrality cap, the number and percent whose plan of care was revised to remain
within the cap
	 
	 	(2)	 	The number of members in Group 2 for whom the CONTRACTOR has
determined that the member’s needs can no longer be safely and effectively met
within the cost neutrality cap and should be enrolled in Group 1
	 
	 	(3)	 	Of the members in Group 2 for whom the CONTRACTOR determined that the
member’s needs can no longer be safely and effectively met within the cost
neutrality cap and should be enrolled in Group 1, the number and percent who
enrolled in Group 1
	 
	 	(4)	 	Of the members in Group 2 for whom the CONTRACTOR determined that the
member’s needs can no longer be safely and effectively met within the cost
neutrality cap and should be enrolled in Group 1, the number and percent who
declined to enroll in Group 1
	 
	 	The report shall include assurance to TENNCARE that the CONTRACTOR has notified each
member who is projected to meet his/her cost neutrality cap that he/she is projected to
meet his/her cost neutrality cap and informed the member of his/her options.

	 	2.30.16.6	 	Upon implementation of CHOICES Group 3, the CONTRACTOR shall submit a quarterly
Expenditure Cap Report that provides information on members in CHOICES Group 3 who are
approaching or have met the expenditure cap (see

Page 296 of 374

 

	 	 	 	Section 2.6.1.5.5). The report shall provide current and cumulative information
regarding specified measures, including but not limited to the following:

	 	(1)	 	The number and percent of members in Group 3 who are
within specified percentages of the expenditure cap
	 
	 	(2)	 	The number and percent of members in Group 3 who have
met the expenditure cap

	 	 	 	The cumulative information shall include information on each of these measures
by and across previous quarters on a rolling twelve (12) month basis. The report
shall include a graphical representation of current and cumulative information.
	 
	 	 	 	The report shall also include assurance to TENNCARE that (a) the CONTRACTOR has
notified each member who is projected to meet the expenditure cap that he/she is
projected to meet the expenditure cap and informed the member of what will
happen when he/she meets the expenditure cap; and (2) has sent a notice to each
member (pursuant to TennCare rules and regulations) who has requested services
in excess of the expenditure cap.
	 
	 	2.30.16.7	 	The CONTRACTOR shall submit a quarterly Cost Effective Alternative Services for
CHOICES Report that provides information on cost effective alternative services
provided to CHOICES members (see Section 2.5.5.3). The report shall provide current and
cumulative information regarding specified measures, including but not limited to the
following:

	 	(1)	 	The number and percent of members in Group 2 who were
enrolled in Group 2 as a CEA
	 
	 	(2)	 	The minimum, maximum, median, and average amount that
members, overall and by Group 2 and 3, have exceeded a benefit limit as a
CEA, by service
	 
	 	(3)	 	The number and percent of members, overall and by Group
2 and 3, who receive non-covered HCBS as a CEA, by non-covered HCBS
	 
	 	(4)	 	The number and percent of members transitioning from a
nursing facility to the community who used a transition allowance as a CEA
	 
	 	The cumulative information shall include information on each of these measures
by and across previous quarters on a rolling twelve (12) month basis. The report
shall include a graphical representation of current and cumulative information.
	 
	 	The CONTRACTOR shall submit its first report following the second calendar
quarter after CHOICES implementation, and that report shall include information
for the period from CHOICES implementation through the second calendar quarter.

2.30.17 Information Systems Reports

	 	2.30.17.1	 	The CONTRACTOR shall submit an annual Systems Refresh Plan on December 1 for the
upcoming year that meets the requirements in Section 2.23.1.6.

Page 297 of 374

 

	 	2.30.17.2	 	The CONTRACTOR shall submit Encounter Data Files in a standardized format as
specified by TENNCARE (see Section 2.23.4) and transmitted electronically to TENNCARE
on a weekly basis.
	 
	 	2.30.17.3	 	The CONTRACTOR shall provide an electronic version of a reconciliation between the
amount paid as captured on the CONTRACTOR’s encounter file submissions and the amount
paid as reported by the CONTRACTOR in the ‘CMS 1450 Claims Triangle’ and ‘CMS 1500
Claims Triangle’ that accompanies the monthly Medical Loss Ratio report (see Section
2.30.15.3.1). In the event of any variances, the CONTRACTOR shall submit a written
explanation accompanied by a ‘CMS 1450 Claims Triangle’ by category of service and a
‘CMS 1500 Claims Triangle’ by category of service, as applicable, to substantiate the
explanation of the variance and identify the categories of services to which the
variance is attributable. In the event that TENNCARE requires further detail of the
variances listed, the CONTRACTOR shall provide any other data as requested by TENNCARE.
This information shall be submitted with the MLR report.
	 
	 	2.30.17.4	 	The CONTRACTOR shall provide any information and/or data requested in a format to
be specified by TENNCARE as required to support the validation, testing or auditing of
the completeness and accuracy of encounter data submitted by the CONTRACTOR.
	 
	 	2.30.17.5	 	The CONTRACTOR shall submit a monthly Systems Availability and Performance Report
that provides information on availability and unavailability by major system as well as
response times for the CONTRACTOR’s Confirmation of MCO Enrollment and Electronic
Claims Management functions, as measured within the CONTRACTOR’s span of control.
	 
	 	2.30.17.6	 	The CONTRACTOR shall submit a baseline Business Continuity and Disaster Recovery
(BC-DR) plan for review and written approval as specified by TENNCARE. The CONTRACTOR
shall communicate proposed modifications to the BC-DR plan at least fifteen (15)
calendar days prior to their proposed incorporation. Such modifications shall be
subject to review and written approval by TENNCARE.

2.30.18 Administrative Requirements Reports

	 	2.30.18.1	 	The CONTRACTOR shall submit a semi-annual Report on the Activities of the
CONTRACTOR’s Behavioral Health Advisory Committee regarding the activities of the
behavioral health advisory committee established pursuant to Section 2.24.2. These
reports shall be submitted to TENNCARE on March 1 and September 1 of each year.
	 
	 	2.30.18.2	 	The CONTRACTOR shall submit a semi-annual Report on the Activities of the
CONTRACTOR’s CHOICES Advisory Group regarding the activities of the CHOICES advisory
group established pursuant to Section 2.24.3. These reports shall be submitted to
TENNCARE on March 1 and September 1 of each year.

2.30.19 Subcontract Reports

	 	2.30.19.1	 	If the CONTRACTOR has subcontracted claims processing for TennCare claims, the
CONTRACTOR shall provide to TENNCARE a Type II examination based on the Statement on
Auditing Standards (SAS) No. 70, Service Organizations for each 

Page 298 of 374

 

	 	 	 	non-affiliated organization processing claims that represent more than twenty percent (20%)
of TennCare medical expenses of the CONTRACTOR. This report shall be performed by an
independent auditor (“service auditor”) and shall be due annually on May 1 for the
preceding year operations or portion thereof.

	 	2.30.19.2	 	In a Type II report, the service
auditor will express an opinion on (1)
whether the service organization’s
description of its controls presents
fairly, in all material respects, the
relevant aspects of the service
organization’s controls that had been
placed in operation as of a specific date,
and (2) whether the controls were suitably
designed to achieve specified control
objectives, and (3) whether the controls
that were tested were operating with
sufficient effectiveness to provide
reasonable, but not absolute, assurance
that the control objectives were achieved
during the period specified. The audit of
control activities over information and
technology related processes related to
TennCare claims processing by the
subcontractor should include the following:
	 
	 	2.30.19.2.1	 	General Controls
	 
	 	2.30.19.2.1.1	 	Personnel Policies
	 
	 	2.30.19.2.1.2	 	Segregation of Duties
	 
	 	2.30.19.2.1.3	 	Physical Access Controls
	 
	 	2.30.19.2.1.4	 	Hardware and System Software
	 
	 	2.30.19.2.1.5	 	Applications System Development and Modifications
	 
	 	2.30.19.2.1.6	 	Computer Operations
	 
	 	2.30.19.2.1.7	 	Data Access Controls
	 
	 	2.30.19.2.1.8	 	Contingency and Business Recovery Planning
	 
	 	2.30.19.2.2	 	Application Controls
	 
	 	2.30.19.2.2.1	 	Input
	 
	 	2.30.19.2.2.2	 	Processing
	 
	 	2.30.19.2.2.3	 	Output
	 
	 	2.30.19.2.2.4	 	Documentation Controls

Page 299 of 374

 

2.30.20 HIPAA Reports

	 	 	 	The CONTRACTOR shall submit a Privacy/Security Incident Report. This report shall be
provided at least annually, but the CONTRACTOR shall provide the report more frequently if
requested by TENNCARE. The report shall include, at a minimum, the date of the incident, the
date of notification to TENNCARE’s privacy officer, the nature and scope of the incident,
the CONTRACTOR’s response to the incident, and the mitigating measures taken by the
CONTRACTOR to prevent similar incidents in the future. “Port scans” or other unsuccessful
queries to the CONTRACTOR’s information system shall not be considered a privacy/security
incident for purposes of this report.

2.30.21 Non-Discrimination Compliance Reports

	 	2.30.21.1	 	The CONTRACTOR shall submit an annual Summary Listing of Servicing Providers that
includes race or ethnic origin of each provider. The listing shall include, at a
minimum, provider name, address, race or ethnic origin and shall be sorted by provider
type (e.g., pediatrician, surgeon, etc.). The CONTRACTOR shall use the following race
or ethnic origin categories: American Indian or Alaskan Native, Asian or Pacific
Islander, Hispanic origin and other race/ethnic origin as indicated by TENNCARE.
	 
	 	2.30.21.2	 	The CONTRACTOR shall submit a quarterly Supervisory Personnel Report that contains
a summary listing totaling the number of supervisory personnel by race or ethnic origin
and sex. This report shall provide the number of male supervisors who are White, Black
(not of Hispanic origin), American Indian or Alaskan Native, Asian or Pacific Islander,
Hispanic origin and other race/ethnicity as indicated by TENNCARE and number of female
supervisors who are White, Black (not of Hispanic origin), American Indian or Alaskan
Native, Asian or Pacific Islander, Hispanic origin and other race/ethnic origin females
as indicated by TENNCARE.
	 
	 	2.30.21.3	 	The CONTRACTOR shall submit a quarterly Alleged Discrimination Report. The report
shall include a listing of all complaints alleging discrimination filed by employees,
members, providers and subcontractors in which discrimination is alleged by the
CONTRACTOR’s MCO. Such listing shall include, at a minimum, the identity of the party
filing the complaint, the complainant’s relationship to the CONTRACTOR, the
circumstances of the complaint, date complaint filed, the CONTRACTOR’s resolution, if
resolved, and the name of the CONTRACTOR staff person responsible for adjudication of
the complaint.
	 
	 	2.30.21.4 	 	On an annual basis the CONTRACTOR shall submit a copy of the CONTRACTOR’s
non-discrimination policy that demonstrates non-discrimination in provision of services
to members with Limited English Proficiency. This shall include a report that lists all
interpreter/translator services used by the CONTRACTOR in providing services to members
with Limited English Proficiency or that need communication assistance in an
alternative format. The listing shall identify the provider by full name, address,
phone number, and hours services are available.
	 
	 	2.30.21.5	 	The CONTRACTOR shall annually submit its Non-Discrimination Compliance Plan and
Assurance of Non-Discrimination to TENNCARE. The signature date of the

Page 300 of 374

 

	 	 	 	CONTRACTOR’s Title VI Compliance Plan shall coordinate with the signature date
of the CONTRACTOR’s Assurance of Non-Discrimination.

2.30.22 Terms and Conditions Reports

	 	2.30.22.1	 	Quarterly, by January 30, April 30, July 30, and October 30 each year the
CONTRACTOR shall make written disclosure regarding conflict of interest that includes
the elements in Section 4.19.
	 
	 	2.30.22.2	 	Pursuant to Section 4.34.2, on a semi-annual basis the CONTRACTOR shall submit the
attestation in Attachment X.

27. Section 2.31 shall be deleted in its entirety.

28. Section 3 shall be deleted in its entirety and replaced with the following:

SECTION 3 — PAYMENTS TO THE CONTRACTOR

3.1 GENERAL PROVISIONS

	3.1.1	 	TENNCARE shall make monthly payments to the CONTRACTOR for its satisfactory performance and
provision of covered services under this Agreement. Capitation rates shall be paid according
to the methodology as described in this Agreement.
	 
	3.1.2	 	The CONTRACTOR agrees that capitation payments, any payments related to processing claims
for services incurred prior to the start date of operations pursuant to Section 3.7.1.2.1, any
incentive payments (if applicable) and any payments that offset the CONTRACTOR’s cost for the
development and implementation of an electronic visit verification system (EVV) (see Section
3.13) are payment in full for all services provided pursuant to this Agreement. TennCare shall
not reimburse CONTRACTOR for any costs, liquidated damages and/or penalties incurred by the
CONTRACTOR and which result from actions or inactions, including penalties associated with
CONTRACTOR’s failure to timely pay any and all expenses, fees, taxes and other
regulatory/ministerial costs associated with the requirements of operating as an HMO in this
state. The taxes, fees, expenses, and other regulatory/ministerial costs referenced herein
shall include but not be limited to premium taxes associated with any and all obligations
required by the Tennessee Health Maintenance Organization Act of 1986 codified at TCA
56-32-101 et seq. or any subsequent amendments thereto and/or the Tennessee Prepaid Limited
Health Services Act of 2000 codified at TCA 56-51-101 et seq. or any subsequent amendments
thereto. TENNCARE shall not share with the CONTRACTOR any financial losses realized under this
Agreement.

3.2 ANNUAL ACTUARIAL STUDY

	 	 	In accordance with TCA 71-5-188, the State will retain a qualified actuary to conduct an
annual actuarial study of the TennCare program. The CONTRACTOR shall provide any information
requested and cooperate in any manner necessary as requested by TENNCARE in order to assist
the State’s actuary with completion of the annual actuarial study.

Page 301 of 374

 

3.3 CAPITATION PAYMENT RATES

	3.3.1	 	The CONTRACTOR will be paid a base capitation rate for each enrollee based on the enrollee’s rate category.
Rate categories are based on various factors, including the enrollee’s enrollment in CHOICES, category of aid,
age/sex combination and the Grand Region served by the CONTRACTOR under this Agreement. The rate categories and
the specific rates associated with each rate category are specified in Attachment XII.
	 
	3.3.2	 	The major aid categories are as follows:

	 	3.3.2.1	 	Medicaid;

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

	3.3.3	 	The CONTRACTOR will also be paid a priority add-on rate for behavioral health services in
accordance with the rates specified in Attachment XII for each priority enrollee. The
CONTRACTOR will be paid the priority add-on rate for priority enrollees, as defined in this
Agreement, who have received behavioral health services as reported pursuant to Section
2.23.4 of this Agreement, within the preceding twelve (12) months from the date of the
calculation of the monthly payment, and who have had a valid CRG/TPG assessment within the
preceding twelve (12) months from the date of the calculation of the monthly payment.
	 
	3.3.4	 	TENNCARE will determine the appropriate rate category to which each enrollee is assigned for
payment purposes under this Agreement.
	 
	3.3.5	 	TENNCARE’s assignment of an enrollee to a rate category is for payment purposes under this
Agreement, only, and is not an “adverse action” or determination of the benefits to which an
enrollee is entitled under the TennCare program, TennCare rules and regulations, TennCare
policies and procedures, the TennCare waiver or relevant court orders or consent decrees.

3.4 CAPITATION RATE ADJUSTMENT

	3.4.1	 	The CONTRACTOR and TENNCARE agree that the capitation rates described in Section 3 of this
Agreement may be adjusted periodically.
	 
	3.4.2	 	The CONTRACTOR and TENNCARE further agree that adjustments to capitation rates shall occur
only by written notice from TENNCARE to the CONTRACTOR. The notice will be given at least
thirty (30) calendar days before the new rates come into effect. Should the CONTRACTOR refuse
to continue this Agreement under the new rates, the CONTRACTOR then may activate the
Termination provisions contained in Section 4.4.7 of this Agreement. During the six (6) month
Termination Notice period the CONTRACTOR will continue to be paid under the new rates. In the
event the CONTRACTOR indicates that it is refusing to accept the new rates, but does not
choose to institute Termination proceedings under Section 4.4.7 of this Agreement then the
State may at its option:

Page 302 of 374

 

	 	3.4.2.1	 	Declare that a public exigency exists under Section 4.2.3 of this Agreement. If
the State makes this declaration the CONTRACTOR will continue to be paid under the
new rates,
	 
	 	3.4.2.2	 	Declare that the contract is Terminated for Convenience under the provisions of
Section 4.4.6 of this Agreement. If the State makes this declaration the
CONTRACTOR will continue to be paid under the new rates for the period of time
until the Termination date.

	3.4.3	 	The base capitation rates shall be adjusted by the State for health plan risk in accordance
with the following:

	 	3.4.3.1	 	Health plan risk assessment scores will be initially recalibrated after current
TennCare enrollees are assigned to the MCOs for retroactive application to
payment rates effective on the start date of operations. This initial
recalibration will be based upon the distribution of enrollment on the start
date of operations and health status information will be derived from encounter
data submitted to TENNCARE by MCOs serving the Grand Region through the most
recent twelve (12) month period deemed appropriate by the State’s actuary.
	 
	 	3.4.3.2	 	In the initial recalibration, if the health plan risk assessment score for any
MCO deviates from the profile for the Grand Region being served by the MCO by more
than three percent (3%), whether a negative or positive change in scores, the
original base capitation rates will be proportionally adjusted.
	 
	 	3.4.3.3	 	Thereafter, health plan risk assessment scores will be recalibrated annually
based upon health status information derived from encounter data submitted to TENNCARE
by MCOs serving the Grand Region through the most recent twelve (12) month
period deemed appropriate by the State’s actuary. If the health plan risk
assessment score for any MCO deviates from the profile for the Grand Region
being served by the MCO by more than three percent (3%), whether a negative or
positive change in scores, the base capitation rates as subsequently adjusted
will be proportionally adjusted.
	 
	 	3.4.3.4	 	TENNCARE will recalibrate health plan risk assessment scores on an ongoing
basis for the purpose of monitoring shifts in enrollment. If warranted prior to the
next scheduled annual recalibration as demonstrated by a significant change in
health plan risk assessment scores, defined as a change of three percent (3%) or
more, whether a negative or positive change in scores, TENNCARE may adjust the
original base capitation rates as subsequently adjusted for all MCOs.
	 
	 	3.4.3.5	 	In addition to the annual recalibration of risk adjustment factors, those
factors will be updated when there is a significant change in program participation. This may
occur when an MCO enters or leaves a Grand Region. If an MCO withdraws from a
Grand Region, that MCO’s membership may be temporarily distributed to TennCare
Select or distributed to the remaining MCOs or to new MCOs. New risk adjustment
values for the remaining MCOs or new MCO(s) will be calculated that consider the
population that will be enrolled in the MCO for the remainder of the contract
year only. In this instance, MCOs would be given the option to provide TENNCARE,
in writing, with a six (6) months notice of termination in accordance with
Section

Page 303 of 374

 

	 	 	 	4.4.7.2. This notice option is not available for rate adjustments as described
in Sections 3.4.3.1 through 3.4.3.4.
	 
	 	3.4.3.6	 	An individual’s health status will be determined using the John Hopkins ACG®
Case-Mix System (ACG System). In the event the State elects to use a different
system to calculate an adjustment for MCO health status risk, the State will
notify the CONTRACTOR prior to its implementation. The ACG System does not
account for long-term care services or service delivery setting.
	 
	 	3.4.3.7	 	For CHOICES members, only the non-long-term care component of the base
capitation rate will be adjusted for health plan risk. The long-term care
component of the base capitation rate will not be adjusted for health plan risk.

	3.4.4	 	Beginning with capitation payment rates effective July 1, 2008, in addition to other
adjustments specified in Section 3.4 of this Agreement, the base capitation rates as
subsequently adjusted and the priority add-on rates shall be adjusted annually for inflation
in accordance with the recommendation of the State’s actuary.
	 
	3.4.5	 	If (i) changes are required pursuant to federal or state statute, federal regulations, the
action of a federal agency, a state or federal court, or rules and regulations of a State of
Tennessee agency other than the TennCare Bureau and (ii) the changes are likely to impact the
actuarial soundness of the capitation rate(s) described in Section 3, as determined by
TENNCARE, TENNCARE shall have its independent actuary review the required change and determine
whether the change would impact the actuarial soundness of the capitation rate(s). If
TENNCARE’s independent actuary determines that the change would impact the actuarial soundness
of one or more of the capitation rates, the actuary shall determine the appropriate adjustment
to the impacted capitation rate(s).
	 
	3.4.6	 	In the event TENNCARE amends TennCare rules or regulations or initiates a policy change not
addressed in Section 3.4.5 above that is likely to impact the capitation rate(s) described in
Section 3, as determined by TENNCARE, TENNCARE shall have its independent actuary review the
proposed change and determine whether the change would impact the actuarial soundness of the
capitation rate(s). If TENNCARE’s independent actuary determines that the change would impact
the actuarial soundness of one or more of the capitation rates, the actuary shall determine
the appropriate adjustment to the impacted capitation rate(s).
	 
	3.4.7	 	In the event the amount of the two percent (2%) premium tax is increased during the term of
this Agreement, the payments shall be increased by an amount equal to the increase in premium
payable by the CONTRACTOR.
	 
	3.4.8	 	Any rate adjustments shall be subject to the availability of state
appropriations.

3.5 CAPITATION PAYMENT SCHEDULE

	 	 	TENNCARE shall make payment by the fifth (5th) business day of each month to the CONTRACTOR
for the CONTRACTOR’s satisfactory performance of its duties and responsibilities as set
forth in this Agreement.

Page 304 of 374

 

3.6 CAPITATION PAYMENT CALCULATION

	3.6.1	 	When eligibility has been established by the State for enrollees, the amount owed to the CONTRACTOR
shall be calculated as described herein.
	 
	3.6.2	 	Each month payment to the CONTRACTOR shall be equal to the number of enrollees enrolled in the
CONTRACTOR’s MCO five (5) business days prior to the date of the capitation payment multiplied by the
appropriate capitation rate(s) for the enrollee.
	 
	3.6.3	 	The capitation rates stated in Attachment XII will be the amounts used to determine the amount of
the monthly capitation payment.
	 
	3.6.4	 	The actual amount owed the CONTRACTOR for each member shall be determined by dividing the
appropriate monthly capitation rate(s) by the number of days in the month and then multiplying the
quotient of this transaction by the actual number of days the member was enrolled in the CONTRACTOR’s MCO.
	 
	3.6.5	 	The amount paid to the CONTRACTOR shall equal the total of the amount owed for all enrollees
determined pursuant to Section 3.6.4 less the withhold amount (see Section 3.9), capitation payment
adjustments made pursuant to Section 3.7 or 3.11, and any other adjustments, which may include withholds
for penalties, damages, liquidated damages, or adjustments based upon a change of enrollee status.

3.7 CAPITATION PAYMENT ADJUSTMENTS

	3.7.1	 	The State has the discretion to retroactively adjust the capitation payment for any enrollee if
TENNCARE determines an incorrect payment was made to the CONTRACTOR; provided, however:

	 	3.7.1.1	 	For determining the capitation rate(s) only, the Grand Region being served by the
enrollee’s MCO under this Agreement will be used to determine payment. The
capitation payment shall not be retroactively adjusted to reflect a different
Grand Region of residence so long as the enrollee’s MCO assignment is effective.
	 
	 	3.7.1.2	 	For individuals enrolled with a retroactive effective date on the date of
enrollment, the payment rate for retroactive periods shall be the capitation rate(s) for the
applicable rate category and the Grand Region in which the enrollee’s assigned
MCO is operating under this Agreement as specified in Attachment XII, except
that:
	 
	 	3.7.1.2.1	 	The CONTRACTOR agrees to manually process claims and reimburse providers for
services incurred prior to the start date of operations of this Agreement; however, the
CONTRACTOR will not be at risk for these services. The CONTRACTOR shall be paid two
dollars ($2.00) per claim as reimbursement for processing claims for services incurred
prior to the start date of operations. Actual expenditures for covered services and the
allowed amount for claims processing are subject to TCA 56-32-124. The CONTRACTOR shall
negotiate provider reimbursement subject to TENNCARE prior written approval and prepare
checks for payment of providers for the provision of covered services incurred during
an enrollee’s period of eligibility prior to the start date of operations on an as
needed basis. The CONTRACTOR shall notify the State of the amount to be paid in a
mutually acceptable form and format at least forty-eight

Page 305 of 374

 

	 	 	 	(48) hours in advance of distribution of any provider payment related to this
requirement. TENNCARE shall remit payment to the CONTRACTOR in an amount equal
to: the amount to be paid to providers; plus, two dollars ($2.00) per claim
processed by the CONTRACTOR; plus, an amount sufficient to cover any payment due
in accordance with TCA 56-32-124 within forty-eight (48) hours of receipt of
notice. The CONTRACTOR shall then release payments to providers within twenty-
four (24) hours of the receipt of funds from the State. The CONTRACTOR is
responsible for any payments required pursuant to TCA 56-32-124.

	 	3.7.1.2.2	 	TENNCARE will be responsible for the payment of claims for long-term care services
provided to a CHOICES member during the member’s period of eligibility prior to the
implementation of CHOICES in the Grand Region covered by this Agreement.
	 
	 	3.7.1.3	 	If a provider seeks reimbursement for a service provided during a retroactive
period of eligibility, the CONTRACTOR shall assess cost sharing responsibilities in
accordance with the cost sharing schedules in effect on the date of service for
which reimbursement is sought (see Attachment II) and collect patient liability
from CHOICES members as applicable (see Sections 2.6.7.2 and 2.21.5).
	 
	 	3.7.1.4	 	Should TENNCARE determine after the capitation payment is made that an
enrollee’s capitation rate category had changed or the enrollee was deceased,
TENNCARE shall retroactively adjust the payment to the CONTRACTOR to accurately
reflect the enrollee’s capitation rate category for the period for which payment
has been made. TENNCARE shall initially retroactively adjust the payment to the
CONTRACTOR, not to exceed twelve (12) months. Subsequently, TENNCARE shall
further retroactively adjust the payment to the CONTRACTOR to accurately reflect
the enrollee’s capitation rate category for the period prior to the twelve (12)
month adjustment initially made by TENNCARE. TENNCARE will make the subsequent
adjustment at least semi-annually.
	 
	 	3.7.1.4.1	 	TENNCARE and the CONTRACTOR agree that the twelve (12) month limitation described
in Sections 3.7.1.4 is applicable only to retroactive capitation rate payment
adjustments described in those paragraphs and shall in no way be construed as limiting
the effective date of eligibility or enrollment in the CONTRACTOR’s MCO.
	 
	 	3.7.1.5	 	Payment adjustments resulting in a reduction or increase of the capitation rate
shall be accomplished through the monthly capitation reconciliation process.

3.8 SERVICE DATES

	 	 	Except where required by this Agreement or by applicable federal or state law, the
CONTRACTOR shall not make payment for the cost of any services provided prior to the
effective date of eligibility in the CONTRACTOR’s MCO. The CONTRACTOR shall make payment for
the cost of any covered services obtained on or after 12:0 1 a.m. on the effective date of
eligibility in the CONTRACTOR’s MCO.

Page 306 of 374

 

3.9 WITHHOLD OF THE CAPITATION RATE

	3.9.1	 	A withhold of the aggregate capitation payment shall be applied to ensure CONTRACTOR
compliance with the requirements of this Agreement and to provide an agreed incentive for
assuring CONTRACTOR compliance with the requirements of this Agreement.
	 
	3.9.2	 	The amount due for the first monthly payment, and for each month thereafter, calculated
pursuant to Section 3.6 shall be reduced by the appropriate cash flow withhold percentage
amount and set aside for distribution to the CONTRACTOR in the next regular monthly payment,
unless retained as provided below.

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

Page 307 of 374

 

	 	 	 	For example, if a specified deficiency(s) is corrected within four (4) months
and there are no other identified deficiencies which the CONTRACTOR has been
given written notice of by TENNCARE, the withhold for the four (4) consecutive
months will be paid to the CONTRACTOR upon TENNCARE determination that the
deficiency(s) was corrected. However, any amounts withheld by TENNCARE for six
(6) consecutive months for the same or similar compliance deficiency(s) shall be
retained by TENNCARE on the anniversary of the sixth consecutive month and shall
not be paid to the CONTRACTOR. If the same or similar specified deficiency(s)
continues beyond six (6) consecutive months, TENNCARE may declare the MCO
ineligible for future distribution of the ten percent (10%) incentive withhold.
Such ineligibility will continue for each month TENNCARE determines the same or
similar specified deficiency(s) continues to exist. Once a CONTRACTOR corrects
the deficiency(s), TENNCARE may reinstate the MCO’s eligibility for distribution
of the ten percent (10%) compliance incentive payment of future withholds. If
TENNCARE determines that distribution of the ten percent (10%) withhold is
appropriate, distribution of the ten percent (10%) shall be made at the time of
the next scheduled monthly check write which includes all other payments due the
CONTRACTOR.

	3.9.3	 	No interest shall be due to the CONTRACTOR on any sums withheld or retained under this
Section. The provisions of this Section may be invoked alone or in conjunction with any other
remedy or adjustment otherwise allowed under this Agreement.
	 
	3.9.4	 	If TENNCARE has not identified CONTRACTOR deficiencies, TENNCARE will pay to the CONTRACTOR
the withhold of the CONTRACTOR’s payments withheld in the month subsequent to the withhold.

3.10 PAY-FOR-PERFORMANCE QUALITY INCENTIVE PAYMENTS

3.10.1 General

	 	3.10.1.1	 	TENNCARE will make incentive payments to the CONTRACTOR in accordance with this
Section 3.10.
	 
	 	3.10.1.2	 	Pursuant to 42 CFR 438.6, the total of all payments made to the CONTRACTOR for
a year shall not exceed one hundred and five percent (105%) of capitation payments
made to the CONTRACTOR.
	 
	 	3.10.1.3	 	In the first year that the incentives specified in Sections 3.10.2 and 3.10.3
below are available, the TennCare regional average HEDIS score (as calculated by
TENNCARE using audited MCO HEDIS results) for each of the measures specified in
Sections 3.10.2 and 3.10.3 for the last full calendar year prior to the year that
the CONTRACTOR began operating under this Agreement will serve as the baseline. If
complete TennCare HEDIS data for these measures is not available for the region
for the year prior to the year that the CONTRACTOR began operating under this
Agreement, then the last year for which complete data is available will serve as
the baseline.
	 
	 	3.10.1.4	 	If NCQA makes changes in any of the measures specified in Section 3.10.2 or
3.10.3 below, such that valid comparison to prior years will not be possible,
TENNCARE, at its sole discretion, may elect to either eliminate the measure from
pay-for-performance incentive eligibility or replace it with another measure.

Page 308 of 374

 

3.10.2 Physical Health HEDIS Measures

	 	3.10.2.1	 	Beginning on July 1, 2010, on July 1 of each year, the CONTRACTOR will
be eligible for a $.03 PMPM payment, applied to member months from the preceding
calendar year, for each of the audited HEDIS measures specified in Section
3.10.2.2 below (calculated from the preceding calendar year’s data) for which
significant improvement has been demonstrated. The CONTRACTOR’s HEDIS result for
the reporting period prior to the current reporting period will serve as the
baseline. Significant improvement is defined using NCQA’s minimum effect size
change methodology (see Section 3.10.5 below).
	 
	 	3.10.2.2	 	Incentive payments will be available for the following audited HEDIS measures:
	 
	 	3.10.2.2.1	 	HbA1C Testing — Diabetes measure;

	 
	 	3.10.2.2.2	 	HbA1C Control — Diabetes measure;
	 
	 	3.10.2.2.3	 	LDL-C Screening Performed — Diabetes measure;
	 
	 	3.10.2.2.4	 	Adolescent Well-Care Visits;
	 
	 	3.10.2.2.5	 	Breast Cancer Screening; and
	 
	 	3.10.2.2.6	 	Controlling High Blood Pressure.
	 
	 	3.10.2.3	 	For HbA1 C control, the reverse of the HEDIS measure (i.e. 100 minus the
percentage of individuals with poorly controlled HbA1C) will serve as the measure
for purposes of this section.

3.10.3 Behavioral Health HEDIS Measures

	 	3.10.3.1	 	Beginning on July 1, 2010, on July 1 of each year, the CONTRACTOR will
be eligible for a $.03 PMPM payment, applied to member months from the preceding
calendar year, for each of the following audited HEDIS measures (calculated from
the preceding calendar year’s data) for which significant improvement has been
demonstrated. The CONTRACTOR’s HEDIS result for the reporting period prior to
the current reporting period will serve as the baseline. To be eligible for
incentive payment for a measure, the CONTRACTOR must demonstrate significant
improvement for both rates comprising the measure. Significant improvement is
defined using NCQA’s minimum effect size change methodology (see Section 3.10.5
below).
	 
	 	3.10.3.1.1	 	Antidepressant Medication Management; and
	 
	 	3.10.3.1.2	 	Follow-up Care for Children Prescribed ADHD Medication.

Page 309 of 374

 

3.10.4 Community Tenure/Hospital Readmission for Mental Illness

	 	3.10.4.1	 	Beginning on July 1, 2010, on July 1 of each year, the CONTRACTOR will be
eligible for a $.03 PMPM payment, applied to member months from the preceding
calendar year, if significant improvement has been demonstrated in the rate at
which members hospitalized for mental illness remain in the community (i.e. are
not readmitted to an inpatient hospital setting for treatment of mental illness)
within thirty (30) days of discharge. Significant improvement is defined using
NCQA’s minimum effect size change methodology (see Section 3.10.5 below). The
baseline rate will be the percentage of the CONTRACTOR’s enrollees that were
discharged following hospitalization for mental illness during the reporting
period prior to the current reporting period and that were not readmitted within
thirty (30) days following discharge, as calculated by TennCare. The baseline
rate will be compared to the percentage of the CONTRACTOR’s members that were
discharged following hospitalization for mental illness during the preceding
calendar year of operation, and that were not readmitted within thirty (30 days)
following discharge. The latter calculation will use methodology identical to
that used in the baseline calculation performed by TENNCARE.

3.10.5 NCQA Minimum Effect Size Change Methodology

	 	 	 	The NCQA minimum effect size change methodology is as follows:

	 	 	 
	Baseline Rate	 	Minimum Effect Size
	0-59
	 	At least a 6 percentage point change

	60-74
	 	At least a 5 percentage point change

	75-84
	 	At least a 4 percentage point change

	85-92
	 	At least a 3 percentage point change

	93-96
	 	At least a 2 percentage point change

	97-99
	 	At least a 1 percentage point change

3.11 EFFECT OF DISENROLLMENT ON CAPITATION PAYMENTS

	3.11.1	 	Payment of capitation payments shall cease effective the date of the member’s disenrollment
from the CONTRACTOR’s MCO, and the CONTRACTOR shall have no further responsibility for the
care of the enrollee. Except for situations involving enrollment obtained by fraudulent
applications or death, disenrollment from TennCare shall not be made retroactively.

3.11.2 Fraudulent Enrollment

	 	3.11.2.1	 	In the case of fraudulent, misrepresented or deceptive applications submitted
by the enrollee, the CONTRACTOR, at its discretion, may refund to TENNCARE all
capitation payments made on behalf of persons who obtained enrollment in TennCare
through such means and the CONTRACTOR may pursue full restitution for all payments
made on behalf of the individual while the person was inappropriately enrolled in
the CONTRACTOR’s MCO.
	 
	 	3.11.2.2	 	In the event of enrollment obtained by fraud, misrepresentation or deception
by the CONTRACTOR’s staff, officers, employees, providers, volunteers,
subcontractors,

Page 310 of 374

 

	 	 	 	or anyone acting for or on behalf of the CONTRACTOR, TENNCARE may retroactively
recover capitation amounts plus interest, as allowed by TCA 47-14-103, and any
other monies paid to the CONTRACTOR for the enrollment of that individual. The
refund of capitation payments plus interest will not preclude the State from
exercising its right to criminal prosecution, civil penalties, trebled damages
and/or other remedial measures.

3.12 HMO PAYMENT TAX

	 	 	The CONTRACTOR shall be responsible for payment of applicable taxes pursuant to TCA 56-
32-124. In the event the amount due pursuant to TCA 56-32-124 is increased during the term
of this Agreement, the payments to the CONTRACTOR shall be increased by an amount equal to
the increase in the amount due by the CONTRACTOR.

3.13 PAYMENTS TO THE CONTRACTOR FOR ELECTRONIC VISIT VERIFICATION SYSTEM

	 	 	TENNCARE will pay the CONTRACTOR $605,600 to offset the CONTRACTOR’s costs related to
implementing an electronic visit verification (EVV) system. In accordance with the
applicable appropriations language, these funds shall be used to implement the EVV, and they
shall not be used for any other purpose. Upon TENNCARE’s request the CONTRACTOR shall submit
documentation that demonstrates that funds were used to offset the CONTRACTOR’s costs
related to implementing the EVV.

3.14 PAYMENT TERMS AND CONDITIONS

3.14.1 Maximum Liability

	 	3.14.1.1	 	In no event shall the maximum liability of the State under this Agreement
during the
original term of the Agreement exceed two billion, three hundred twenty one
million, nine hundred ninety five thousand, six hundred forty seven dollars
($2,321,995,647.00).
	 
	 	3.14.1.2	 	If the Agreement maximum would be exceeded as a result of an increase in
enrollment, a change in mix of enrollment among rate cells or any rate
adjustment pursuant to Section 3.4 above, the State shall adjust the Agreement
maximum liability to accommodate the aforementioned circumstances. This
adjustment shall be based on consultation with the State’s independent actuary.
	 
	 	3.14.1.3	 	This Agreement does not obligate the State to pay a fixed minimum amount and
does not create in the CONTRACTOR any rights, interests or claims of entitlement
in any funds.
	 
	 	3.14.1.4	 	The CONTRACTOR is not entitled to be paid the maximum liability for any period
under the Agreement or any extensions of the Agreement. The maximum liability
represents available funds for payment to the CONTRACTOR and does not guarantee
payment of these funds to the CONTRACTOR under this Agreement.

Page 311 of 374

 

3.14.2 Compensation Firm

The capitation rates and the Maximum Liability of the State under this Agreement are firm
for the duration of the Agreement and are not subject to escalation for any reason unless
amended, or changed by the Notice specified in Section 3.4.2 of this Agreement.

3.14.3 Capitation Payment Amounts After the First Year

The base capitation rates (see Section 3) for the period from the start date of operations
to June 30, 2008 for all non-CHOICES rate categories will be established through a
competitive bid process, and the priority add-on rate and the base capitation rate for
CHOICES members will be established by the State. The base capitation rates (for CHOICES and
non-CHOICES members) and the priority add-on rate for subsequent years will be set by Notice
as provided under Section 3.4.2 of this Agreement.

3.14.4 Payment Methodology

The CONTRACTOR shall be compensated in accordance with Section 3 above as authorized by the
State in a total amount not to exceed the Agreement Maximum Liability established in Section
3.13.1 above. The CONTRACTOR’s compensation shall be contingent upon the satisfactory
completion of requirements under this Agreement.

3.14.5 Return of Funds and Deductions

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

3.14.6 Automatic Deposits

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

Page 312 of 374

 

29. Sections 4.2 through 4.5 shall be deleted in their entirety and replaced with the
following:

4.2 AGREEMENT TERM

4.2.1 Term of the Agreement

	 	 	This Agreement, including any amendments and any changes made by notice to adjust the
capitation rates, shall be effective commencing on August 15, 2006 and ending on June 30,
2010.

4.2.2 Term Extension

	 	 	The State reserves the right to extend this Agreement for an additional period or periods of
time representing increments of no more than one (1) year and a total term of no more than
five (5) years, provided that the State notifies the CONTRACTOR in writing of its intention
to do so at least six (6) months prior to the Agreement expiration date. An extension of the
term of this Agreement will be effected through an amendment to the Agreement.

4.2.3 Exigency Extension

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

4.3 APPLICABLE LAWS AND REGULATIONS

	 	 	The CONTRACTOR agrees to comply with all applicable federal and state laws, rules and
regulations, policies (including TennCare Standard Operating Procedures (so long as said
TennCare Standard Operating Procedure does not constitute a material change to the
obligations of the CONTRACTOR pursuant to this Agreement)), consent decrees, and court
orders, including Constitutional provisions regarding due process and equal protection of
the law, including but not limited to:

	4.3.1	 	42 CFR Chapter IV, Subchapter C (with the exception of those parts waived under the TennCare
Section 1115(a) waiver).
	 
	4.3.2	 	45 CFR Part 74, General Grants Administration Requirements.

Page 313 of 374

 

	4.3.3	 	Titles 4, 47, 56, and 71, Tennessee Code Annotated, including, but not limited to, the
TennCare Drug Formulary Accountability Act, Public Chapter 276 and The Standardized Pharmacy
Benefit Identification Card Act.
	 
	4.3.4	 	All applicable standards, orders, or regulations issued pursuant to the Clean Air Act of
1970 (42 USC 7401, et seq.).
	 
	4.3.5	 	Title VI of the Civil Rights Act of 1964 (42 USC 2000d) and regulations issued pursuant
thereto, 45 CFR Part 80.
	 
	4.3.6	 	Title VII of the Civil Rights Act of 1964 (42 USC 2000e) in regard to employees or
applicants for employment.
	 
	4.3.7	 	Section 504 of the Rehabilitation Act of 1973, 29 USC 794, which prohibits discrimination on
the basis of handicap in programs and activities receiving or benefiting from federal
financial assistance, and regulations issued pursuant thereto, 45 CFR Part 84.
	 
	4.3.8	 	The Age Discrimination Act of 1975, 42 USC 6101 et seq., which prohibits discrimination on
the basis of age in programs or activities receiving or benefiting from federal financial
assistance.
	 
	4.3.9	 	The Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits discrimination on
the basis of sex and religion in programs and activities receiving or benefiting from federal
financial assistance.
	 
	4.3.10	 	Americans with Disabilities Act, 42 USC 12101 et seq., and regulations issued pursuant
thereto, 28 CFR Parts 35, 36.
	 
	4.3.11	 	Sections 1128 and 1156 of the Social Security Act relating to exclusion of providers for
fraudulent or abusive activities involving the Medicare, S CHIP and/or Medicaid program.
	 
	4.3.12	 	Tennessee Consumer Protection Act, TCA 47-18-101 et seq.
	 
	4.3.13	 	The TennCare Section 1115 waiver and all Special Terms and Conditions which relate to the
waiver.
	 
	4.3.14	 	Executive Orders, including Executive Order 1 effective January 26, 1995 and Executive Order
3 effective February 3, 2003.
	 
	4.3.15	 	The Clinical Laboratory Improvement Amendments (CLIA) of 1988.
	 
	4.3.16	 	Requests for approval of material modification as provided at TCA 56-32-201 et
seq.

	 
	4.3.17	 	Investigatory Powers of TDCI pursuant to TCA 56-32-232.
	 
	4.3.18	 	42 USC 1396 et seq. (with the exception of those parts waived under the TennCare Section
1115(a) waiver).
	 
	4.3.19	 	The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Section 117 1(5)(E)
of the Social Security Act as enacted by HIPAA.
	 
	4.3.20	 	Title IX of the Education Amendments of 1972 regarding education programs and activities.

Page 314 of 374

 

	4.3.21	 	Title 42 CFR 422.208 and 210, Physician Incentive
Plans.
	 
	4.3.22	 	Equal Employment Opportunity (EEO) Provisions.
	 
	4.3.23	 	Copeland Anti-Kickback Act.
	 
	4.3.24	 	Davis-Bacon Act.
	 
	4.3.25	 	Contract Work Hours and Safety Standards.
	 
	4.3.26	 	Rights to Inventions Made Under a Contract or
Agreement.
	 
	4.3.27	 	Byrd Anti-Lobbying Amendment.
	 
	4.3.28	 	Subcontracts in excess of one hundred thousand dollars ($100,000) shall require compliance
with all applicable standards, orders or requirements issued under Section 306 of the Clean
Air Act (42 USC 1857 (h)), Section 508 of the Clean Water Act (33 USC 1368), Executive Order
11738, and Environmental Protection Agency regulations (40 CFR Part 15).
	 
	4.3.29	 	Mandatory standards and policies relating to energy efficiency which are contained in the
state energy conservation plan issued in compliance with the Energy Policy and Conservation
Act (P. L. 94-165.)
	 
	4.3.30	 	TennCare Reform Legislation signed May 11, 2004.
	 
	4.3.31	 	Federal Pro-Children Act of 1994 and the Tennessee Children’s Act for Clean Indoor Air of
1995.
	 
	4.3.32	 	Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2.
	 
	4.3.33	 	Title 33 (Mental Health Law) of the Tennessee Code Annotated.
	 
	4.3.34	 	Rules of the Tennessee Department of Mental Health and Developmental Disabilities, Rule 0940
et seq.
	 
	4.3.35	 	Section 1902(a)(68) of the Social Security Act regarding employee education about false
claims recovery.
	 
	4.3.36	 	TennCare rules and regulations.
	 
	4.3.37	 	TCA 3-6-101 et seq., 3-6-201 et seq., 3-6-301 et seq., and
8-50-505.

	 
	4.3.38	 	TCA 71-6-101 et seq.
	 
	4.3.39	 	TCA 37-1-401 et seq. and 37-1-601 et seq.
	 
	4.3.40	 	TCA 68-11-1001 et seq.
	 
	4.3.41	 	TCA 71-5-1401 et seq.

Page 315 of 374

 

4.4 TERMINATION

	 	 	In the event of termination, it is agreed that neither party shall be relieved from any
financial obligations each may owe to the other as a result of liabilities incurred during
the course of this Agreement. For terminations pursuant to Sections 4.4.1, 4.4.2, 4.4.3,
4.4.4, or 4.4.6, TENNCARE will assume responsibility for informing all affected enrollees of
the reasons for their termination from the CONTRACTOR’s MCO.

4.4.1 Termination Under Mutual Agreement

	 	 	Under mutual agreement, TENNCARE and the CONTRACTOR may terminate this Agreement for any
reason if it is in the best interest of TENNCARE and the CONTRACTOR. Both parties will sign
a notice of termination which shall include, inter alia, the date of termination, conditions
of termination, and extent to which performance of work under this Agreement is terminated.

4.4.2 Termination by TENNCARE for Cause

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

	 
	 	4.4.2.3.4	 	Declare a default and terminate this Agreement.
	 
	 	4.4.2.4	 	In the event of a conflict between any other Agreement provisions and Section 4.4.2.3, Section 4.4.2.3 shall control.
	 
	 	4.4.2.5	 	In the event of Breach by the CONTRACTOR, TENNCARE may provide the
CONTRACTOR written notice of the Breach and twenty (20) calendar days to cure

Page 316 of 374

 

	 	 	 	the Breach described in the notice. In the event that the CONTRACTOR fails to
cure the Breach within the time period provided, then TENNCARE shall have
available any and all remedies described herein and available at law.
	 
	 	4.4.2.6	 	In the event the CONTRACTOR disagrees with the determination of noncompliance
or designated corrective action described in the notice, the CONTRACTOR shall
nevertheless implement said corrective action, without prejudice to any rights
the CONTRACTOR may have to later dispute the finding of noncompliance or
designated corrective action.

4.4.3 Termination for Unavailability of Funds

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

4.4.4 Termination Due to Change in Ownership

	 	4.4.4.1	 	In the event that an entity that contracts with TENNCARE to provide the covered
services of this Agreement in the same Grand Region(s) as the CONTRACTOR has or
acquires an indirect ownership interest or an ownership or control interest (as
defined in 42 CFR Part 455, Subpart B) in the CONTRACTOR, TENNCARE may terminate
this Agreement immediately in writing to the CONTRACTOR without penalty. The
CONTRACTOR will be entitled to reimbursement under the Agreement provisions
regarding mutual termination in Section 4.4.1.
	 
	 	4.4.4.2	 	In the event that the CONTRACTOR has or acquires an indirect ownership interest
or an ownership or control interest (as defined in 42 CFR Part 455, Subpart B)
of an entity that contracts with TENNCARE to provide the covered services of
this Agreement in the same Grand Region(s) as the CONTRACTOR, TENNCARE may
terminate this Agreement immediately in writing to the CONTRACTOR without
penalty. The CONTRACTOR will be entitled to reimbursement under the Agreement
provisions regarding mutual termination in Section 4.4.1.
	 
	 	4.4.4.3	 	If an entity that contracts with TENNCARE to provide the covered services of
this Agreement in the same Grand Region(s) as the CONTRACTOR proposes to acquire an
indirect ownership interest or an ownership or control interest (as defined in
42 CFR Part 455, Subpart B) in the CONTRACTOR, or the CONTRACTOR proposes to
acquire an indirect ownership interest or an ownership or control interest (as
defined in 42 CFR Part 455, Subpart B) in an entity that contracts with TENNCARE
to provide covered services of this Agreement in the same Grand Region(s) as the
CONTRACTOR, the CONTRACTOR shall notify TENNCARE and shall provide TENNCARE with
regular updates regarding the proposed acquisition.

4.4.5 Termination for CONTRACTOR Financial Inviability, Insolvency or Bankruptcy

	 	4.4.5.1	 	If TENNCARE reasonably determines that the CONTRACTOR’s financial condition
is not sufficient to allow the CONTRACTOR to provide the services as described
herein in the manner required by TENNCARE, TENNCARE may terminate this

Page 317 of 374

 

	 	 	 	Agreement in whole or in part, immediately or in stages. Said termination shall
not be deemed a Breach by either party. The CONTRACTOR’s financial condition
shall be presumed not sufficient to allow the CONTRACTOR to provide the services
described herein in the manner required by TENNCARE if the CONTRACTOR can not
demonstrate to TENNCARE’s satisfaction that the CONTRACTOR has risk reserves and
a net worth to meet the applicable net worth requirement specified in Section
2.2 1.5 of this Agreement.
	 
	 	4.4.5.2	 	CONTRACTOR insolvency or the filing of a petition in bankruptcy by or against the
CONTRACTOR shall constitute grounds for termination for cause. In the event of
the filing of a petition in bankruptcy by or against a principal subcontractor
or provider or the insolvency of said subcontractor or provider, the CONTRACTOR
shall immediately advise TENNCARE.

4.4.6 Termination by TENNCARE for Convenience

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

4.4.7 Termination by CONTRACTOR

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

4.4.8 Termination Procedures

	 	4.4.8.1	 	The party initiating the termination shall render written notice of termination
to the other party by certified mail, return receipt requested, or in person with proof
of delivery. The notice of termination shall specify the provision of this
Agreement giving the right to terminate, the circumstances giving rise to
termination, and the date on which such termination shall become effective.
	 
	 	4.4.8.2	 	Upon receipt of notice of termination, and subject to the provisions of this
Section, on the date and to the extent specified in the notice of termination, the
CONTRACTOR shall:
	 
	 	4.4.8.2.1	 	Stop work under the Agreement, but not before the termination date;

Page 318 of 374

 

	 	4.4.8.2.2	 	At the point of termination, assign to TENNCARE in the manner and extent
directed by TENNCARE all the rights, title and interest of the CONTRACTOR for the
performance of the subcontracts to be determined at need in which case TENNCARE shall
have the right, in its discretion, to settle or pay any of the claims arising out of
the termination of such agreements and subcontracts;
	 
	 	4.4.8.2.3	 	Complete the performance of such part of the Agreement that shall have not been
terminated under the notice of termination;
	 
	 	4.4.8.2.4	 	Take such action as may be necessary, or as a contracting officer may direct, for the
protection of property related to this Agreement which is in possession of the CONTRACTOR and
in which TENNCARE has or may acquire an interest;
	 
	 	4.4.8.2.5	 	In the event the Agreement is terminated by TENNCARE, continue to serve or arrange for
provision of services to the enrollees in the CONTRACTOR’s MCO for up to forty-five (45)
calendar days from the Agreement termination date or until the members can be transferred to
another MCO, whichever is longer. During this transition period, TENNCARE shall continue to
make payment as specified in Section 3;
	 
	 	4.4.8.2.6	 	Promptly make available to TENNCARE, or another MCO acting on behalf of TENNCARE, any and
all records, whether medical, behavioral, related to long-term care services or financial,
related to the CONTRACTOR’s activities undertaken pursuant to this Agreement. Such records
shall be in a usable form and shall be provided at no expense to TENNCARE;
	 
	 	4.4.8.2.7	 	Promptly supply all information necessary to TENNCARE or another MCO acting on behalf of
TENNCARE for reimbursement of any outstanding claims at the time of termination;
	 
	 	4.4.8.2.8	 	Submit a termination plan to TENNCARE for review, which is subject to TENNCARE written
approval. This plan shall, at a minimum, contain the provisions in Sections 4.4.8.2.9 through
4.4.8.2.14 below. The CONTRACTOR shall agree to make revisions to the plan as necessary in
order to obtain approval by TENNCARE. Failure to submit a termination plan and obtain written
approval of the termination plan by TENNCARE shall result in the withhold of ten percent (10%)
of the CONTRACTOR’s monthly capitation payment;
	 
	 	4.4.8.2.9	 	Agree to maintain claims processing functions as necessary for a minimum of nine (9)
months (or longer if it is likely there are additional claims outstanding) in order to
complete adjudication of all claims;
	 
	 	4.4.8.2.10	 	Agree to comply with all duties and/or obligations incurred prior to the actual
termination date of the Agreement, including but not limited to, the appeal process as
described in Section 2.19;
	 
	 	4.4.8.2.11	 	File all reports concerning the CONTRACTOR’s operations during the term of the Agreement
in the manner described in this Agreement;

Page 319 of 374

 

	 	4.4.8.2.12	 	Take whatever other actions are necessary in order to ensure the
efficient and orderly transition of members from coverage under this Agreement
to coverage under any new arrangement developed by TENNCARE;
	 
	 	4.4.8.2.13	 	In order to ensure that the CONTRACTOR fulfills its continuing obligations both
before and after termination, maintain the financial requirements (as described in this
Agreement as of the CONTRACTOR’s date of termination notice), fidelity bonds and
insurance set forth in this Agreement until the State provides the CONTRACTOR written
notice that all continuing obligations of this Agreement have been fulfilled; and
	 
	 	4.4.8.2.14	 	Upon expiration or termination of this Agreement, submit reports to TENNCARE
every thirty (30) calendar days detailing the CONTRACTOR’s progress in completing its
continuing obligations under this Agreement. The CONTRACTOR, upon completion of these
continuing obligations, shall submit a final report to TENNCARE describing how the
CONTRACTOR has completed its continuing obligations. TENNCARE shall within twenty (20)
calendar days of receipt of this report advise in writing whether TENNCARE agrees that
the CONTRACTOR has fulfilled its continuing obligations. If TENNCARE finds that the
final report does not evidence that the CONTRACTOR has fulfilled its continuing
obligations, then TENNCARE shall require the CONTRACTOR to submit a revised final
report. TENNCARE shall in writing notify the CONTRACTOR once the CONTRACTOR has
submitted a revised final report evidencing to the satisfaction of TENNCARE that the
CONTRACTOR has fulfilled its continuing obligations.

30. Section 4.7.2 shall be deleted in its entirety.

31. Section 4.12 shall be amended by replacing “must’ with “shall” to read as follows:

4.12 CONTRACTOR APPEAL RIGHTS

	 	 	The CONTRACTOR shall have the right to contest TENNCARE decisions pursuant to the
provisions of TCA 9-8-30 1 et seq. for the resolution of disputes under this
Agreement. Written notice describing the substance and basis of the contested
action shall be submitted to TENNCARE within thirty (30) calendar days of the
action taken by TENNCARE. The CONTRACTOR shall comply with all requirements
contained within this Agreement pending the final resolution of the contested
action.

32. Section 4.15 shall be amended by correcting a CFR reference and replacing “must” with
“shall to read as follows:

4.15 DATA THAT MUST BE CERTIFIED

	4.15.1	 	In accordance with 42 CFR 438.604 and 438.606, when State payments to the
CONTRACTOR are based on data submitted by the CONTRACTOR, the CONTRACTOR shall
certify the data. The data that shall be certified include, but are not limited to,
enrollment information, encounter data, and other information required by the State
and contained in contracts, proposals and related documents including the medical
loss ratio (MLR) report. The data shall be certified by one of the following: the
CONTRACTOR’s Chief Executive Officer, the CONTRACTOR’s Chief Financial

Page 320 of 374

 

	 	 	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 shall attest, based on best knowledge, information, and belief, as
follows:

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

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

33. Sections 4.20 shall be deleted in its entirety and replaced with the following:

4.20 FAILURE TO MEET AGREEMENT REQUIREMENTS

	 	 	It is acknowledged by TENNCARE and the CONTRACTOR that in the event of CONTRACTOR’s failure
to meet the requirements provided in this Agreement and all documents incorporated herein,
TENNCARE will be harmed. The actual damages which TENNCARE will sustain in the event of and
by reason of such failure are uncertain, are extremely difficult and impractical to
ascertain and determine. The parties therefore acknowledge that the CONTRACTOR shall be
subject to damages and/or sanctions as described below. It is further agreed that the
CONTRACTOR shall pay TENNCARE liquidated damages as directed by TENNCARE; provided however,
that if it is finally determined that the CONTRACTOR would have been able to meet the
Agreement requirements listed below but for TENNCARE’s failure to perform as provided in
this Agreement, the CONTRACTOR shall not be liable for damages resulting directly therefrom.

4.20.1 Intermediate Sanctions

	 	4.20.1.1	 	TENNCARE may impose any or all of the sanctions as described in this Section
upon TENNCARE’s reasonable determination that the CONTRACTOR failed to comply
with any corrective action plan (CAP) as described under Section 2.25.9 or
Section 2.23.13 of this Agreement, or is otherwise deficient in the performance
of its obligations under the Agreement, which shall include, but may not be
limited to the following:
	 
	 	4.20.1.1.1	 	Fails substantially to provide medically necessary covered services;
	 
	 	4.20.1.1.2	 	Imposes on members cost sharing responsibilities that are in excess of the cost
sharing permitted by TENNCARE;
	 
	 	4.20.1.1.3	 	Acts to discriminate among enrollees on the basis of their health status or need
for health care services;
	 
	 	4.20.1.1.4	 	Misrepresents or falsifies information that it furnishes to CMS or to the State;
	 
	 	4.20.1.1.5	 	Misrepresents or falsifies information that it furnishes to a member, potential
member, or provider;
	 
	 	4.20.1.1.6	 	Fails to comply with the requirements for physician incentive plans, as required
by 42 CFR 438.6(h) and set forth (for Medicare) in 42 CFR 422.208 and 422.2 10;

Page 321 of 374

 

	 	4.20.1.1.7	 	Has distributed directly, or indirectly through any agent or
independent contractor, marketing or member materials that have not been
approved by the State or that contain false or materially misleading
information; and
	 
	 	4.20.1.1.8	 	Has violated any of the other applicable requirements of Sections 1903(m) or 1932
of the Social Security Act and any implementing regulations.
	 
	 	4.20.1.2	 	TENNCARE shall only impose those sanctions it determines to be appropriate for
the deficiencies identified. However, TENNCARE may impose intermediate sanctions on
the CONTRACTOR simultaneously with the development and implementation of a
corrective action plan if the deficiencies are severe and/or numerous.
Intermediate sanctions may include:
	 
	 	4.20.1.2.1	 	Liquidated damages as described in Section 4.20.2;
	 
	 	4.20.1.2.2	 	Suspension of enrollment in the CONTRACTOR’s MCO;
	 
	 	4.20.1.2.3	 	Disenrollment of members;
	 
	 	4.20.1.2.4	 	Limitation of the CONTRACTOR’s service area;
	 
	 	4.20.1.2.5	 	Civil monetary penalties as described in 42 CFR 438.704;
	 
	 	4.20.1.2.6	 	Appointment of temporary management for an MCO as provided in 42 CFR 438.706;
	 
	 	4.20.1.2.7	 	Suspension of all new enrollment, including default enrollment, after the
effective date of the sanction;
	 
	 	4.20.1.2.8	 	Suspension of payment for recipients enrolled after the effective date of the
sanction and until CMS or the State is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur; or
	 
	 	4.20.1.2.9	 	Additional sanctions allowed under federal law or state statute or regulation
that address areas of noncompliance.

4.20.2 Liquidated Damages

	 	4.20.2.1	 	Reports and Deliverables 
	 
	 	4.20.2.1.1	 	For each day that a report or deliverable is late, incorrect, or deficient, the
CONTRACTOR shall be liable to TENNCARE for liquidated damages in the amount of one
hundred dollars ($100) per day per report or deliverable unless specified otherwise in
this Section. Liquidated damages for late reports/deliverables shall begin on the first
day the report/deliverable is late.
	 
	 	4.20.2.1.2	 	Liquidated damages for incorrect reports or deficient deliverables shall begin on
the first day after the report/deliverable was due.

Page 322 of 374

 

	 	4.20.2.1.3	 	For the purposes of determining liquidated damages in accordance with this Section,
reports or deliverables are due as specified elsewhere in this Agreement or by TENNCARE.
	 
	 	4.20.2.2	 	Program Issues
	 
	 	4.20.2.2.1	 	Liquidated damages for failure to perform specific responsibilities or responsibilities
as described in this Agreement are shown in the chart below. Damages are grouped into three
categories: Level A, Level B, and Level C program issues.
	 
	 	4.20.2.2.2	 	Failure to perform specific responsibilities or requirements categorized as Level A are
those which pose a significant threat to patient care or to the continued viability of the
TENNCARE program.
	 
	 	4.20.2.2.3	 	Failure to perform specific responsibilities or requirements categorized as Level B are
those with pose threats to the integrity of the TENNCARE program, but which do not
necessarily imperil patient care.
	 
	 	4.20.2.2.4	 	Failure to perform specific responsibilities or requirements categorized as Level C are
those which represent threats to the smooth and efficient operation of the TENNCARE program
but which do not imperil patient care or the integrity of the TENNCARE program.
	 
	 	4.20.2.2.5	 	TENNCARE may also assess liquidated damages for failure to meet performance standards
as provided in Section 2.24.3, Attachment VII, and Attachment XI of this Agreement.
	 
	 	4.20.2.2.6	 	TENNCARE reserves the right to assess a general liquidated damage of five hundred
dollars ($500) per occurrence with any notice of deficiency.
	 
	 	4.20.2.2.7	 	Liquidated Damages Chart

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.1

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

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

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

Page 323 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.4

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

	 	Denial of a request for services
to
a child at risk of entering DCS
custody when the services have
been reviewed and authorized by
the TENNCARE Chief Medical
Officer
	 	The actual amount paid by DCS and/or
TENNCARE for necessary services or
$1000, whichever is greater
	 
	 	 	 	 
	A.6(a)

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

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

	 	Failure to comply with this
Agreement and federal rules/law
regarding
Sterilizations/Abortions/Hysterectomies
as outlined in
Section 2.7.8 of this Agreement
	 	$500 per occurrence or the actual
amount of the federal penalty created by
the CONTRACTOR’s failure to
comply, whichever is greater
	 
	 	 	 	 
	A.8

	 	Failure to provide coverage for
prenatal care without a delay in
care and in accordance with
Section 2.7.5 of this Agreement
	 	$500 per day, per occurrence, for each
calendar day that care is not provided in
accordance with the terms of this
Agreement

Page 324 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.9

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

$500 per day for each calendar day
beyond the 2nd business day after an On
Request Report regarding a member’s
request for continuation of benefits is
sent by TENNCARE
	 
	 	 	 	 
	A.10.(a)

	 	Failure to comply with the notice
requirements of this Agreement,
TennCare rules and regulations
or any subsequent amendments
thereto, and all court orders and
consent decrees governing
appeal procedures, as they
become effective
	 	$500 per occurrence in addition to $500
per calendar day for each calendar day
required notices are late or deficient or
for each calendar day beyond the
required time frame that the appeal is
unanswered in each and every aspect
and/or each day the appeal is not
handled according to the provisions set forth by this Agreement or required by TENNCARE
	 
	 	 	 	 
	A.l0.(b)

	 	Failure to submit a timely
corrected notice of adverse
action to TENNCARE for
review and approval prior to
issuance to the member
	 	$1,000 per occurrence if the notice
remains defective plus a per calendar
day assessment in increasing increments
of $500 ($500 for the first day, $1,000
for the second day, $1,500 for the third
day, etc,) for each day the notice is late
and/or remains defective
	 
	 	 	 	 
	A.11

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

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

Page 325 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.13

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

Damages per instance shall increase in
$500 increments for each subsequent
“systemic problem or violation of the
law” ($500 per instance the first time a
“systemic problem or violation of the
law” relating to a particular requirement
is identified; $1,000 per instance for the
2nd time a “systemic problem or
violation of the law” relating to the
same requirement is identified; etc.)
	 
	 	 	 	 
	A.14

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

Page 326 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	A.15

	 	Failure to comply with the
timeframes for developing and
approving a plan of care for
transitioning CHOICES members
in Group 2, initiating nursing
facility services for transitioning
CHOICES members in Group 1,
or initiating long-term care
services for CHOICES members
(see Sections 2.9.2, 2.9.3, and
2.9.6)
	 	$5,000 per month that the
CONTRACTOR’s performance is 85-
89% by service setting (nursing facility
or HCBS)

$10,000 per month that the
CONTRACTOR’s performance is 80-
84% by service setting (nursing facility
or HCBS)

$15,000 per month that the
CONTRACTOR’s performance is 75-
79% by service setting (nursing facility
or HCBS)

$20,000 per month that the
CONTRACTOR’s performance is 70-
74% by service setting (nursing facility
or HCBS)

$25,000 per month that the
CONTRACTOR’s performance is 69%
or less by service setting (nursing facility
or HCBS)
	 
	 	 	 	 
	A.16

	 	Failure to meet the performance
standards established by
TENNCARE regarding missed
visits for personal care, attendant
care, homemaker, or home-
delivered meals for CHOICES
members (referred to herein as
“specified HCBS”)
	 	$5,000 per month that 11-15% of visits
are missed for a reason attributable to the
provider (provider initiated), by specified
HCBS

$10,000 per month that 16-20% of visits
are missed for a reason attributable to the
provider (provider initiated), by specified
HCBS

$15,000 per month that 21 -25% of visits
are missed for a reason attributable to the
provider (provider initiated), by specified
HCBS

$20,000 per month that 26-30% of visits
are missed for a reason attributable to the
provider (provider initiated), by specified
HCBS

$25,000 per month that 31% or more of
visits are missed for a reason attributable
to the provider (provider initiated), by
specified HCBS
	 
	 	 	 	 
	B.1

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

Page 327 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.2

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

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

	 	Failure to submit NCQA
Accreditation Report
as described in
Section 2.15.6
	 	$500 per day for every calendar day
beyond the 10th calendar day
Accreditation Status is not reported
	 
	 	 	 	 
	B.5

	 	Failure to comply
with Conflict of
Interest, Lobbying,
and/or Gratuities
requirements described
in Section 4.19,
4.23, 4.24, or 2.12.9.4.8
	 	110% of the total amount of
compensation paid by the CONTRACTOR to
inappropriate individuals
	 
	 	 	 	 
	B.6

	 	Failure to disclose
Lobbying Activities
and/or quarterly
conflict of interest
disclosure as required
by Section 4.24, 4.19,
or 2.12.9.4.8
	 	$1000 per day that disclosure is late
	 
	 	 	 	 
	B.7

	 	Failure to obtain
approval of member
materials as required
by Section 2.17 of
this Agreement
	 	$500 per day for each calendar day that TENNCARE determines the CONTRACTOR has
provided member material that has not been approved by TENNCARE
	 
	 	 	 	 
	B.8

	 	Failure to comply with
time frames for
providing Member
Handbooks, I.D. cards,
Provider Directories,
Quarterly Member
Newsletters, and
CHOICES member
education materials as
required in Section
2.17
	 	$5000 for each occurrence
	 
	 	 	 	 
	B.9

	 	If the CONTRACTOR knew
or should have known
that a member has not
received long-term
care services for
thirty (30) days or
more, failure to
report on that member
in accordance with
Section 2.30.10.5 (see
also Section 2.6.1.5.
7)
	 	For each member, an amount equal to the
CHOICES capitation rate prorated for
the period of time in which the member
did not receive long-term care services
	 
	 	 	 	 
	B.10

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

	 	Failure to submit the
CONTRACTOR’S annual
NAIC filing as
described in Section
2.30.l5.3
	 	$500 per calendar day

Page 328 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.12

	 	Failure to submit the
CONTRACTOR’s
quarterly NAIC filing
as described in
Section 2.30.15.3
	 	$500 per calendar day
	 
	 	 	 	 
	B.13

	 	Failure to submit
audited financial
statements as
described in Section
2.30.15.3
	 	$500 per calendar day
	 
	 	 	 	 
	B. 14

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

	 	Failure to require and
ensure compliance with
Ownership and
Disclosure
requirements as
required in Section
2.12.9.60 of this
Agreement
	 	$5000 per provider 

disclosure/attestation
for each disclosure/attestation
that is not received
or is received and signed by a
provider that does not request
or contain complete and
satisfactory disclosure of the
requirements outlined in 42 CFR
455, Subpart B
	 
	 	 	 	 
	B.16

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

	 	Failure to comply with
the time frame for
resolving complaints
(see Section 2.19.2)
	 	$1,000 per month that the

CONTRACTOR’s performance is
85-89%

 $2,000 per month that the

CONTRACTOR’s performance is
80-84%

 $3,000 per month that the

CONTRACTOR’s performance is
75-79%

 $4,000 per month that the

CONTRACTOR’s performance is
70-74%

 $5,000 per month that the

CONTRACTOR’s performance is 69%
or less
	 
	 	 	 	 
	B.18

	 	Failure to maintain
required insurance as
required in Section
2.21.8 of this
Agreement
	 	$500 per calendar day
	 
	 	 	 	 
	B.19

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

Page 329 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.20

	 	Imposing arbitrary
utilization guidelines or
other quantitative coverage
limits as prohibited in
Section 2.6.3 and 2.14.1
of this Agreement
	 	$500 per occurrence
	 
	 	 	 	 
	B.21

	 	Failure to provide CRG/TPG
assessments within the time
frames specified in Section
2.7.2.9 of this Agreement
	 	$500 per month per Enrollee
	 
	 	 	 	 
	B.22

	 	Failure to provide CRG/TPG
assessments by
TDMHDD-certified raters or
in accordance with TDMHDD
policies and procedures as
required in Section 2.7.2.9
of this Agreement
	 	$500 per occurrence per case
	 
	 	 	 	 
	B.23

	 	Failure to meet any
timeframe regarding care
coordination for CHOICES
members (see Sections
2.9.2,2.9.3, and 2.9.6)
other than the timeframes
referenced in A.15 or A.16
	 	$1,000 per month for each
timeframe that the CONTRACTOR’s
performance is 85-89%

 $2,000 per
month for each timeframe that the
CONTRACTOR’s performance is 80-84%

$3,000 per month for each
timeframe that the CONTRACTOR’s
performance is 75-79% 

$4,000 per
month for each timeframe that the
CONTRACTOR’s performance is 70-74%

$5,000 per month for each

timeframe that the CONTRACTOR’s
performance is 69% or less
	 
	 	 	 	 
	B.24

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

And/Or 

	 

	 	 	 	$1000 per application per day for
each day beyond thirty (30)
calendar days that a completed
credentialing application has not
been processed as described in
Section 2.11.8 of this Agreement

Page 330 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	B.25

	 	Failure to maintain provider
agreements in accordance with
Section 2.12 and Attachment
XI of this Agreement
	 	$5000 per provider agreement
found to be non-compliant with
the requirements outlined in
this Agreement
	 
	 	 	 	 
	B.26

	 	Failure to comply with the
requirements regarding an
agreement to audit accounts
(Section 2.2 1.10)
	 	$1,500 for each day after
December 1 of each year that
the fully executed agreement
for audit accounts is not
submitted or for each day after
December 1 of each year that
the fully executed agreement
does not include the required
language
	 
	 	 	 	 
	C.1

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

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

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

	 	Failure to address or resolve
problems with individual
encounter records in a timely
manner as required by
TENNCARE
	 	An amount equal to the paid
amount of the individual
encounter record(s) that was
rejected or, in the case of
capitated encounters, the
fee-for-service equivalent
thereof as determined by
TENNCARE
	 
	 	 	 	 
	C.5

	 	Failure to reimburse the
first MCO within thirty (30)
calendar days of receipt of a
properly documented request
for a misaligned newborn in
accordance with Section
2.4.9.5
	 	$1000.00 per day for each day
beyond thirty (30) calendar
days of receipt of a properly
documented request in addition
to a one time assessment of
$5,000 per occurrence
	 
	 	 	 	 
	C.6

	 	Failure to comply with the
requirements regarding
documentation for CHOICES
members (see Section 2.9.6)
	 	$500 per plan of care for
members in Group 2 or 3 that
does not include all of the
required elements 

$500 per
member file that does not
include all of the required
elements 

$500 per face-to-face
visit where the care
coordinator fails to document
the specified observations

Page 331 of 374

 

	 	 	 	 	 
	LEVEL	 	PROGRAM ISSUES	 	DAMAGE
	C.7

	 	Failure to submit a Provider
Enrollment File that meets
TENNCARE’s specifications (see
Section 2. 30.7.1)
	 	$250 per day after the due
date that the Provider
Enrollment File fails to meet
TENNCARE’s specifications

	 	4.20.2.3	 	Payment of Liquidated Damages
	 
	 	4.20.2.3.1	 	It is further agreed by TENNCARE and the CONTRACTOR that any liquidated damages
assessed by TENNCARE shall be due and payable to TENNCARE within thirty (30) calendar days
after CONTRACTOR receipt of the notice of damages. If payment is not made by the due date,
said liquidated damages may be withheld from future payments by TENNCARE without further
notice, as provided in Section 3.14.5 of this Agreement. It is agreed by TENNCARE and the
CONTRACTOR that
the collection of liquidated damages by TENNCARE shall be made without regard to any
appeal rights the CONTRACTOR may have pursuant to this Agreement; however, in the
event an appeal by the CONTRACTOR results in a decision in favor of the CONTRACTOR,
any such funds withheld by TENNCARE will be immediately returned to the CONTRACTOR.
Any cure periods referenced in this Agreement shall not apply to the liquidated
damages described in this Section. With respect to Level B and Level C program issues
(failure to perform responsibilities or requirements), the due dates mentioned above
may be delayed if the CONTRACTOR can show good cause as to why a delay should be
granted. TENNCARE has sole discretion in determining whether good cause exists for
delaying the due dates.
	 
	 	4.20.2.3.2	 	Liquidated damages as described in Section 4.20.2 shall not be passed to a provider
and/or subcontractor unless the damage was caused due to an action or inaction of the
provider and/or subcontractor. Nothing described herein shall prohibit a provider and/or a
subcontractor from seeking judgment before an appropriate court in situations where it is
unclear that the provider and/or the subcontractor caused the damage by an action or
inaction.
	 
	 	4.20.2.3.3	 	All liquidated damages imposed pursuant to this Agreement, whether paid or due, shall
be paid by the CONTRACTOR out of administrative costs and profits.
	 
	 	4.20.2.4	 	Application of Liquidated Damages for CHOICES
	 
	 	 	 	In applying liquidated damages related to care coordination timeframes (see A. 15 and
B.23), HCBS missed visits (see A. 16), and the CHOICES Utilization Report (see B.9)
TENNCARE may take into consideration whether, as determined by TENNCARE, the
CONTRACTOR promptly remedied a deficiency and/or a deficiency was due to circumstances
beyond the CONTRACTOR’s control. Such consideration shall be based on information
provided by the CONTRACTOR in the applicable report (see Section 2.30) and/or
additional information submitted by the CONTRACTOR as requested by TENNCARE.

Page 332 of 374

 

	 	4.20.2.5	 	Waiver of Liquidated Damages
	 
	 	 	 	TENNCARE may waive the application of liquidated damages and/or withholds upon
the CONTRACTOR if the CONTRACTOR is placed in rehabilitation or under
administrative supervision if TENNCARE determines that such waiver is in the
best interests of the TennCare program and its enrollees.

4.20.3 Claims Processing Failure

	 	 	 	If it is determined that there is a claims processing deficiency related to the CONTRACTOR’s
ability/inability to reimburse providers in a reasonably timely and accurate fashion as
required by Section 2.22, TENNCARE shall provide a notice of deficiency and request
corrective action. The CONTRACTOR may also be subject to the application of liquidated
damages and/or intermediate sanctions specified in Sections 4.20.1 and 4.20.2 and the
retention of withholds as specified in Section 3.9. If the CONTRACTOR is unable to
successfully implement corrective action and demonstrate adherence with timely claims
processing requirements within the time approved by TENNCARE, the State may terminate this
Agreement in accordance with Section 4.4 of this Agreement.

4.20.4 Failure to Manage Medical Costs

	 	 	 	If TENNCARE determines the CONTRACTOR is unable to successfully manage costs for covered
services, TENNCARE may terminate this Agreement with ninety (90) calendar days advance
notice in accordance with Section 4.4 of this Agreement.

4.20.5 Sanctions by CMS

	 	 	 	Payments provided for under this Agreement will be denied for new enrollees when, and for so
long as, payment for those enrollees is denied by CMS in accordance with the requirements in
42 CFR 438.730.

4.20.6 Temporary Management

	 	 	 	TENNCARE may impose temporary management if it finds that the CONTRACTOR has repeatedly
failed to meet substantive requirements in Section 1903(m) or Section 1932 of the Social
Security Act.

	34.	 	 	Section 4.24.1 shall be amended by deleting the parenthetical and shall read as
follows:

	 	4.24.1	 	The CONTRACTOR certifies by signing this Agreement, to the best of its knowledge and
belief, that federal funds have not been used for lobbying in accordance with 45 CFR
Part 93 and 31 USC 1352.

Page 333 of 374

 

	 	4.30	 	 VOLUNTARY BUYOUT PROGRAM

	 	4.30.1	 	The CONTRACTOR acknowledges and understands that, for a period of two years
beginning August 16, 2008, restrictions are imposed on former state employees who
received a State of Tennessee Voluntary Buyout Program (VBP) severance payment with
regard to contracts with state agencies that participated in the VBP.

	 	4.30.2	 	The State will not contract with either a former state employee who received a
VBP severance payment or an entity in which a former state employee who received a
VBP severance payment or the spouse of such an individual holds a controlling
financial interest.

	 	4.30.3	 	The State may contract with an entity with which a former state employee
who received a VBP severance payment is an employee or an independent contractor.
Notwithstanding the foregoing, the CONTRACTOR understands and agrees that there may be
unique business circumstances under which a return to work by a former state employee
who received a VBP severance payment as an employee or an independent contractor of a
State contractor would not be appropriate, and in such cases the State may refuse
CONTRACTOR personnel. Inasmuch, it shall be the responsibility of the State to review
CONTRACTOR personnel to identify any such issues.

	 	4.30.4	 	With reference to either Section 4.30.2 or 4.30.3 above, the CONTRACTOR may submit a
written request for a waiver of the VBP restrictions regarding a former state employee
and a contract with a state agency that participated in the VBP. Any such request must
be submitted to the State in the form of the VBP Contracting Restriction Waiver
Request format available from the State and the Internet at:
www.state.tn.us/finance/rds/ocr/waiver.html. The determination on such a
request shall be at the sole discretion of the head of the state agency that is a
Party to this Agreement, the Commissioner of Finance and Administration, and the
Commissioner of Human Resources.

	36.	 	 	 Section 4.34 shall be amended to replace “Contractor” with “CONTRACTOR” and
“contract” with “Agreement” and shall read as follows:

	 	4.34	 	 PROHIBITION OF ILLEGAL IMMIGRANTS

	 	4.34.1	 	The requirements of Public Acts of 2006, Chapter Number 878, of the state of
Tennessee, addressing the use of illegal immigrants in the performance of any contract
to supply goods or services to the state of Tennessee, shall be a material provision
of this Contract, a breach of which shall be grounds for monetary and other penalties,
up to and including termination of this Contract.
	 
	 	4.34.2	 	The CONTRACTOR hereby attests, certifies, warrants, and assures that the
CONTRACTOR shall not knowingly utilize the services of an illegal immigrant in the
performance of this Contract and shall not knowingly utilize the services of any
subcontractor who will utilize the services of an illegal immigrant in the
performance of this Agreement. The CONTRACTOR shall reaffirm this attestation, in
writing, by submitting to the State a completed and signed copy of the document as
Attachment X,

Page 334 of 374

 

	 	 	hereto, semi-annually during the period of this Agreement. Such attestations
shall be maintained by the contractor and made available to state officials
upon request.

	 	4.34.3	 	Prior to the use of any subcontractor in the performance of this Agreement, and
semiannually thereafter, during the period of this Agreement, the CONTRACTOR shall
obtain and retain a current, written attestation that the subcontractor shall not
knowingly utilize the services of an illegal immigrant to perform work relative to this
Agreement and shall not knowingly utilize the services of any subcontractor who will
utilize the services of an illegal immigrant to perform work relative to this
Agreement. Attestations obtained from such subcontractors shall be maintained by the
CONTRACTOR and made available to state officials upon request.

	 	4.34.4	 	The CONTRACTOR shall maintain records for all personnel used in the performance of
this Agreement. Said records shall be subject to review and random inspection at any
reasonable time upon reasonable notice by the State.

	 	4.34.5	 	The CONTRACTOR understands and agrees that failure to comply with this section will
be subject to the sanctions of Public Chapter 878 of 2006 for acts or omissions
occurring after its effective date. This law requires the Commissioner of Finance and
Administration to prohibit a contractor from contracting with, or submitting an
offer, proposal, or bid to contract with the State of Tennessee to supply goods or
services for a period of one year after a contractor is discovered to have knowingly
used the services of illegal immigrants during the performance of this Agreement.

	 	4.34.6	 	For purposes of this Agreement, “illegal immigrant” shall be defined as any person
who is not either a United States citizen, a Lawful Permanent Resident, or a person
whose physical presence in the United States is authorized or allowed by the federal
Department of Homeland Security and who, under federal immigration laws and/or
regulations, is authorized to be employed in the U.S. or is otherwise authorized to
provide services under the Agreement.

	37.	 	 	Section 4 shall be amended by adding a new Section 4.37 and renumbering the
existing Sections accordingly, including any references thereto.

	 	4.37	 	FEDERAL ECONOMIC STIMULUS FUNDING

	 	 	 	This Agreement requires the CONTRACTOR to provide products and/or services that are
funded in whole or in part under the American Recovery and Reinvestment Act of 2009,
Public Law 111-5 (Recovery Act). The CONTRACTOR is responsible for ensuring that all
applicable requirements of the Recovery Act are met and that the CONTRACTOR provides
information to the State as required by, but not limited to, the following:

	 	4.37.1	 	The Recovery Act, including but not limited to the following sections of that Act:

	 	4.37.1.1	 	Section 1606 — Wage Rate Requirements.
	 
	 	4.37.1.2	 	Section 1512 — Reporting and Registration Requirements.
	 
	 	4.37.1.3	 	Sections 902, 1514, and 1515 — General Accounting
Office/Inspector General Access.

Page 335 of 374

 

	 	4.37.1.4	 	Section 1553 — Whistleblower Protections.
	 
	 	4.37.1.5	 	Section 1605 — Buy American Requirements for Construction
Material.

	 	4.37.2	 	Executive Office of the President, Office of Management and Budget (OMB)
Guidelines as posted at
http://www.whitehouse.gov/omb/recovery_default/, as well as OMB
Circulars, including but not limited to A- 102 and A- 133 as posted at
http://www.whitehouse.gov/omb/financial_offm_circulars/.
	 
	 	4.37.3	 	Federal Grant Award Documents.
	 
	 	4.37.4	 	Office of Tennessee Recovery Act Management Directives.

38. Attachment I shall be deleted in its entirety and replaced with the following:

ATTACHMENT I

BEHAVIORAL HEALTH SPECIALIZED SERVICE DESCRIPTIONS

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

			
	 	 	 
	SERVICE
	 	Mental Health Case Management
	 	 	 

DEFINITION

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

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

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

Page 336 of 374

 

SERVICE DELIVERY

The CONTRACTOR shall:

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

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

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

	 	20 individuals: 1 team

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

(C&Y)CTT

	 	15 individuals:1 team

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

	 	15 individuals:1 team

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

	 	100 individuals:1 team

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

	 	100 individuals:1 team

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

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

 

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

The CONTRACTOR shall ensure that the following requirements are met:

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

Page 337 of 374

 

Level 1

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

Assertive Community Treatment (ACT)

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

	 	1)	 	Services targeted to a specific group of individuals with severe mental illness;
	 
	 	2)	 	Treatment, support and rehabilitation services provided directly by the ACT team;
	 
	 	3)	 	Sharing of responsibility between team members and individuals served by the team;
	 
	 	4)	 	Small staff (all team staff including case managers) to individual ratios (approx. 1 to 10);
	 
	 	5)	 	Comprehensive and flexible range of treatment and services;
	 
	 	6)	 	Interventions occurring in community settings rather than in hospitals or clinic settings;
	 
	 	7)	 	No arbitrary time limit on receiving services;
	 
	 	8)	 	Individualized treatment, support and rehabilitation services;
	 
	 	9)	 	Twenty-four (24) hour a day availability of services; and
	 
	 	10)	 	Engagement of individuals in treatment and monitoring.

Continuous Treatment Team (CTT)

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

Comprehensive Child and Family Treatment (CCFT)

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

Page 338 of 374

 

Program of Assertive and Community Treatment (PACT)

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

Level 2

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

SERVICE COMPONENTS

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

Crisis Facilitation

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

Assessment of Daily Functioning

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

Assessment/Referral/Coordination

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

Mental Health Liaison

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

Page 339 of 374

 

DEFINITION

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

Services included under psychiatric rehabilitation are as follows.

SERVICE COMPONENTS

Psychosocial Rehabilitation

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

Supported Employment

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

Peer Support

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

Page 340 of 374

 

Illness Management & Recovery

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

Supported Housing

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

39. Attachment II shall be deleted in its entirety and replaced with the following:

ATTACHMENT II

COST SHARING SCHEDULE

Non-Pharmacy
Copayment Schedule Prior to January 1, 2010

(unless otherwise directed by TENNCARE)

	 	 	 
	Poverty	 	 
	Level	 	Copayment Amounts
	0% - 99%

	 	$0.00 
	 
	 	 
	100% - 199%

	 	$25.00, Hospital Emergency Room (waived if admitted) $5.00,
Primary Care Provider and Community Mental Health Agency
Services Other Than Preventive Care $15.00, Physician
Specialists (including Psychiatrists) $100.00, Inpatient
Hospital Admission
	 
	 	 
	200% and above

	 	$50.00, Hospital Emergency Room (waived if admitted) $10.00,
Primary Care Provider and Community Mental Health Agency
Services Other Than Preventive Care $25.00, Physician
Specialists (including Psychiatrists) $200.00, Inpatient
Hospital Admission

Non-Pharmacy
Copayment Schedule Effective January 1, 2010

(unless otherwise directed by TENNCARE)

	 	 	 
	Poverty	 	 
	Level	 	Copayment Amounts
	0% -  99%

	 	$0.00 

Page 341 of 374

 

	 	 	 
	Poverty	 	 
	Level	 	Copayment Amounts
	100% - 199% 

	 	$10.00, Hospital Emergency Room
(waived if admitted) $5.00,
Primary Care Provider and Community Mental Health Agency
Services Other Than Preventive Care $5.00, Physician
Specialists (including Psychiatrists) $5.00, Inpatient
Hospital Admission (waived if readmitted within 48 hours
for the same episode)
	 
	 	 
	200% and above

	 	$50.00, Hospital Emergency Room (waived if admitted)
$15.00, Primary Care Provider and Community Mental Health
Agency Services Other Than Preventive Care $20.00,
Physician Specialists (including Psychiatrists) $100.00,
Inpatient Hospital Admission (waived if readmitted within
48 hours for the same episode)

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

40. Attachment III shall be deleted in its entirety and replaced with the following:

ATTACHMENT III

GENERAL ACCESS STANDARDS

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

	 	•	 	Primary Care Physician or Extender:

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

	 	+	 	Documentation — Plans must have a system in place to
document appointment scheduling times.
	 
	 	+	 	Tracking — Plans must have a system in place to
document the exchange of member information if a provider, other than
the primary care provider (i.e., school-based clinic or health
department clinic), provides health care.

Page 342 of 374

 

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

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

	•	 	Long-Term Care Services:

Transport time for adult day care will be the usual and customary, not to exceed 30 miles.

	•	 	General Optometry Services:

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

	•	 	Lab and X-Ray Services:

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

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

Page 343 of 374

 

ATTACHMENT V

ACCESS & AVAILABILITY FOR BEHAVIORAL HEALTH SERVICES

The CONTRACTOR shall adhere to the following behavioral health network requirements to
ensure access and availability to behavioral health services for all members (adults
and children). For the purpose of assessing behavioral health provider network
adequacy, TENNCARE will evaluate the CONTRACTOR’s provider network relative to the
requirements described below. Providers serving adults will be evaluated separately
from those serving children.

Access to Behavioral Health Services

The CONTRACTOR shall ensure access to behavioral health providers for the provision
of covered services. At a minimum, this means that:

The CONTRACTOR shall have provider agreements with providers of the services
listed in the table below and meet the geographic and time for
admission/appointment requirements.

	 	 	 	 	 
	 	 	 	 	Maximum Time
	 	 	Geographic Access	 	for Admission/
	Service Type	 	Requirement	 	Appointment
	Psychiatric Inpatient 

Hospital Services

	 	Travel distance does not
exceed 60 miles for at
least 75% of members and
does not exceed 90 miles
for at least 90% of
members
	 	4 hours (emergency

involuntary )/24 hours

(involuntary)/24 hours

(voluntary)
	 
	 	 	 	 
	24 Hour Psychiatric 

Residential Treatment

	 	Travel distance does not
exceed 75 miles for at
least 75% of ADULT members
and does not exceed 150
miles for at least 90% of
ADULT members
	 	Within 30 calendar days
	 
	 	 	 	 
	 

	 	Travel distance does not
exceed 60 miles for at
least 75% of CHILD members
and does not exceed 90
miles for at least 90% of
CHILD members	 	 
	 
	 	 	 	 
	Outpatient Non-MD Services

	 	Travel distance does not

exceed 30 miles for ALL

members
	 	Within 10 business
days; if urgent,
within 48 hours

Page 344 of 374

 

	 	 	 	 	 
	 	 	 	 	Maximum Time
	 	 	Geographic Access	 	for Admission/
	Service Type	 	Requirement	 	Appointment
	Intensive Outpatient (may
include Day Treatment
(adult), Intensive Day
Treatment (Children &
Adolescent) or Partial
Hospitalization

	 	Travel distance
does not exceed 60
miles for at least
75% of members and
does not exceed 90
miles for at least
90% of members
	 	Within 10 business days;
if urgent, within 48
hours
	 
	 	 	 	 
	Inpatient Facility Services

(Substance Abuse)

	 	Travel distance
does not exceed 60
miles for at least
75% of members and
does not exceed 90
miles for at least
90% of members
	 	Within 2 calendar days;
for detoxification
-within 4 hours in an
emergency and 24 hours
for non-emergency
	 
	 	 	 	 
	24 Hour Residential 

Treatment Services

(Substance Abuse)*

	 	Travel distance
does not exceed 75
miles for at least
75% of members and
does not exceed 120
miles for at least
90% of members
	 	Within 10 business days
	 
	 	 	 	 
	Outpatient Treatment 

Services (Substance Abuse)

	 	Travel distance
does not exceed 30
miles for ALL
members
	 	Within 10 business days;
for detoxification-within
24 hours
	 
	 	 	 	 
	Mental Health Case 

Management

	 	Not subject to
geographic access
standards
	 	Within 7 calendar days
	 
	 	 	 	 
	Psychosocial Rehabilitation
(may include Supported
Employment, Illness
Management & Recovery, or
Peer Support (TDMHDD Rule
Chapter 1940-5-29)

	 	Not subject to
geographic access
standards
	 	Within 10 business days
	 
	 	 	 	 
	Supported Housing

	 	Travel distance
does not exceed 60
miles for at least
75% of ADULT
members and does
not exceed 90 miles
for at least 90% of
ADULT members
	 	Within 30 calendar days
	 
	 	 	 	 
	Crisis Services (Mobile)

	 	Not subject to
geographic access
standards
	 	Face-to-face contact
within 1 hour for
emergency situations and
4 hours for urgent
situations
	 
	 	 	 	 
	Crisis Stabilization

	 	Not subject to
geographic access
standards
	 	Within 4 hours of referral

 

			
	*	 	24 Hour Residential Treatment Substance Abuse Services may be provided by
facilities licensed by the Tennessee Department of Health as Halfway House
Treatment Facilities (DOH Rule Chapter 1200-8-17), Residential
Detoxification Treatment Facilities (DOH Rule Chapter 1200-8-22) or
Residential Rehabilitation

Page 345 of 374

 

			
	 	 	Treatment Facilities (DOH Rule Chapter 1200-8-23). (Effective 1/1/2008, the
Tennessee Department of Mental Health and Developmental Disabilities will
license these facilities.)

When the above standards are not met, an acceptable Corrective Action Plan will be
requested which details the CONTRACTOR’s intended course of action to resolve any
deficiency (ies) identified. The Bureau of TennCare will evaluate Corrective Action
Plans and, at its sole discretion, determine network adequacy considering any
alternate measures and documentation of unique market conditions.

At a minimum, providers for the following service types shall be reported
on the Provider Enrollment File:

	 	 	 
	 	 	Service Code(s) for use in
	 	 	position 330-331 of the
	Service Type	 	Provider Enrollment File
	Psychiatric Inpatient Hospital Services

	 	Adult - 11, 79, 85 
Child - A1 or H9
	 
	 	 
	24 Hour Psychiatric Residential Treatment

	 	Adult - 13,81,82 
Child - A9,
H1, or H2
	 
	 	 
	Outpatient MD Services (Psychiatry)

	 	Adult - 19
 Child - B5
	 
	 	 
	Outpatient Non-MD Services

	 	Adult - 20 
Child - B6
	 
	 	 
	Intensive Outpatient/ Partial Hospitalization

	 	Adult - 21,23, 62 
Child - B7,
C2, C3
	 
	 	 
	Inpatient Facility Services (Substance Abuse)

	 	Adult - 15, 17
 Child - A3, A5
	 
	 	 
	24 Hour Residential Treatment Services (Substance Abuse)

	 	Adult - 56 
Child - F6
	 
	 	 
	Outpatient Treatment Services (Substance Abuse)

	 	Adult - 27 or 28 
Child - D3 or D4
	Mental Health Case Management

	 	Adult - 31, 66, or 83
 Child - C7, D7,
G2, G6, or K1
	 
	 	 
	Psychiatric Rehabilitation Services:
	 	 
	 
	 	 
	Psvchosocial Rehabilitation

	 	42 
	 
	 	 
	     Supported Employment
	 	44 
	 
	 	 
	     Peer Support

	 	88 
	 
	 	 
	     Illness Management & Recovery

	 	91 
	 
	 	 
	Supported Housing

	 	32 and 33 
	 
	 	 
	Crisis Services (Mobile)

	 	Adult - 37, 38, 39 
Child - D8, D9, E1
	 
	 	 
	Crisis Respite

	 	Adult - 40 
Child - E2
	 
	 	 
	Crisis Stabilization

	 	Adult - 41

Page 346 of 374

 

42. Attachment VII shall be deleted in its entirety and replaced with the following:

ATTACHMENT VII

PERFORMANCE STANDARDS

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	1

	 	Timely Claims

Processing
	 	Report from TDCI
	 	90% of clean electronic
claims for nursing
facility services and
HCBS excluding PERS,
assistive technology,
minor home
modifications, and pest
control are processed
and paid within fourteen
(14) calendar days of
receipt
	 	Percentage of clean
electronic claims
paid within 14
calendar days of
receipt of claim,
for each month
	 	Monthly
	 	$10,000 for each
month determined
not to be in
compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	99.5% of clean
electronic claims for
nursing facility and
HCBS other than PERS,
assistive technology,
minor home
modifications, and pest
control shall be
processed and paid
within twenty-one (21)
calendar days of receipt
	 	Percentage of clean
electronic claims
processed within 21
calendar days of
receipt of claim,
determined for
month	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	90% of all of other
claims (for which no
further written
information or
substantiation is
required in order to
make payment) are paid
within thirty (30)
calendar days of the
receipt of claim.
	 	Percentage of
claims paid
within 30 calendar
days of receipt
of claim, for each
month	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	99.5% of all other
claims are processed
within sixty (60)
calendar days.
	 	Percentage of
claims processed
within 60 calendar
days of receipt
of claim, for each
month	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	2

	 	Claims Payment

Accuracy
	 	Self-reported

results based on

an internal audit

conducted on a

statistically valid

random sample

will be validated

by TDCI
	 	97% of claims paid
accurately upon initial
submission
	 	Percentage of total
claims paid
accurately for each
month and by
provider type (NF,
HCBS, and other)
	 	Monthly
	 	$5,000 for each
full percentage
point accuracy is
below 97% for each
month for each
provider type (NF,
HCBS, and other)

Page 347 of 374

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	3

	 	Telephone Response

Time/Call Answer

Timeliness-Member

Services Line
	 	Member Services and
Provider Services
Phone Line Report
	 	85% of all calls to each
line are answered by a
live voice within thirty
(30) seconds or the
prevailing benchmark
established by NCQA
	 	The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation) during the
measurement period
	 	Quarterly
	 	$25,000 for each

full percentage

point below 85% per

month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	4

	 	Telephone Response

Time/Call Answer

Timeliness-Provider Services

Line
	 	Member Services and
Provider Services
Phone Line Report
	 	85% of all calls to each
line are answered by a
live voice within thirty
(30) seconds or the
prevailing benchmark
established by NCQA
	 	The number of calls
answered by a live
voice within 30
seconds, divided by
the number of calls
received by the
phone line (during
hours of operation)
during the
measurement period
	 	Quarterly
	 	$25,000 for each

full percentage

point below 85% per

month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	Telephone Call

Abandonment Rate

(unanswered calls)

—Member Services

Line
	 	Member Services and
Provider Services
Phone Line Report
	 	Less than 5% of
telephone calls are
abandoned
	 	The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
	 	Quarterly
	 	$25,000 for each

full percentage

point above 5% per

month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	6

	 	Telephone Call
Abandonment Rate
(unanswered calls)
— Provider
Services Line
	 	Member Services and
Provider Services
Phone Line Report
	 	Less than 5% of
telephone calls are
abandoned
	 	The number of calls
abandoned by the
caller or the
system before being
answered by a live
voice divided by
the number of calls
received by the
phone line (during
open hours of
operation) during
the measurement
period
	 	Quarterly
	 	$25,000 for each

full percentage

point above 5% per

month
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	7(a)

	 	Left blank

intentionally	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	7(b)

	 	Left blank

intentionally	 	 	 	 	 	 	 	 	 	 

Page 348 of 374

 

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

	 	Provider Network

Documentation
	 	Provider Enrollment
File and provider
agreement signature
pages
	 	100% of providers on the
Provider Enrollment File
have a signed provider
agreement with the
CONTRACTOR
	 	 	 	Upon TENNCARE

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

Page 349 of 374

 

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

	 	Specialist Provider Network
	 	Provider Enrollment File
	 	1 . Physician Specialists: Executed
speciality physician contracts in all areas required by this
Agreement for the following specialists: allergy; cardiology;
dermatology; endocrinology; gastroenterology; general surgery;
nephrology; neurology; neurosurgery; otolaryngology; ophthalmology;
orthopedics; oncology/hematology; psychiatry (adults); psychiatry (child/adolescent); and urology

2. Essential Hospital Services: Executed
contract with at least (1) tertiary care center for each essential hospital service

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

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

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

Page 350 of 374

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	10 

	 	HCBS Provider Network
	 	Provider Enrollment File
	 	At least two (2) providers for each HCBS, other than community-based residential alternatives, to cover each county in the Grand Region
	 	Executed contract is a signed provider agreement with a provider to participate in the CONTRACTOR’s network as a contract provider
	 	Quarterly
	 	Beginning after the first calendar
quarter following implementation of CHOICES in the Grand Region covered by this Agreement, $25,000 if ANY of the listed standards are not met, either individually or in combination on a quarterly basis
	 

	 	 	 	 	 	 	 	 	 	 	 	The liquidated damage may be waived
if the CONTRACTOR provides sufficient documentation to demonstrate that the deficiency is attributable to a lack of HCBS provider serving the county and the CONTRACTOR has used good faith efforts to
develop HCBS providers to serve the county.
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	The liquidated damage may be lowered to $5,000 in the event the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE

Page 351 of 374

 

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

	 	Provider Participation Accuracy
	 	Provider Enrollment File
	 	At least 90% of listed providers confirm participation in the CONTRACTOR’s network
	 	A statistically valid sample of participating providers on the most recent monthly provider enrollment file confirm that they are participating in the CONTRACTOR’s network
	 	Quarterly
	 	$25,000 per quarter if less than 90% of providers confirm participation. The liquidated damage may be lowered to $5,000 in the event that the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE, or may be
waived by TENNCARE if the CONTRACTOR submits sufficient documentation
to demonstrate 90% of providers in the sample are participating
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	12

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

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

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

Page 352 of 374

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	13

	 	Distance from provider to member
	 	Provider Enrollment File
	 	In accordance with this Agreement, including Attachments III through V
	 	Time and travel distance as measured by GeoAccess
	 	Monthly
	 	S25,000 if ANY of the listed standards are not met, either individually or in combination, on a monthly basis.
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	The liquidated damage may be lowered to $5,000 in the event that the CONTRACTOR provides a corrective action plan that is accepted by TENNCARE.
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 	 	For the first six months after CHOICES implementation, TENNCARE will waive the liquidated damage related to distance to adult day care if the
CONTRACTOR demonstrates that it is providing NEMT to adult day care in accordance with Section 2.11.1.8. Thereafter, TENNCARE may waive the
liquidated damage regarding distance to adult day care if the CONTRACTOR provides sufficient documentation to demonstrate that the deficiency
is attributable to a lack of adult day care providers and the CONTRACTOR has used good faith efforts to develop adult day care providers.

Page 353 of 374

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	14

	 	Initial appointment

timeliness for behavioral health services
	 	Behavioral Health Initial Appointment Timeliness Report
	 	85% of all initial appointments for
behavioral health services for outpatient mental health services (MD and Non-MD) and outpatient substance abuse services shall meet the access and availability standards indicated in Attachment V
	 	Average time between the intake assessment appointment and the member’s next appointment scheduled or admission by type of service
	 	Quarterly
	 	$2,000 for each service type for which less than 85% of all initial appointments for the specified provider types meet the access and availability standards indicated in Attachment V
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	15

	 	Percentage of SPMI/SED members who receive a behavioral health service (excluding a CRG/TPG assessment)
	 	Claims and encounter data
	 	The percentage of SPMI/SED members who receive a behavioral health service (excluding a CRG/TPG assessment) will not be less than 76%
	 	The number of SPMI/SED members
receiving a behavioral health service (excluding a CRG/TPG assessment) during the fiscal year divided by the MCO’s number of SPMI/SED members during the fiscal year is not less than the benchmark
	 	Annually
	 	$25,000 for each year determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	16

	 	Non-IMD Impatient

Use
	 	Behavioral Health Crisis Service Response Reports and utilization data
	 	10% decrease of total inpatient
days at freestanding psychiatric hospitals subject to IMD exclusion compared to the base year’s utilization
	 	Total inpatient psychiatric
hospital days at IMD exclusion facilities for members reduced by 10% after base line year
	 	Annually
	 	$10,000 for each year determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	17

	 	TENNderCare Screening
	 	MCO encounter data
	 	TENNderCare screening ratio, 80%
	 	The EPSDT screening ratio, calculated by TENNCARE utilizing MCO encounter data submissions in accordance with specifications for the CMS—416 report
	 	Quarterly
	 	$5,000 for each full percentage point TENNderCare screening ratio is below 80% for the most recent rolling twelve month period
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	18

	 	Increase in utilization of supported employment
	 	Supported Employment Reports
	 	15% of all adults (21 — 64 years of age) designated as SPMI actively receiving supported
employment services will be gainfully employed in either part time or full time capacity for a continuous 90 day period within one (1) year of receiving supported employment services
	 	Total number of SPMI adults
receiving supported employment services as defined in Attachment I
employed for a continuous 90-day period within one (1) year of receiving supported employment services divided by the total number of SPMI adults
	 	Annually
	 	$25,000 for each year determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	19

	 	Generic Prescription Drug Utilization
	 	Encounter data
	 	Sixty percent (60%)
	 	Number of generic prescriptions divided by the total number of prescriptions
	 	Quarterly
	 	$5,000 for each full percentage point Generic Prescription Utilization ratio is below 60%

Page 354 of 374

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	PERFORMANCE	 	 	 	 	 	 	 	MEASUREMENT	 	 
	 	 	MEASURE	 	DATA SOURCE(S)	 	BENCHMARK	 	DEFINITION	 	FREQUENCY	 	LIQUIDATED DAMAGE
	20

	 	Length of time between psychiatric hospital/RTF discharge and first subsequent mental health case management service
	 	Mental Health Case Management Report
	 	90% of discharged members receive a mental health case management service as medically necessary within seven (7) calendar days of discharge, excluding situations involving member reschedules, no shows, and refusals	 	(I) Number of members discharged by
length of time between discharge and first subsequent mental health case management service as medically necessary reported by CMHA and type of service received; determined for each month
	 	Quarterly
	 	$3,000 for each quarter determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	(2) Average length of time
between hospital discharge and first subsequent medically necessary MHCM visit reported by CMHA and type of service received excluding member reschedules, no shows, and refusals; determined for each month	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	21

	 	Seven (7) day readmission rate
	 	Psychiatric Hospital/RTF Readmission Report
	 	Not more than 10% of members discharged from an inpatient or residential facility are readmitted within seven (7) calendar days of discharge
	 	Number of members discharged from
an inpatient or residential facility divided by the number of members readmitted within seven (7) calendar days of discharge; determined for each month in the quarter
	 	Quarterly
	 	$1,500 for each quarter determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	22

	 	Thirty (30) day
readmission rate
	 	Psychiatric Hospital/RTF Readmission Report
	 	Not more than 15% of members discharged from an inpatient or residential facility are readmitted within thirty (30) calendar days of discharge	 	Number of members discharged from
an inpatient or residential facility divided by the number of members readmitted within thirty (30) calendar days of discharge; detemined for each month in the quarter
	 	Quarterly
	 	$1,500 for each quarter determined to not be in compliance
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	23

	 	Members are satisfied with the services they receive from behavioral health providers
	 	Annual consumer satisfaction survey administered by TDMHDD
	 	85% of respondent rale their experience to be fair or better
	 	Distribution of members by satisfaction score
	 	Annually
	 	$10,000 for each response below 85%

Page 355 of 374

 

ATTACHMENT VIII

DELIVERABLE REQUIREMENTS

GENERAL

This is a preliminary list of deliverables. The CONTRACTOR and TENNCARE shall agree to the
appropriate deliverables, deliverable format/submission requirements, submission and approval time
frames, and technical assistance as required. Deliverables shall be submitted to the TennCare
Bureau unless otherwise specified.

TENNCARE will require that some or all deliverables be reviewed and/or approved by TENNCARE during
the readiness review and/or during operations. As specified by TENNCARE, material modifications to
certain deliverables must be reviewed and/or approved by TENNCARE.

DELIVERABLE ITEMS

	1.	 	Evidence of TDCI license for CONTRACTOR and subcontractors (as applicable) to ensure
compliance with Section 2.1.1
	 
	2.	 	Notification that a member may satisfy any of the conditions for termination from the
TennCare program in accordance with Section 2.5.4
	 
	3.	 	Request for prior approval/notice of use of cost effective alternative services in
accordance with Section 2.6.5
	 
	4.	 	Request for prior approval of incentives in accordance with Section 2.6.6
	 
	5.	 	Policies and procedures for patient liability that ensure compliance with Section 2.6.7.2
	 
	6.	 	Policies and procedures for self-direction of health care tasks in accordance with Section
2.7.3
	 
	7.	 	Description of health education and outreach programs and activities to ensure
compliance with Section 2.7.4
	 
	8.	 	TENNderCare policies and procedures that ensure compliance with the requirements of
Section 2.7.6
	 
	9.	 	Policies and procedures for advance directives that ensure compliance with Section 2.7.7
	 
	10.	 	Disease management program policies and procedures that ensure compliance with Section 2.8
	 
	11.	 	Service coordination policies and procedures that ensure compliance with Section 2.9.1
	 
	12.	 	Policies and procedures for transition of new members that ensure compliance
with the requirements of Section 2.9.2

Page 356 of 374

 

	13.	 	Policies and procedures for transition of member receiving long-term care services at the
time of CHOICES implementation that ensure compliance with Section 2.9.3
	 
	14.	 	Transition of care polices and procedures that ensure compliance with Section 2.9.4
	 
	15.	 	MCO case management policies and procedures that ensure compliance with Section 2.9.5
	 
	16.	 	Care coordination policies and procedures that ensure compliance with Section 2.9.6
	 
	17.	 	Policies and procedures for consumer direction of HCBS that ensure compliance with Section
2.9.7
	 
	18.	 	Policies and procedures for coordination of physical health, behavioral health, and
long-term care services that ensure compliance with Section 2.9.8
	 
	19.	 	If CONTRACTOR subcontracts for the provision of behavioral health services, agreement with
the subcontractor in accordance with Section 2.9.8.2 to ensure compliance with Section 2.9.8
	 
	20.	 	Policies and procedures for coordination among behavioral health providers that ensure
compliance with Section 2.9.9
	 
	21.	 	Policies and procedures for coordination of pharmacy services that ensure compliance with
Section 2.9.10
	 
	22.	 	Policies and procedures for coordination of dental services that ensure compliance with
Section 2.9.11
	 
	23.	 	Identification of members serving on the claims coordination committee in accordance with
Section 2.9.11.5.3
	 
	24.	 	Policies and procedures for coordination with Medicare that ensure compliance with Section
2.9.12
	 
	25.	 	Policies and procedures for inter-agency coordination that ensure compliance with Section
2.9.14
	 
	26.	 	Polices and procedures regarding non-covered services that ensure compliance with Section
2.10
	 
	27.	 	Policies and procedures to develop and maintain a provider network that ensure compliance
with Section 2.11.1, including policies and procedures for selection and/or retention of
providers
	 
	28.	 	Policies and procedures for PCP selection and assignment that ensure compliance with
Section 2.11.2, including policies and procedures regarding change of PCP and use of
specialist as PCP
	 
	29.	 	Plan to identify, develop, or enhance existing inpatient and residential treatment capacity
for adults and adolescents with co-occurring mental health and substance abuse disorders to
ensure compliance with Section 2.11.5.2
	 
	30.	 	Credentialing manual and policies and procedures that ensure compliance with Section 2.11.8
	 
	31.	 	Policies and procedures that ensure compliance with notice requirements in Section 2.11.9
	 
	32.	 	Notice of provider and subcontractor termination and additional documentation as
required by Section 2.11.9.2

Page 357 of 374

 

	33.	 	Provider agreement template(s) and revisions to TDCI as required in Section 2.12
	 
	34.	 	Indemnity language in provider agreements if different than standard indemnity language
(see Section 2.12.9.49)
	 
	35.	 	Intent to use a physician incentive plan (PIP) to TennCare Bureau and TDCI (see Section
2.13.8)
	 
	36.	 	Any provider agreement templates or subcontracts that involve a PIP for review as a
material modification (to TDCI) as required by (see Section 2.13.8)
	 
	37.	 	Pricing policies for emergency services provided by non-contract providers that ensure
compliance with Section 2.13.9.1
	 
	38.	 	Policies and procedures for PCP profiling to ensure compliance with Section 2.14.9
	 
	39.	 	Information on PCP profiling as requested by TENNCARE (see Section 2.14.9)
	 
	40.	 	QM/QI policies and procedures to ensure compliance with Section 2.15
	 
	41.	 	Copy of signed contract with NCQA approved vendor to perform CAHPS as required by Section
2.15.5
	 
	42.	 	Copy of signed contract with NCQA approved vendor to perform HEDIS audit as required by
Section 2.15.5
	 
	43.	 	Evidence that NCQA accreditation application submitted and fee paid (Section 2.15.5.1)
	 
	44.	 	HEDIS BAT as required by Section 2.15.6
	 
	45.	 	Copy of signed NCQA survey contract as required by Section 2.15.5.1
	 
	46.	 	Notice of date for ISS submission and NCQA on-site review as required by Section 2.15.5.1
	 
	47.	 	Notice of final payment to NCQA as required by Section 2.15.5.1
	 
	48.	 	Notice of submission of ISS to NCQA as required by Section 2.15.5.1
	 
	49.	 	Copy of completed NCQA survey and final report as required by Section 2.15.5.1
	 
	50.	 	Notice of any revision to NCQA accreditation status
	 
	51.	 	Policies and procedures regarding critical incident management and reporting to ensure
compliance with Section 2.15.8
	 
	52.	 	Member materials as described in Section 2.17, including but not limited to, member
handbook, quarterly member newsletters, identification card, and provider directory along
with any required supporting materials
	 
	53.	 	Member services phone line policies and procedures that ensure compliance with Section 2.18.1

Page 358 of 374

 

	54.	 	Policies and procedures regarding interpreter and translation services that ensure
compliance with Section 2.18.2
	 
	55.	 	Provider service and phone line policies and procedures that ensure compliance with Section
2.18.4
	 
	56.	 	Description of 24/7 ED Assistance Line (see Section 2.18.4.7)
	 
	57.	 	Provider handbook that is in compliance with requirements in Section 2.18.5
	 
	58.	 	Provider education and training plan and materials that ensure compliance with Section 2.18.6
	 
	59.	 	Provider relations policies and procedures in compliance with Section 2.18.7
	 
	60.	 	Protocols regarding one-on-one assistance to long-term care providers that ensure compliance
with Section 2.18.7.2
	 
	61.	 	Policies and procedures to monitor and ensure provider compliance with the Agreement
(see Section 2.18.7.3)
	 
	62.	 	Policies and procedures for a provider complaint system that ensure compliance with Section
2.18.8
	 
	63.	 	FEA education and training plan and materials that ensure compliance with Section 2.18.9
	 
	64.	 	Policies and procedures regarding member involvement with behavioral health services that
ensure compliance with Section 2.18.10
	 
	65.	 	Appeal and complaint policies and procedures that ensure compliance with Section 2.19
	 
	66.	 	Fraud and abuse policies and procedures that ensure compliance with Section 2.20
	 
	67.	 	Report all confirmed or suspected fraud and abuse to the appropriate agency as required in
Section 2.20.2
	 
	68.	 	Fraud and abuse compliance plan (see Section 2.20.3)
	 
	69.	 	TPL policies and procedures that ensure compliance with Section 2.21.4
	 
	70.	 	Accounting policies and procedures that ensure compliance with Section 2.21.7
	 
	71.	 	Proof of insurance coverage (see Section 2.21.8)
	 
	72.	 	Executed agreement for audit accounts that contains the required language (see Section
2.21.11)
	 
	73.	 	Claims management policies and procedures that ensure compliance with Section 2.22
	 
	74.	 	Internal claims dispute procedure (see Section 2.22.5)
	 
	75.	 	EOB policies and procedures to ensure compliance with Section 2.22.8
	 
	76.	 	Systems policies and procedures, manuals, etc. to ensure compliance with Section 2.23 (see
Section 2.23.10)

Page 359 of 374

 

	77.	 	Proposed approach for remote access in accordance with Section 2.23.6.10
	 
	78.	 	Information security plan as required by Section 2.23.6.11
	 
	79.	 	Notification of Systems problems in accordance with Section 2.23.7
	 
	80.	 	Systems Help Desk services in accordance with Section 2.23.8
	 
	81.	 	Notification of changes to Systems in accordance with Section 2.23.9
	 
	82.	 	Notification of changes to membership of behavioral health advisory committee and
current membership lists in accordance with Section 2.24.2
	 
	83.	 	Notification of changes to membership of CHOICES Advisory Group and current membership lists
in accordance with Section 2.24.3
	 
	84.	 	An abuse and neglect plan in accordance with Section 2.24.4
	 
	85.	 	Medical record keeping policies and procedures that ensure compliance with Section 2.24.6
	 
	86.	 	Subcontracts (see Section 2.26)
	 
	87.	 	HIPAA policies and procedures that ensure compliance with Section 2.27
	 
	88.	 	Accounting of disclosures in accordance with Section 2.27.2.10
	 
	89.	 	Notification of use or disclosure in accordance with Section 2.27.2.13.3.3
	 
	90.	 	Notification of any unauthorized acquisition of enrollee PHI in accordance with Section
2.27.2.13.3
	 
	91.	 	Third (3rd) party certification of HIPAA transaction compliance in accordance with
Section 2.27.2.27
	 
	92.	 	Notification of any security incident in accordance with Section 2.27.3
	 
	93.	 	Non-discrimination policies and procedures as required by Section 2.28
	 
	94.	 	Names, resumes, and contact information of key staff as required by Section 2.29.1.2
	 
	95.	 	Changes to key staff as required by Section 2.29.1.2
	 
	96.	 	Staffing plan as required by Section 2.29.1.8
	 
	97.	 	Changes to location of staff from in-state to out-of-state as required by Section 2.29.1.9
	 
	98.	 	Background check policies and procedures that ensure compliance with Section 2.29.2.1
	 
	99.	 	List of officers and members of Board of Directors (see Section 2.29.3)
	 
	100.	 	Changes to officers and members of Board of Directors (see Section 2.29.3)

Page 360 of 374

 

	101.	 	Eligibility and Enrollment Data (see Section 2.30.2.1)
	 
	102.	 	Monthly Enrollment/Capitation Payment Reconciliation Report (see Section 2.30.2.2)
	 
	103.	 	Quarterly Member Enrollment/Capitation Payment Report (see Section 2.30.2.3)
	 
	104.	 	Information on members (see Section 2.30.2.4)
	 
	105.	 	Psychiatric Hospital/RTF Readmission Report (see Section 2.30.4.1)
	 
	106.	 	Mental Health Case Management Report (see Section 2.30.4.2)
	 
	107.	 	Supported Employment Report (see Section 2.30.4.3)
	 
	108.	 	Behavioral Health Crisis Response Report (see Section 2.30.4.4)
	 
	109.	 	Member CRG/TPG Assessment Report (see Section 2.30.4.5)
	 
	110.	 	Rejected CRG/TPG Assessment Report (see Section 2.30.4.6)
	 
	111.	 	CRG/TPG Assessments Audit Report (see Section 2.30.4.7)
	 
	112.	 	Methodology for conducting CRG/TPG assessment audits (see Section 2.30.4.8)
	 
	113.	 	Adverse Occurrences Report (see Section 2.30.4.9)
	 
	114.	 	TENNderCare Report (see Section 2.30.4.10)
	 
	115.	 	Self-Directed Health Care Tasks Report (see Section 2.30.4.11)
	 
	116.	 	Disease Management Update Report (see Section 2.30.5.1)
	 
	117.	 	Disease Management Report (see Section 2.30.5.2)
	 
	118.	 	Disease Management for CHOICES Update Report (see Section 2.30.5.3)
	 
	119.	 	Disease Management for CHOICES Report (see Section 2.30.5.4)
	 
	120.	 	Disease Management Program Description (see Section 2.30.5.5)
	 
	121.	 	MCO Case Management Program Description (see Section 2.30.6.1.1)
	 
	122.	 	MCO Case Management Services Report (see Section 2.30.6.1.2)
	 
	123.	 	MCO Case Management Update Report (see Section 2.30.6.1.3)
	 
	124.	 	Status of Transitioning CHOICES Member Report (see Section 2.30.6.2)
	 
	125.	 	New Member Assessment and Care Planning and Initiation of Services Report (see Section
2.30.6.3)

Page  361 of  374

 

	126.	 	CHOICES Intake, Enrollment, and Service Initiation Report (see Section 2.30.6.4)
	 
	127.	 	Ongoing Assessment and Care Planning and Service Initiation Report (see Section 2.30.6.5)
	 
	128.	 	Post-Enrollment Care Coordination Contact Report (see Section 2.30.6.6)
	 
	129.	 	Nursing Facility Diversion Report (see Section 2.30.6.7)
	 
	130.	 	Nursing Facility to Community Transition Report (see Section 2.30.6.8)
	 
	131.	 	Nursing Facility Utilization Report (see Section 2.30.6.9)
	 
	132.	 	Missed Visits Report (see Section 2.30.6.10)
	 
	133.	 	Care Coordination Staffing Report (see Section 2.30.6.11)
	 
	134.	 	Care Coordination Quality Assurance Plan and Care Coordination Quality Assurance Plan Report
(see Section 2.30.6.12)
	 
	135.	 	Consumer Direction of HCBS Report (see Section 2.30.6.13)
	 
	136.	 	Members identified as potential pharmacy lock-in candidates (see Section 2.30.6.14)
	 
	137.	 	Pharmacy Services Report (see Section 2.30.6.15)
	 
	138.	 	Pharmacy Services Report, On Request (see Section 2.30.6.16)
	 
	139.	 	Provider Enrollment File (see Section 2.30.7.1)
	 
	140.	 	Provider Compliance with Access Requirements Report (see Section 2.30.7.2)
	 
	141.	 	PCP Assignment Report (see Section 2.30.7.3)
	 
	142.	 	Report of Essential Hospital Services (see Section 2.30.7.4)
	 
	143.	 	Behavioral Health Initial Appointment Timeliness Report (see Section 2.30.7.5)
	 
	144.	 	Long-Term Care Provider Network Development Plan (see Section 2.30.7.6)
	 
	145.	 	Long-Term Care Provider Capacity Performance Report (see Section 2.30.7.7)
	 
	146.	 	Qualified Workforce Strategies Report (see Section 2.30.7.8)
	 
	147.	 	FQHC Reports (see Section 2.30.7.9)
	 
	148.	 	Institutions for Mental Diseases (IMD) Out-of-State Report (see Section 2.30.7.10)
	 
	149.	 	Single Case Agreements Report (see Section 2.30.8)
	 
	150.	 	Related Provider Payment Report (see Section 2.30.9)

Page  362 of  374

 

	151.	 	UM program description, work plan, and evaluation (see Section 2.30.10.1)
	 
	152.	 	Cost and Utilization Reports (see Section 2.30.10.2)
	 
	153.	 	Cost and Utilization Summaries (see Section 2.30.10.3)
	 
	154.	 	Identification of high-cost claimants (see Section 2.30.10.4)
	 
	155.	 	CHOICES Utilization Report (see Section 2.30.10.5)
	 
	156.	 	Prior Authorization Reports (see Section 2.30.10.6)
	 
	157.	 	Referral Provider Listing and supporting materials (see Section 2.30.10.7)
	 
	158.	 	ED Threshold Report (see Section 2.30.10.8)
	 
	159.	 	QM/QI Program Description, Associated Work Plan and Annual Evaluation (see Section 2.30.
11. 1)
	 
	160.	 	Report on Performance Improvement Projects (see Section 2.30.11.2)
	 
	161.	 	NCQA Accreditation Report (see Section 2.30.11.3)
	 
	162.	 	NCQA revaluation of accreditation status based on HEDIS scores (see Section 2.30.11.4)
	 
	163.	 	Reports of Audited CAHPS Results and Audited HEDIS Results (see Section 2.30.11.5)
	 
	164.	 	Health Outcomes Survey data files (see Section 2.30.11.6)
	 
	165.	 	Critical Incidents Report (see Section 2.30.11.7)
	 
	166.	 	Member Services and Provider Services Phone Line Report (see Section 2.30.12.1.1)
	 
	167.	 	24/7 Nurse Triage Line Report (see Section 2.30.12.1.2)
	 
	168.	 	ED Assistance Tracking Report (see Section 2.30.12.1.3)
	 
	169.	 	Translation/Interpretation Services Report (see Section 2.30.12.3)
	 
	170.	 	Provider Satisfaction Survey Report (see Section 2.30.12.4)
	 
	171.	 	Provider Complaints Report (see Section 2.30.12.5)
	 
	172.	 	Member Complaints Report (see Section 2.30.13)
	 
	173.	 	Fraud and Abuse Activities Report (see Section 2.30.14.1)
	 
	174.	 	Policies in compliance with Section 1 902(a)(68) of the Social Security Act (see Section
2.30.14.3)
	 
	175.	 	Recovery and Cost Avoidance Report (see Section 2.30.15.1.1)

Page  363 of  374

 

	176.	 	Other Insurance Report (see Section 2.30.15.1.2)
	 
	177.	 	Patient Liability Report (see Section 2.30.15.2)
	 
	178.	 	Medical Loss Ratio (MLR) Report (see Section 2.30.15.3.1)
	 
	179.	 	Ownership and Financial Disclosure Report (see Section 2.30.15.3.2)
	 
	180.	 	Annual audit plan (see Section 2.30.15.3.3)
	 
	181.	 	Financial Plan and Projection of Operating Results Report (to TDCI) (see Section 2.30.15.4.1)
	 
	182.	 	Comparison of Actual Revenues and Expenses to Budgeted Amounts Report (to TDCI) (see
Section 2.30.15.4.2)
	 
	183.	 	Annual Financial Report (to TDCI) (see Section 2.30.15.4.3)
	 
	184.	 	Quarterly Financial Report (to TDCI) (see Section 2.30.15.4.4)
	 
	185.	 	Audited Financial Statements (to TDCI) (see Section 2.30.15.4.5)
	 
	186.	 	Claims Payment Accuracy Report (see Section 2.30.16.1)
	 
	187.	 	EOB Report (see Section 2.30.16.2)
	 
	188.	 	Claims Activity Report (see Section 2.30.16.3)
	 
	189.	 	HCBS Annual Benefit limits Report (see Section 2.30.16.4)
	 
	190.	 	Cost Neutrality Report (see Section 2.30.16.5)
	 
	191.	 	Expenditure Cap Report (see Section 2.30.16.6)
	 
	192.	 	Cost Effective Alternative Services for CHOICES Report (see Section 2.30.16.7)
	 
	193.	 	Systems Refresh Plan (see Section 2.30.17.1)
	 
	194.	 	Encounter Data Files (see Section 2.30.17.2)
	 
	195.	 	Electronic version of claims paid reconciliation (see Section 2.30.17.3)
	 
	196.	 	Information and/or data to support encounter data submission (see Section 2.30.17.4)
	 
	197.	 	Systems Availability and Performance Report (see Section 2.30.17.5)
	 
	198.	 	Business Continuity and Disaster Recovery Plan (see Section 2.30.17.6)
	 
	199.	 	Reports on the Activities of the CONTRACTOR’s Behavioral Health Advisory Committee (see
Section 2.30.18.1)

Page  364 of  374

 

	200.	 	Report on the Activities of the CONTRACTOR’s CHOICES Advisory Group (see Section
2.30.18.2)
	 
	201.	 	Subcontracted claims processing report (see Section 2.30.19.1)
	 
	202.	 	Security Incident Report (see Section 2.30.20)
	 
	203.	 	Summary Listings of Servicing Providers (see Section 2.30.21.1)
	 
	204.	 	Supervisory Personnel Report (see Section 2.30.21.2)
	 
	205.	 	Alleged Discrimination Report (see Section 2.30.21.3)
	 
	206.	 	Non-discrimination policy (see Section 2.30.21.4)
	 
	207.	 	Non-Discrimination Compliance Plan and Assurance of Non-Discrimination (see Section
2.30.21.5)
	 
	208.	 	Provider reimbursement rates for services incurred prior to the start date of operations
in accordance with Section 3.7.1.2.1
	 
	209.	 	Disclosure of conflict of interest (see Section 2.30.22.1)
	 
	210.	 	Attestation Re: Personnel Used in Contract Performance (see Section 2.30.22.2)
	 
	211.	 	Return of funds in accordance with Section 3.14.5
	 
	212.	 	Termination plan in accordance with Section 4.4.8.2.8
	 
	213.	 	Policies and procedures for delivering NEMT services, including an operating procedures
manual, as provided in Section A. 1 of Attachment XI

Page  365 of  374

 

	44.	 	Delete Attachment IX, Exhibit A, Quarterly Enrollment/Capitation Payment
Reconciliation Reports, and replace with “Intentionally Left Blank.”
	 
	45.	 	Attachment IX, Exhibit G shall be deleted in its entirety and replaced with the
following:

ATTACHMENT IX, EXHIBIT G

REPORT OF ESSENTIAL HOSPITAL SERVICES

Instructions for Completing Report of Essential Hospital Services

The chart for the Report of Essential Hospital Services required in Section 2.30.7.4 is to be
prepared based on the CONTRACTOR’s provider network for essential hospital services in each Grand
Region in which the CONTRACTOR has (or expects to have) TennCare members.

	 	•	 	Fill out one report for each Grand Region. In the top portion of the grid, indicate the
MCO name, the Grand Region, the total number of MCO members in the Grand Region and the
date that such total enrollment was established.
	 
	 	•	 	Provide information on each contract and non-contract facility that serves (or will
serve) members in the identified Grand Region. The MCO should use a separate row to report
information on each such facility.

	1.	 	In the first column, “Name of Facility” indicate the complete name of the facility.
	 
	2.	 	In the second column, “TennCare ID” indicate the TennCare ID assigned to the facility.
	 
	3.	 	In the third column, “NPI” indicate the National Provider Identifier issued to the facility.
	 
	4.	 	In the fourth column, “City/Town” indicate the city or town in which the designated
facility is located.
	 
	5.	 	In the fifth column, “County” indicate the name of the county in which this facility is
located.
	 
	6.	 	In the sixth through the twelfth columns indicate the status of the CONTRACTOR’s relationship
with the specific facility for each of these covered hospital services, e.g. Neonatal,
Perinatal, Pediatric, Trauma, Burn, Center of Excellence for AIDS, and Centers of Excellence
for Behavioral Health. For example:

	 	•	 	If the CONTRACTOR has an executed provider agreement with the facility for neonatal
services, insert an “E” in the column labeled “Neonatal”.
	 
	 	•	 	If the CONTRACTOR does not have an executed provider agreement with this facility for
“Neonatal”, but has another type of arrangement with this facility, the CONTRACTOR should
indicate the code that best describes its relationship (L=letter of intent; R=on referral
basis; N=in contract negotiations; O=other arrangement). For any facility in which the
CONTRACTOR does not have an executed provider agreement and is using as a non-contract
provider, the CONTRACTOR should submit a brief description (one paragraph) of its
relationship with the facility including an estimated timeline for executing a provider
agreement, if any.
	 
	 	•	 	If the CONTRACTOR does not have any relationship for neonatal services with the
facility on this row, the CONTRACTOR should leave the cell labeled “neonatal” blank.

Page  366 of  374

 

ATTACHMENT IX, EXHIBIT G

ESSENTIAL HOSPITAL SERVICES REPORT

MCO Name:                                                              Grand Region:

Number of TennCare Members:                                          as of (date):

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Center of	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Excellence	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	AIDS	 	 	for	 	 	 	 
	Name of	 	TennCare	 	 	 	 	 	 	City/	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Center of	 	 	Behavioral	 	 	 	 
	Facility	 	ID	 	 	NPI	 	 	Town	 	 	County	 	 	Neonatal	 	 	Perinatal	 	 	Pediatric	 	 	Trauma	 	 	Burn	 	 	Excellence	 	 	Health	 	 	Comments	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

E = Executed Provider Agreement

L = Letter of Intent

R = On Referral Basis

N = In Contract Negotiations

O = Other Arrangement

If no relationship for a particular service leave cell blank

Page  367 of  374

 

	46.	 	Delete Attachment IX, Exhibit J, Cost and Utilization Reports, and replace with
“Intentionally Left Blank.”
	 
	47.	 	Delete Attachment IX, Exhibit K, Cost and Utilization Summaries, and replace with the
following:

ATTACHMENT IX, EXHIBIT K

COST AND UTILIZATION SUMMARIES

The quarterly Cost and Utilization Summaries required in Section 2.30.10.3 shall include
information for each of the following populations:

	 	•	 	Medicaid
	 
	 	•	 	Uninsured
	 
	 	•	 	Medically Eligible Child
	 
	 	•	 	Non-CHOICES Disabled
	 
	 	•	 	Non-CHOICES Duals
	 
	 	•	 	CHOICES Duals
	 
	 	•	 	CHOICES Non-Duals

Summaries for the following shall be provided:

	 	1)	 	Data elements for Top 25 Providers (broken down by facilities, practitioners,
ancillary providers, transportation providers) by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Provider type
	 
	 	•	 	Provider Name
	 
	 	•	 	Street Address (Physical Location)
	 
	 	•	 	City
	 
	 	•	 	State
	 
	 	•	 	Zip Code

	 	•	 	Amount Paid to Each Provider
	 
	 	•	 	Amount Paid as a Percentage of Total Provider Payments

	 	2)	 	Data elements for Top 25 Inpatient Diagnoses by Number of Admissions

	 	•	 	Rank
	 
	 	•	 	DRG Code (Diagnosis Code)
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Admits
	 
	 	•	 	Admits as a Percentage of Total Admits

	 	3)	 	Data elements for Top 25 Inpatient Diagnoses by Amount Paid

	 	•	 	Rank
	 
	 	•	 	DRG Code (Diagnosis Code)
	 
	 	•	 	Description

Page  368 of  374

 

	 	•	 	Admits
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Inpatient Dollars

	 	4)	 	Data elements for Top 25 Outpatient Diagnoses by Number of Visits

	 	•	 	Rank
	 
	 	•	 	Diagnosis code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Visits
	 
	 	•	 	Visits as a percentage of Total Outpatient Visits

	 	5)	 	Data elements for Top 25 Outpatient Diagnoses by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Diagnosis Code
	 
	 	•	 	Description
	 
	 	•	 	Visits
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Outpatient Payments

	 	6)	 	Data elements for Top 10 Inpatient Surgical/Maternity Procedures (DRGs) by Number of
Admissions

	 	•	 	Rank
	 
	 	•	 	DRG Code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Number of Admissions
	 
	 	•	 	Admissions as a Percentage of Total Admissions

	 	7)	 	Data elements for Top 10 Inpatient Surgical/Maternity Procedures (DRGs) by Amount Paid

	 	•	 	Rank
	 
	 	•	 	DRG Code
	 
	 	•	 	Description
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Inpatient Surgical/Maternity Payments

	 	8)	 	Data elements for Top 10 Outpatient Surgical/Maternity Procedures by Number of Procedures

	 	•	 	Rank
	 
	 	•	 	Procedure Code
	 
	 	•	 	Description
	 
	 	•	 	Amount Paid
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Procedures as a Percentage of Total Surgical/Maternity Procedures

Page  369 of  374

 

	 	9)	 	Data elements for Top 10 Outpatient Surgical/Maternity Procedures by Amount Paid

	 	•	 	Rank
	 
	 	•	 	Procedure Code
	 
	 	•	 	Description
	 
	 	•	 	Number of Procedures
	 
	 	•	 	Amount Paid
	 
	 	•	 	Amount Paid as a Percentage of Total Outpatient Surgical/Maternity Payments

	48.	 	Delete Attachment IX, Exhibit L, Prior Authorization Reports, and replace with
“Intentionally Left Blank.”
	 
	49.	 	Attachment IX, Exhibit M, shall be deleted and replaced with the following:

ATTACHMENT IX, EXHIBIT M

MEMBER SERVICES AND PROVIDER SERVICES PHONE LINE REPORT

Instructions for Completing the Member Services and Provider Services Phone Line Report

The following definitions shall be used:

Abandoned Call: A call in the phone line queue that is terminated by the caller before reaching
a live voice.

Average Time to Answer: The average time that callers waited in the phone line queue (when
the call was placed during the hours the phone line is open for services) before speaking to
a MCO representative. This shall be reported in minutes: seconds (e.g. one minute and
twenty-five seconds should be reported as 1:25).

Call Abandonment Rate: The number of calls (where the member/provider called directly into the
phone line or selected a member/provider services option and was put in the call queue) that
are abandoned by the caller or the system before being answered by a live voice, divided by the
number of calls received by the phone line (during hours when the line is staffed with
personnel—hours open for services) during the measurement period.

Call Answer Timeliness: The number of calls (where the member called directly into the phone
line or selected a member/provider services option and was put in the call queue) that are
answered by a live voice within thirty (30) seconds, divided by the number of calls received by
the phone line (during hours when the line is staffed with personnel—hours open for services)
during the measurement period.

Page  370 of  374

 

ATTACHMENT IX, EXHIBIT M

MEMBER SERVICES AND PROVIDER SERVICES PHONE

LINE REPORT

MCO
Name:                                         

Report Submission Date:

Reporting
Quarter:                                         

	 	 	 	 	 	 	 
	 	 	[ Month 1 ]	 	[ Month 2 ]	 	[
Month 3 ]
	Member Services Line
	 	 	 	 	 	 
	Total Number of Calls Received
	 	 	 	 	 	 
	% of Calls Abandoned
	 	 	 	 	 	 
	Average Time to Answer
	 	 	 	 	 	 
	% of Calls Answered within 30 Seconds
	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Nurse Triage Line
	 	 	 	 	 	 
	Total Number of Calls Received
	 	 	 	 	 	 
	% of Calls Abandoned
	 	 	 	 	 	 
	Average Time to Answer
	 	 	 	 	 	 
	% of Calls Answered within 30 Seconds
	 	 	 	 	 	 
	 
	 	 	 	 	 	 
	Provider Services Line
	 	 	 	 	 	 
	Total Number of Calls Received
	 	 	 	 	 	 
	% of Calls Abandoned
	 	 	 	 	 	 
	Average Time to Answer
	 	 	 	 	 	 
	% of Calls Answered within 30 Seconds
	 	 	 	 	 	 

Page  371 of  374

 

	50.	 	Delete Attachment IX, Exhibit N, Medical Loss Ratio Report, and replace with
“Intentionally Left Blank”
	 
	51.	 	Attachment X shall be deleted in its entirety and replaced with the following:

ATTACHMENT X

ATTESTATION RE PERSONNEL USED IN CONTRACT PERFORMANCE

	 
	SUBJECT CONTRACT NUMBER:

	 

	CONTRACTOR LEGAL ENTITY NAME:

	 

	FEDERAL EMPLOYER IDENTIFICATION NUMBER:

	(or Social Security Number)

The Contractor, identified above, does hereby attest, certify, warrant, and assure that the
Contractor shall not knowingly utilize the services of an illegal immigrant in the performance
of this Contract and shall not knowingly utilize the services of any subcontractor who will
utilize the services of an illegal immigrant in the performance of this Contract.

 

CONTRACTOR SIGNATURE

NOTICE: This attestation MUST be signed by an individual empowered to contractually bind the
Contractor. If said individual is not the chief executive or president, this document shall
attach evidence showing the individual’s authority to contractually bind the Contractor.

 

PRINTED NAME AND TITLE OF SIGNATORY

 

DATE OF ATTESTATION

Page  372 of  374

 

	52.	 	In Attachment XI, NEMT Requirements, Section A.12.5 is deleted in its entirety and
replaced with the following:

	 	A.12.5 	 	The CONTRACTOR shall provide Division of Mental Retardation Services (DMRS)
residential and day service waiver providers the opportunity to become a NEMT
provider if the provider is qualified to provide the service and agrees to the terms
of the CONTRACTOR’s NEMT provider agreement, which shall be no more restrictive than
for other NEMT providers. These providers shall only provide covered NEMT services
to members receiving HCBS MR waiver services from the provider. The CONTRACTOR shall
reimburse these providers for covered NEMT to TennCare covered services (see
definition in Exhibit A) and shall not reimburse these providers for NEMT to
services provided though a HCBS MR waiver. The CONTRACTOR shall reimburse these
providers in accordance with rates paid to other NEMT providers for the provision of
NEMT services.

	53.	 	In Attachment XI, NEMT Requirements, Item 13 in Exhibit A is deleted in its
entirety and replaced with the following:

	 	13.	 	TennCare Covered Services: The health care services available to TennCare
enrollees, as defined in TennCare rules and regulations. This includes, but is not
limited to, physical health, behavioral health, pharmacy, dental services, and
institutional services. TennCare covered services includes TENNderCare services. For
purposes of NEMT, TennCare covered services does not include alternatives to
institutional services (HCBS or 1915(c) waiver services).

	54.	 	Effective July 1, 2009, Exhibit C of Attachment XII shall be amended by deleting the
words “through June 30, 2009” at the top of the chart. Further, effective upon the CHOICES
Implementation Date, Exhibit C, Attachment XII shall be amended by adding the following
capitation rate cells: “CHOICES Duals — $4,529.19 PMPM” and “CHOICES Non-Duals — $5,942.45
PMPM”.

Page  373 of  374

 

All of the provisions of the original Agreement not specifically deleted or modified herein shall
remain in full force and effect. Unless a provision contained in this Amendment specifically
indicates a different effective date, for purposes of the provisions contained, this Amendment
shall become effective September 1, 2009.

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

	 	 	 	 	 	 	 	 	 	 	 
	STATE OF TENNESSEE 

DEPARTMENT OF FINANCE 

AND ADMINISTRATION	 	 	 	AMERIGROUP, TENNESSEE, INC.	 	 
	 
	BY:

	 	/s/ M. D. Goetz, Jr. 	 	 	 	BY:	 	/s/ Alvin B. King	 	 
	 

	 	 

M. D. Goetz, Jr.
	 	 
	 	 	 	 

Alvin B. King
	 	 
	 

	 	Commissioner
	 	 	 	 	 	President and Chief Executive Officer	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:

	 	8/4 	 	 	 	DATE:	 	8-12-09 	 	 
	 

	 	 
	 	 
	 	 	 	 
	 	 
	APPROVED BY: 

STATE OF TENNESSEE 

DEPARTMENT OF FINANCE 

AND ADMINISTRATION	 	 	 	APPROVED BY:

STATE OF TENNESSEE

COMPTROLLER OF THE TREASURY	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	/s/ M. D. Goetz, Jr. 	 	 	 	BY:	 	/s/ Justin P. Wilson 	 	 
	 

	 	 

M. D. Goetz, Jr.
	 	 
	 	 	 	 

Justin P. Wilson
	 	 
	 

	 	Commissioner
	 	 	 	 	 	Comptroller	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	DATE:

	 	9/1/09 	 	 	 	DATE:	 	9/11/09Exhibit 10.2

Exhibit 10.2

MEMORANDUM OF UNDERSTANDING

The parties to this Memorandum of Understanding (“Memorandum”) are Integra Bank
Corporation, Evansville, Indiana (“Corporation”), a bank holding company, and the Federal Reserve
Bank of St. Louis, St. Louis, Missouri (“Reserve Bank”).

On September 16, 2009, Corporation, at a duly constituted meeting, adopted a resolution
authorizing and directing Michael J. Alley, Interim Chairman and Chief Executive Officer, on
Corporation’s behalf, to enter into this Memorandum and consented to compliance with each of the
following provisions:

1. Corporation will utilize its financial managerial resources to assist
its subsidiary bank in addressing weaknesses identified at its most recent examination, and
achieving/maintaining compliance with any supervisory action between the bank and its primary
regulator.

2. Corporation will declare no corporate dividends without the prior
written approval of this Reserve Bank. Any request to pay such a dividend will be submitted 30
days in advance of the proposed payment date and will be supported by a written analysis that
clearly shows the payment of the dividend to be consistent with the Board of Governors’ Policy
Statement on the Payment of Cash Dividends.

3. Corporation will not incur additional debt without the prior written
approval of this Reserve Bank.

4. Corporation and its nonbank affiliates will not make any
distributions of interest or other sums on trust preferred securities without the prior written
approval of this Reserve Bank. All requests for prior approval will be submitted at least 30 days
prior to the required notice of deferral on the trust preferred securities. All requests will
contain, but not limited to, current and projected information on consolidated earnings, cash flow,
capital, asset quality, and ALLL needs of the subsidiary bank.

5. Within 30 days of the end of each calendar quarter (September 30,
December 31, March 31, and June 30) following the date of this Memorandum, Corporation shall submit
to this Reserve Bank a parent company balance sheet, income statement, and statement of cash flow
for the parent company, as well as a status report on compliance with each provision of the
Memorandum.

 

 

 

All communications regarding this Memorandum shall be addressed to:

	 	 	 	 	 	 	 
	(a)

	 	Mr. Timothy A. Bosch
	 	(b)
	 	Mr. Michael J. Alley
	 

	 	Vice President
	 	 	 	Interim Chairman of the Board
	 

	 	Federal Reserve Bank of St. Louis
	 	 	 	Integra Bank Corporation
	 

	 	One Federal Reserve Bank Plaza
	 	 	 	21 S.E. Third Street
	 

	 	St. Louis, Missouri 63166-0442
	 	 	 	P.O. Box 868
	 

	 	 	 	 	 	Evansville, Indiana 47705-0868

This Memorandum is not a “written agreement” for purposes of Section 8 of the Federal Deposit
Insurance Act, as amended.

WHEREAS, the parties have caused this Memorandum to be executed as of the 16th day of
September, 2009.

	 	 	 	 	 	 	 	 	 
	FEDERAL RESERVE BANK OF ST. LOUIS	 	 	 	INTEGRA BANK CORPORATION
	 
	By:

	 	/s/ Timothy A. Bosch
	 	 	 	By:
	 	/s/ Michael J. Alley
	 

	 	 
	 	 	 	 	 	 

The undersigned directors of Integra Bank Corporation acknowledge that they have read and
understand each provision of the Memorandum.

	 	 	 
	/s/ Michael J. Alley

	 	/s/ Sandra Clark Berry
	 

	 	 
	Michael J. Alley, Interim Chairman

	 	Sandra Clark Berry
	 
	 	 
	/s/ H. Ray Hoops

	 	/s/ Thomas W. Miller
	 

	 	 
	Dr. H. Ray Hoops

	 	Thomas W. Miller
	 
	 	 
	/s/ Arthur D. Pringle, III

	 	/s/ Robert L. Goocher
	 

	 	 
	Arthur D. Pringle, III

	 	Robert L. Goocher
	 
	 	 
	/s/ Richard M. Stivers

	 	/s/ Daniel T. Wolfe
	 

	 	 
	Richard M. Stivers

	 	Daniel T. Wolfe

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00164-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00164-of-00352.parquet"}]]