Document:

Third Amendment to loan agreement

 THIRD AMENDMENT 
 (dated and effective April 26, 2004) 
 to 
 LOAN AGREEMENT 
 (that was effective
May 1, 2002) 
 by and between 
 LASALLE BANK NATIONAL ASSOCIATION, 
 as Lender, 
 and 
 CENTENE CORPORATION, 
 as Borrower 
  
 In consideration of their mutual agreements herein and for other sufficient consideration, the receipt of which is hereby acknowledged, CENTENE
CORPORATION, a Delaware corporation (Borrower) and LASALLE BANK NATIONAL ASSOCIATION (Lender) agree as follows: 
  
 1. Definitions; Section References. The term Original Loan Agreement means the Loan Agreement dated as of May 1, 2002 between Borrower and Lender, as
amended by that certain First Amendment thereto dated as of June 30, 2003 and effective as of May 1, 2003, as further amended by that certain Second Amendment thereto dated and effective as of August 1, 2003. The term this Amendment
means this Third Amendment. The term Loan Agreement means the Original Loan Agreement as amended by this Amendment. Capitalized terms used and not otherwise defined herein have the meanings defined in the Loan Agreement. Section and
Exhibit references are to sections of, and exhibits to, respectively, the Original Loan Agreement unless otherwise specified. 
  
 2. Conditions to Effectiveness of this Amendment. This Amendment is effective as of April 26, 2004, but only if the following conditions have been satisfied
on or before April 26, 2004: 
  
 2.1. This Amendment
has been executed by Borrower and Lender. 
  
 2.2. That
certain Amended and Restated Revolving Note payable to Lender in the principal amount of $50,000,000 has been executed by Borrower. 
  
 2.3. That certain Stock Pledge Agreement regarding Borrower’s capital stock in Buckeye Community Health Plan, Inc. dated as of even date
herewith has been executed by Borrower (and original certificates representing 100% of the outstanding capital stock of Buckeye Community Health Plan, Inc., together with a stock power duly executed in blank, have been delivered to Lender).

  
 2.4. Borrower has delivered to Lender certificates of
good standing for the following Persons, issued by the Secretary of State of the following states: 
  
 2.4.1. Borrower (Delaware and Missouri). 
  
 2.4.2. Buckeye Community Health Plan, Inc. (Ohio). 
  

2.5. Borrower has delivered to Lender a Certificate of the Secretary of Borrower certifying (i) that the Charter Documents of Borrower have not
been amended since May 1, 2002, (ii) that the Charter Documents of the direct Subsidiaries of Borrower have not been amended since the later of the date of formation of such Subsidiary or May 1, 2002, (iii) that resolutions duly adopted by the Board
of Directors of Borrower authorizing the execution, delivery and 

  

 
performance of this Amendment and the documents described herein by Borrower and the performance of this Amendment and the transactions described herein by
Borrower are attached to such certificate and remain in full force and effect, and (iv) the names, titles, and true signatures of the incumbent corporate officers who are authorized to sign this Amendment or attest signatures or seals on this
Amendment on behalf of Borrower. 
  
 2.6. Borrower has
delivered to Lender a Certificate or Articles of Incorporation for Buckeye Community Health Plan, Inc., certified by the Ohio Secretary of State. 
  
 2.7. Borrower has caused to be delivered to Lender an opinion of Borrower’s counsel in form and substance satisfactory to Lender. 

 
 3. Amendments to Original Loan Agreement. The Original Loan Agreement is hereby
amended as follows: 
  
 3.1. Covered Persons. Section 2.3
is deleted in its entirety and replaced with the following: 
  
 2.3. References to Covered Persons. The words Covered Person, a Covered Person, any Covered Person, each Covered Person and every Covered Person refer to Borrower and each of its Subsidiaries (direct or indirect,
whether now existing or hereafter created) separately, excluding any Dormant Subsidiary so long as it qualifies as a Dormant Subsidiary hereunder, but specifically including Centene Management Company LLC, a Wisconsin limited liability company,
Centene Corporation of Texas, a Texas corporation, Managed Health Services Insurance Corp., a Wisconsin corporation, Superior HealthPlan, Inc., a Texas corporation, Coordinated Care Corporation Indiana, Inc., an Indiana corporation, Managed Health
Services Illinois, Inc., an Illinois corporation, MHS Consulting Corporation, a Wisconsin corporation, Bankers Reserve Life Insurance Company of Wisconsin, a Wisconsin insurance company, University Health Plans, Inc., a New Jersey corporation,
Cenphiny, Inc., a Delaware corporation, Centene Finance Corporation, a Delaware corporation, and Buckeye Community Health Plan, Inc., an Ohio corporation. The words Covered Persons refer to Borrower and its now existing or hereafter created
Subsidiaries (whether direct or indirect), excluding any Dormant Subsidiary so long as it qualifies as a Dormant Subsidiary hereunder, but specifically including each of the Persons specifically mentioned in the prior sentence, collectively.
Borrower agrees that any Subsidiary which is a Dormant Subsidiary will automatically become a Covered Person hereunder without any further action if at any time such Subsidiary ceases to be a Dormant Subsidiary. 
  
 3.2. Revolving Commitment. Section 3.1.1 is amended by
replacing the figure “$25,000,000” with the figure “$50,000,000”. 
  
 3.3. Maturity Date. Section 6.1 is amended by replacing the date “May 1, 2004” with the date “May 1, 2005”. 
  
 3.4. Charter Documents. Section 13 is amended by inserting the following new Section 13.21: 

 
 13.21. Charter Documents of Subsidiaries. Within five Business
Days of Lender’s written request, Borrower will deliver, or cause to be delivered to 

  

 2 

 
Lender, then current copies of the Charter Documents of Borrower or any Subsidiary of Borrower so requested by Lender, certified by Borrower or such
Subsidiary as being true and correct. 
  
 3.5. New
Subsidiaries. Section 14.14 is deleted in its entirety and replaced with the following: 
  
 14.14. New Subsidiaries. Acquire, organize or create any Subsidiary; provided, however, that Borrower may (or may permit a Covered Person to) (i) acquire a Subsidiary as part of a Permitted
Acquisition or (ii) organize or create a Subsidiary, so long as, in the case of clauses (i) or (ii), Borrower notifies Lender in writing at least 15 days prior to the acquisition, organization, or creation of such Subsidiary and contemporaneously
with such acquisition, organization, or creation, (a) if such Subsidiary is a direct Subsidiary of Borrower or if Lender so requests in writing, the applicable Covered Person executes and delivers to Lender a pledge of 100% of such Subsidiary’s
capital stock, membership interests, or other equity interests owned by such Covered Person on terms satisfactory to Lender, (b) such Subsidiary becomes (and if Lender so requests in writing, confirms in writing that it is) a Covered Person under
this Agreement (provided, however, that such Subsidiary will automatically become a Covered Person hereunder upon such acquisition, organization, or creation regardless of whether Lender requests or such Subsidiary provides such written
confirmation), and (c) all of the representations and warranties contained in this Agreement are true and correct with respect to such Subsidiary as of the date of acquisition, organization, or creation. 
  
 3.6. Modification of Charter Documents. Section 14 is amended by
inserting the following new Section 14.18: 
  
 14.18.
Modification of Charter Documents. Amend, restate, modify, or replace its Charter Documents unless (i) in the case of Borrower or any direct Subsidiary of Borrower, copies of such amendment, restatement, modification, or replacement are promptly
provided to Lender, (ii) in all cases such amendment, restatement, modification, or replacement does not adversely affect any rights of Lender hereunder, under any Security Documents, or at law, and (iii) in all cases such amendment, restatement,
modification, or replacement is not reasonably likely to have a Material Adverse Effect. 
  
 3.7. Definition of Dormant Subsidiary. Exhibit 2.1 (Glossary) is amended by inserting the following new term and definition in its proper alphabetical location: 
  
 Dormant Subsidiary – any Subsidiary of Borrower which (i) has no
employees, (ii) conducts no business operations, (iii) has no income, (iv) has no assets or liabilities, and (v) maintains no deposit accounts. 
  
 3.8. Disclosure Schedule. Exhibit 12 (Borrower’s Disclosure Schedule) is replaced with Exhibit 12, attached hereto. 
  

 3 

 4. Representations and Warranties. Borrower hereby represents and warrants to Lender as of the date hereof
that (i) this Amendment and each and every other document and instrument delivered by Borrower in connection with this Amendment (each, an Amendment Document and, collectively, the Amendment Documents) has been duly authorized by its Board of
Directors, (ii) no consents are necessary from any third Person for its execution, delivery or performance of the Amendment Documents to which it is a party which have not been obtained and a copy thereof delivered to Lender, (iii) each of the
Amendment Documents to which it is a party constitutes its legal, valid and binding obligation enforceable against it in accordance with its terms, except to the extent that the enforceability thereof against it may be limited by bankruptcy,
insolvency, fraudulent conveyance, reorganization, moratorium or similar laws affecting the enforceability of creditors’ rights generally or by equitable principles of general application (whether considered in an action at law or in equity),
(iv) all of the representations and warranties contained in Section 12, as amended by this Amendment, are true and correct in all material respects with the same force and effect as if made on and as of the date of this Amendment, except that with
respect to the representations and warranties made regarding financial data, such representations and warranties are hereby made with respect to the most recent Financial Statements and other financial data (in the form required by the Original Loan
Agreement) delivered by it to Lender, and (v) there exists no Default or Event of Default under the Original Loan Agreement. 
  
 5. Effect of Amendment. The execution, delivery and effectiveness of this Amendment shall not operate as a waiver of any right, power or remedy of Lender
under the Original Loan Agreement or any of the other Loan Documents, nor constitute a waiver of any provision of the Original Loan Agreement or any of the other Loan Documents or any Existing Default or Event of Default, nor act as a release or
subordination of the Security Interests of Lender under the Security Documents. Each reference in the Original Loan Agreement to the Agreement, hereunder, hereof, herein, or words of like import, shall be read as referring to the Original
Loan Agreement as amended hereby. Each reference in the other Loan Documents to the Loan Agreement shall be read as referring to the Original Loan Agreement, as amended hereby. 
  
 6. Reaffirmation. Borrower hereby acknowledges and confirms that (i) except as
expressly amended hereby, the Original Loan Agreement and other Loan Documents remain in full force and effect, (ii) the Loan Agreement, as amended hereby, is in full force and effect, (iii) it has no defenses to its obligations under the Loan
Agreement or any of the other Loan Documents to which it is a party, (iv) the Security Interests of Lender under the Security Documents continue in full force and effect and have the same priority as before this Amendment, and (v) it has no claim
against Lender arising from or in connection with the Loan Agreement or the other Loan Documents. 
  
 7. Counterparts. This Amendment may be executed by the parties hereto on any number of separate counterparts, each of which shall be deemed an original, but all of which counterparts taken together shall
constitute one and the same instrument. It shall not be necessary in making proof of this Amendment to produce or account for more than one counterpart signed by the party to be charged. 
  
 8. Counterpart Facsimile Execution. This Amendment, or a signature page thereto
intended to be attached to a copy of this Amendment, signed and transmitted by facsimile machine or telecopier shall be deemed and treated as an original document. The signature of any Person thereon, for purposes hereof, is to be considered as an
original signature, and the document transmitted is to be considered to have the same binding effect as an original signature on an original document. At the request of any party hereto, any facsimile or telecopy document is to be re-executed in
original form by the Persons who executed the facsimile or telecopy document. No party hereto may raise the use of a facsimile machine or telecopier or the fact that any signature was transmitted through the use of a facsimile or telecopier machine
as a defense to the enforcement of this Amendment. 
  

 4 

 9. Governing Law. This Amendment and the rights and obligations of the parties hereunder shall be governed
by and construed and interpreted in accordance with the internal laws of the State of Illinois applicable to contracts made and to be performed wholly within such state, without regard to choice or conflict of laws provisions. 
  
 10. Section Titles. The section titles in this Amendment are for convenience of
reference only and shall not be construed so as to modify any provisions of this Amendment. 
  
 11. Incorporation By Reference. Lender and Borrower hereby agree that all of the terms of the Loan Documents are incorporated in and made a part of this Amendment by this reference. 
  
 12. Statutory Notice - Oral Commitments. Nothing contained in such notice shall
be deemed to limit or modify the terms of the Loan Documents or this Amendment: 
  
 ORAL AGREEMENTS OR COMMITMENTS TO LOAN MONEY, EXTEND CREDIT OR TO FORBEAR FROM ENFORCING REPAYMENT OF A DEBT INCLUDING PROMISES TO EXTEND OR RENEW SUCH DEBT ARE NOT ENFORCEABLE. TO PROTECT YOU (BORROWER) AND US
(CREDITOR) FROM MISUNDERSTANDING OR DISAPPOINTMENT, ANY AGREEMENTS WE REACH COVERING SUCH MATTERS ARE CONTAINED IN THIS WRITING, WHICH IS THE COMPLETE AND EXCLUSIVE STATEMENT OF THE AGREEMENT BETWEEN US, EXCEPT AS WE MAY LATER AGREE IN WRITING TO
MODIFY IT. 
  
 BORROWER ACKNOWLEDGES THAT THERE ARE NO OTHER AGREEMENTS
BETWEEN LENDER AND BORROWER, ORAL OR WRITTEN, CONCERNING THE SUBJECT MATTER OF THE LOAN DOCUMENTS, AND THAT ALL PRIOR AGREEMENTS CONCERNING THE SAME SUBJECT MATTER, INCLUDING ANY PROPOSAL, TERM SHEET OR LETTER, ARE MERGED INTO THE LOAN DOCUMENTS AND
THEREBY EXTINGUISHED. 
  
 {remainder of page intentionally left
blank} 
  

 5 

 IN WITNESS WHEREOF, the parties have caused this Amendment to be executed by appropriate duly authorized
officers as of the date first above written. 
  

			
	Borrower:
	
	CENTENE CORPORATION
		
	By:	 	   /s/ Karey L. Witty

	 Name:
	 	   Karey L. Witty

	 Title:
	 	   SVP, CFO & Secretary

  

			
	Lender:
	
	LASALLE BANK NATIONAL ASSOCIATION
		
	By:	 	   /s/ Sam L. Dendrinos

	 Name:
	 	   Sam L. Dendrinos

	 Title:
	 	   First Vice PresidentAmendments to contract included as Exhibit 10.28 to Form 10-K

 STATE OF NEW JERSEY 
  
 DEPARTMENT OF HUMAN SERVICES 
  

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES 
  
 AND 
  
 UNIVERSITY HEALTH PLANS, INC. 
  
 AGREEMENT TO PROVIDE HMO SERVICES 
  
 In
accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between University Health Plans, Inc. and the State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services (DMAHS), effective date
October 1, 2000, all parties agree that the contract shall be amended, effective June 1, 2004, as follows: 
  

	1.	Article 4, “Provision of Health Care Services” Sections 4.1.7(A)12 (new) and 4.1.7(C)38 shall be amended as reflected in Article 4, Sections 4.1.7(A)12 and
4.1.7(C)38 attached hereto and incorporated herein. 

  

	3.	Article 5, “Enrollee Services” Section 5.8.2(M) shall be amended as reflected in Article 5, Section 5.8.2(M) attached hereto and incorporated herein.

  

 All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain unchanged except as noted
above. 
  
 The contracting parties indicate their agreement by their signatures.

  

									
	University Health Plans, Inc.	 	 	 	 State of New Jersey
  
 Department of Human Services

					
	BY:	 	/s/    ALEXANDER H.
MCLEAN          	 	 	 	BY:	 	/s/    DOUGHLAS MCGRUTHER
for          
	 	 	 	 	 	 	 	 	Ann Clemency kohler
	TITLE:	 	President & CEO	 	 	 	TITLE:	 	Director, DMAHS
	DATE:	 	5/6/04	 	 	 	DATE:	 	5/27/04

  
 APPROVED AS TO FORM ONLY

  
 Attorney General 
  
 State of New Jersey 
  

			
		
	BY:	 	/s/    DIANNA
ROSENHEIM          
	 	 	Deputy Attorney General
	DATE:	 	5/25/04

  

 Improvement Act (CLIA) certificate of waiver or a certificate of registration along with a CLIA
identification number. Those providers with certificates of waiver shall provide only the types of tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory services.

  

	 	7.	Radiology Services – Diagnostic and therapeutic 

  

	 	8.	Prescription drugs, excluding over-the-counter drugs Exception: See Article 8 regarding Protease Inhibitors and other antiretrovirals. 

  

	 	9.	Transportation Services – Limited to ambulance for medical emergency only. 

  

	 	10.	Diabetic supplies and equipment 

  

	 	11.	DME – limited benefit, only covered when medically necessary part of inpatient hospital discharge plan – (see Appendix, Section B.4.1 for list of covered items)

  

	 	12.	Family Planning Services, including medical history and physical examinations (including pelvic and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies
and devices, counseling, continuing medical supervision, continuity of care and genetic counseling. 

  
 Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical and clinic)
visits, drugs, laboratory services, radiological and diagnostic services and surgical procedures are not covered by the NJ FamilyCare program. Obtaining family planning services from providers outside the contractor’s provider network is not
available in NJ FamilyCare Plan H enrollees. 
  

	 	B.	Services Available To NJ FamilyCare Plan H Under Fee-For-Service. The following services are available to NJ FamilyCare Plan H enrollees under fee-for-service:

  

	 	1.	Outpatient mental health services, limited to 60 days per calendar year. 

  

	 	2.	Abortion services 

  

	 	C.	Exclusions. The following services not covered for NJ FamilyCare Plan H participants either by the contractor or the Department include, but are not limited to:

  

	 	35.	Inpatient and outpatient services for substance abuse 

  

			
	Amended as of November 1, 2003	  	IV-16

	 	36.	Partial hospitalization 

  

	 	37.	Skilled nursing facility services 

  

	 	38.	Hospice Services 

  

	 	39.	Optometrist Services 

  

	 	40.	Optical Appliances 

  

	 	41.	Organ Transplant Services 

  

	 	42.	Podiatrist Services 

  

	 	43.	Prosthetic Appliances 

  

	 	44.	Outpatient Rehabilitation Services 

  

	 	45.	Maternity and related newborn care 

  

	4.1.8 	SUPPLEMENTAL BENEFITS 

  
 Any service, activity or product not covered under the State Plan may be provided by the contractor only through written approval by the Department and
the cost of which shall be borne solely by the contractor. 
  

	4.1.9 	CONTRACTOR AND DMAHS SERVICE EXCLUSIONS 

  
 Neither the contractor nor DMAHS shall be responsible for the following: 
  

	 	A.	All services not medically necessary, provided, approved or arranged by a contractor’s physician or other provider (within his/her scope of practice) except emergency services.

  

	 	B.	Cosmetic surgery except when medically necessary and approved. 

  

	 	C.	Experimental organ transplants. 

  

	 	D.	Services provided primarily for the diagnosis and treatment of infertility, including sterilization reversals, and related office (medical or clinic), drugs, laboratory services,
radiological and diagnostic services and surgical-procedures. 

  

	 	E.	Respite Care 

  

	 	F.	Rest cures, personal comfort and convenience items, services and supplies not directly related to the care of the patient, including but not limited to, guest meals and
accommodations, telephone charges, travel expenses other than those services not in Article 4.1 of this contract, take home supplies and similar cost. Costs incurred by an accompanying parent(s) for an out-of-state medical intervention are covered
under EPSDT by the contractor. 

  

			
	Amended as of June 1, 2004	  	IV-18

	 	H.	An explanation of the process for accessing emergency services and services which require or do not require referrals; 

  

	 	I.	A definition of the terms “emergency medical condition” and “post stabilization care services” and an explanation of the procedure for obtaining emergency
services, including the need to contact the PCP for urgent care situations and prior to accessing such services in the emergency room; 

  

	 	J.	An explanation of the importance of contacting the PCP immediately for an appointment and appointment procedures; 

  

	 	K.	An explanation of where and how twenty-four (24) hour per day, seven (7) day per week, emergency services are available, including out-of-area coverage, and procedures for emergency
and urgent health care service, including the fact that the enrollee has a right to use any hospital or other setting for emergency care; 

  

	 	L.	A list of the Medicaid and/or NJ FamilyCare services not covered by the contractor and art explanation of how to receive services not covered by this contract including the fact
that such services may be obtained through the provider of their choice according to regular Medicaid program regulations. The contractor may also assist an enrollee or, where applicable, an authorized person, in locating a referral provider;

  

	 	M.	A notification of the enrollee’s right to obtain family planning services from the contractor or from any appropriate’ Medicaid participating family planning provider (42
C.F.R. § 431,51(b)); as well as an explanation that enrollees covered under NJ FamilyCare Plan D (except PSC 380) and Plan H may only obtain family planning services through the contractor’s provider network, and that family planning
services outside the contractor’s provider network are not covered services. 

  

	 	N.	A description, of the process for referral to specialty and ancillary care providers and second opinions; 

  

	 	O.	An explanation of the reasons for which an enrollee may request a change of PCP, the process of effectuating that change, and the circumstances under which such a request may be
denied; 

  

	 	P.	The reasons and process by which a provider may request an enrollee to change to a different PCP; 

  

	 	Q.	An explanation of an enrollee’s rights to disenroll or transfer at any time for cause; disenroll or transfer in the first 90 days after the latter of the date the
individual enrolled or the date they receive notice of enrollment and at least every twelve (12) months thereafter without cause and that the lock-in period does not apply to ABD, DDD or DYFS individuals; 

  

			
	Amended as of June 1, 2004	  	V - 14

 STATE OF NEW JERSEY 
  
 DEPARTMENT OF HUMAN SERVICES 
  

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES 
  
 AND 
  
 UNIVERSITY HEALTH PLANS, INC. 
  
 AGREEMENT TO PROVIDE HMO SERVICES 
  
 In
accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between University Health Plans, Inc. and the State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services (DMAHS), effective date
October 1, 2000, all parties agree that the contract shall be amended, effective July 1, 2004, as follows: 
  

	1.	Article 1, “Definitions”, the definition of Complaint shall be amended as reflected in the relevant page of Article 1 attached hereto and incorporated
herein. 

  

	2.	Article 4, “Provision of Health Care Services” Sections 4.1.1.Q (new); 4.1.2(A)24; 4.1.4(A); 4.1.4(B); 4.1.5(A); 4.2.1(E); 4.2.6(B)7(d)ii; 4.2.6(B)7(f)ii.1;
4.4(B)1; 4.6.1 (C)5; 4.6.2(P); 4.6.2(Q)1; 4.8.3(B) (new); 4.8.5; 4.8.8(H)7; 4.8.8(1); 4.8.8(M)3(c); 4.8.8(M)30); 4.8.8(M)3(n); 4.8.8(M)3(q); 4.8.8(M)3(s) and 4.9.2 shall be amended as reflected in Article 4, Sections 4.1.1.Q, 4.1.2(A)24,
4.1.4(A), 4.1.4(B), 4.1.5(A), 4.2.1(E), 4.2.6(B)7(d)ii, 4.2.6(B)7(f)ii.1, 4.4(B)1, 4.6.1(C)5, 4.6.2(P), 4.6.2(Q)1, 4.8.3(B), 4.8.5, 4.8.8(H)7, 4.8.8(1), 4.8.8(M)3(c), 4.8.B(M)30), 4.8.8(M)3(n), 4.8.8(M)3(q), 4.8.8(M)3(s) and 4.9.2 attached hereto
and incorporated herein. 

  

	3.	Article 5, “Enrollee Services” Sections 5.5(G); 5.8.2(S) and 5.15.1(A) shall be amended as reflected in Article 5, Sections 5.5(G), 5.8.2(S) and 5.15.1 (A) attached
hereto and incorporated herein. 

  

	4.	Article 6, “Provider Information” Section 6.2(D) shall be amended as reflected in Article 6, Section 6.2(D) attached hereto and incorporated herein.

  

	5.	Article 7, “Terms and Conditions” Sections 7,16J(A)1; 7.16.7(B)1; 7.20.2(C); 7.26(F) and 7.26(L) (new) shall be amended as reflected in Article 7, Sections
7.16.7(A)1, 7.16.7(B)1, 7.20.2(C), 7.26(F) and 7.26(L) attached hereto and incorporated herein. 

  

	6.	Article 8, “Financial Provisions” Sections 8.5.4; 8.8(0) and 8.10(B) shall be amended as reflected in Article 8, Sections 8.5.4, 8.8(0) and 8.10(B) attached hereto
and incorporated herein. 

  

	7.	Appendix, Section A, “Reports” 

  

	 	•	A.4.1 – Provider Network File: Attachment E (revised); 

  

	 	•	A.4.2 – Organ Transplant Procedure (new); 

  

	 	•	A.4.4 – Certification Of Provider Network Report; 

  

	 	•	A.7.1 – Certifications: 1) Certification of Enrollment Information Relating to Payment Under The Medicaid/NJ FamilyCare Programs; 2) Certification of Encounter Information
Relating to Payment Under the Medicaid/NJ FamilyCare Programs; 3) Certification of Any Information Required By the State and Contained in Contracts Proposals and Related Documents Relating to Payments Under the Medicaid/NJ FamilyCare Programs;

  

	 	•	A.7.8 – Table 6D: Revenue and Expenses, Summary of MCSA Groups on Claims Paid During Current Quarter (new); 

  

	 	•	A.7.8 – Table 6E: Revenue and Expenses, Summary of MCSA Groups on Claims Paid Year to Date (new); 

  

	 	•	A.7.20 – Table 18B: Federally Qualified Health Center Encounters (new); 

  

	 	•	A.7.21 – Table 19: Income Statements By Rate Cell Grouping, Table 19A thru V; 

  

	 	•	A.7.22 – Table 20: Lag Reports; 

  

	 	•	A.7.24 – Table 22: Plan H Invoice Form 

  
 shall be amended as reflected in Appendix, Section A, A.4.1, A.4.2, A.4.4, A.7.1, A.7.8, A.7.20, A.7.21, A.7.22 and A.7.24 attached hereto and
incorporated herein. 
  

	8.	Appendix, Section B, “Reference Materials” 

  

	 	•	B.5.2 – Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan H Beneficiaries; 

  

	 	•	B.7.3 – Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping Costs; and 

  

	 	•	B.7.5 – EPSDT Codes; 

  
 shall be amended as reflected in Appendix, Section B, B.5.2, B.7.3, and B.7.5 attached hereto and incorporated herein. 
  

	9.	Appendix, Section C, “Capitation Rates,” shall be revised as reflected in SFY 2005 Capitation Rates attached hereto and incorporated herein

  

 All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain unchanged except as noted
above. 
  
 The contracting parties indicate their agreement by their signatures.

  

									
	 	 	University	 	 	 	 State of New Jersey

	 	 	Health Plans, Inc.	 	 	 	 Department of Human Services

					
	BY:	 	/s/    ALEXANDER H.
MCLEAN        	 	 	 	BY:	 	/s/    ANN CLEMENCY KOHLER
        
	 	 	 	 	 	 	 	 	Ann Clemency Kohler
					
	TITLE:	 	President & CEO	 	 	 	TITLE:	 	Director, DMAHS
	DATE:	 	 3/24/04
	 	 	 	DATE:	 	 4/13/04

  
 APPROVED AS TO FORM ONLY

  

			
	 Attorney General

	
	 State of New Jersey

		
	BY:	 	/s/    DIANNA ROSENHEIM        
	 	 	Deputy Attorney General
		
	DATE:	 	 4/2/04

  

 with the contractor. Marketing by an employee of the contractor is considered direct; marketing by an
agent is considered indirect. 
  
 Commissioner–the
Commissioner of the New Jersey Department of Human Services or a duly authorized representative. 
  
 Complaint–a protest by an enrollee as to the conduct by the contractor or any agent of the contractor, or an act or failure to act by
the contractor or any agent of the contractor, or any other matter in which an enrollee feels aggrieved by the contractor, that is communicated to the contractor and that could be resolved by the contractor within five (5) business days, except for
urgent situations, and as required by the exigencies of the situation. 
  
 Complaint Resolution—completed actions taken to fully settle a complaint to the DMAHS’ satisfaction. 
  
 Comprehensive Risk Contract–a risk contract that covers comprehensive services, that is, inpatient hospital services and any of the following
services, or any three or more of the following services: 
  

	 	1.	Outpatient hospital services. 

  

	 	2.	Rural health clinic services. 

  

	 	3.	FQHC services. 

  

	 	4.	Other laboratory and X-ray services. 

  

	 	5.	Nursing facility (NF) services. 

  

	 	6.	Early and periodic screening, diagnosis and treatment (EPSDT) services. 

  

	 	7.	Family planning services. 

  

	 	8.	Physician services. 

  

	 	9.	Home health services. 

  
 Condition–a disease, illness, injury, disorder, or biological or psychological condition or status for which treatment is indicated.

  
 Contested Claim–a claim that is denied because
the claim is an ineligible claim, the claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the claim requires special treatment. 
  
 Continuity of Care–the plan of care for a particular enrollee
that should assure progress without unreasonable interruption. 
  
 Contract–the written agreement between the State and the contractor, and comprises the contract, any addenda, appendices, attachments, or amendments thereto. 
  
 Contracting Officer–the individual empowered to act and respond for the State throughout the life of any
contract entered into with the State. 
  
 Contractor–the Health Maintenance Organization with a valid Certificate of Authority in New Jersey that contracts hereunder with the State for the provision of comprehensive 
  

			
	Amended as of July 1, 2004	  	I-5

	 	N.	Protection of Enrollee – Provider Communications. Health care professionals may not be prohibited from advising their patients about their health status or medical care or
treatment, regardless of whether this care is covered as a benefit under the contract. 

  

	 	O.	Medical or Dental Procedures. For procedures that may be considered either medical or dental such as surgical procedures for fractured jaw or removal of cysts, the contractor shall
establish written policies and procedures clearly and definitively delineated for all providers and administrative staff, indicating that either a physician specialist or oral surgeon may perform the procedure and when, where, and how authorization,
if needed, shall be promptly obtained. 

  

	 	P.	Out-of-Network Services. If the contractor is unable to provide in-network necessary services, covered under the contract to a particular enrollee, the contractor must adequately
and timely cover those services out-of-network for the enrollee, for as long as the contractor is unable to provide them in-network. 

  

	 	Q.	Termination of Benefits. For benefits terminated at the direction of the State, the contractor shall be responsible for previously authorized services for a period of sixty (60)
days after the effective date of termination. 

  

	4.1.2 	BENEFIT PACKAGE 

  

	 	A.	The following categories of services shall be provided by the contractor for all Medicaid and NJ FamilyCare Plans A, B, and C enrollees, except where indicated. See Section B.4.1 of
the Appendices for complete definitions of the covered services. 

  

	 	1.	Primary and Specialty Care by physicians and, within the scope of practice and in accordance with State certification/licensure requirements, standards and practices, by Certified
Nurse Midwives, Certified Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants 

  

	 	2.	Preventive Health Care and Counseling and Health Promotion 

  

	 	3.	Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program Services 

  
 For NJ FamilyCare Plans B and C participants, coverage includes early and periodic screening and diagnosis medical
examinations, dental, vision, hearing, and lead screening services. It includes only those treatment services identified through the examination that are available under the contractor’s benefit package or specified services under the FFS
program. 
  

	 	4.	Emergency Medical Care 

  

			
	Amended as of July 1, 2004	  	IV-4

	 	21.	Medical Supplies 

  

	 	22.	Prosthetics and Orthotics including certified shoe provider. 

  

	 	23.	Dental Services 

  

	 	24.	Organ Transplants – includes donor and recipient costs. Exception: The contractor will not be responsible for transplant-related donor and recipient inpatient hospital costs
for an individual placed on a transplant list while in the Medicaid FFS program prior to initial enrollment into the contractor’s plan. 

  

	 	25.	Transportation Services for any contractor-covered service or non- contractor covered service including ambulance, mobile intensive care units (MICUs) and invalid coach (including
lift equipped vehicles) 

  

	 	26.	Post-acute Care 

  

	 	27.	Mental Health/Substance Abuse Services for enrollees who are clients of the Division of Developmental Disabilities 

  

	 	B.	Conditions Altering Mental Status. Those diagnoses which are categorized as altering the mental status of an individual but are of organic origin shall be part of the
contractor’s medical, financial and care management responsibilities for all categories of enrollees. These include the diagnoses in the following ICD-9-CM Series: 

  

					
	1.	  	290.0	  	 Senile dementia, simple type

	2.	  	290.1	  	 Presenile dementia

	3.	  	290.10	  	 Presenile dementia, uncomplicated

	4.	  	290.11	  	 Presenile dementia with delerium

	5.	  	290.12	  	 Presenile dementia with delusional features

	6.	  	290.13	  	 Presenile dementia with depressive features

	7.	  	290.2	  	 Senile dementia with delusional or depressive features

	8.	  	290.20	  	 Senile dementia with delusional features

	9.	  	290.21	  	 Senile dementia with depressive features

	10.	  	290.3	  	 Senile dementia with delerium

	11.	  	290.4	  	 Arteriosclerotic dementia

	12.	  	290.40	  	 Arteriosclerotic dementia, uncomplicated

	13.	  	290.41	  	 Arteriosclerotic dementia with delirium

	14.	  	290.42	  	 Arteriosclerotic dementia with delusional features

	15.	  	290.43	  	 Arteriosclerotic dementia with depressive features

	16.	  	290.8	  	 Other specific senile psychotic conditions

	17.	  	290.9	  	 Unspecified senile psychotic condition

	18.	  	291.1	  	 Alcohol amnestic syndrome

  

			
	Amended as of July 1, 2004	  	IV-6

							
	02721	  	02952	  	05120	  	 
	02722	  	02954	  	05211	  	 
	02750	  	03310	  	05211-52	  	 
	02751	  	03320	  	05212	  	 
	02752	  	03330	  	05212-52	  	 
	02790	  	03410-22	  	05213	  	 
	02791	  	03411	  	05214	  	 

  

	 	2.	Procedure Codes to be paid by Medicaid FFS up to 120 days from date of last preliminary extractions after patient enrolls in New Jersey Care 2000+ (applies to tooth codes 5-12 and
21-28 only); 

  

	
	 05130

	 05130-22

	 05140

	 05140-22

  

	 	3.	Extraction Procedure Codes to be paid by Medicaid FFS up to 120 days from last date of preliminary extractions after first time New Jersey Care 2000+ enrollment in conjunction with
the following codes (05130, 05130- 22, 05140, 05140-22): 

  

	
	 07110

	 07130

	 07210

  

	4.1.4	MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR 

  

	 	A.	Mental Health/Substance Abuse. The following mental health/substance abuse services (except for the conditions listed in 4.1.2.B) will be managed by the State or its agent for
non-DDD enrollees, including all NJ FamilyCare enrollees. (The contractor will retain responsibility for furnishing menial health/substance abuse services, excluding the cost of the drugs listed below, to Medicaid enrollees who are clients of the
Division of Developmental Disabilities). 

  

	 	•	Substance Abuse Services—diagnosis, treatment, and detoxification 

  

	 	•	Costs for Methadone maintenance and its administration 

  

	 	•	Mental Health Services 

  

	 	B.	Drugs. The following drugs will be paid fee-for-service by the Medicaid program for all DMAHS enrollees: 

  

	 	•	Atypical antipsychotic drugs within the Specific Therapeutic Drug Classes H7T and H7X 

  

			
	Amended as of July 1, 2004	  	IV-9

	 	•	Methadone maintenance – cost and its administration. Except as provided in Article 4.4, the contractor will remain responsible for the medical care of enrollees requiring
substance abuse treatment 

  

	 	•	Generically-equivalent drug products of the drugs listed in this section. 

  

	 	C.	Up to twelve (12) inpatient hospital days required for social necessity in accordance with Medicaid regulations. 

  

	 	D.	DDD/CCW waiver services: individual supports (which includes personal care and training), habilitation, case management, respite, and Personal Emergency Response Systems (PERS).

  

	4.1.5	INSTITUTIONAL FEE-FOR-SERVICE BENEFITS – NO COORDINATION BY THE CONTRACTOR 

  
 The following institutional services shall remain in the fee-for-service program without requiring coordination by the
contractor. In addition, Medicaid beneficiaries participating in a waiver (except the Division of Developmental Disabilities Community Care Waiver) or demonstration program or admitted for long term care treatment in one of the following shall be
disenrolled from the contractor’s plan on the date of admission to institutionalized care. 
  

	 	A.	Nursing Facility care (Exception: if the admission is only for inpatient rehabilitation/postacute care services and is 30 days or less, the enrollee will not be disenrolled. The
contractor remains financially responsible for rehabilitation/postacute services in this setting for 30 days. Thereafter, if the enrollee continues to receive rehabilitation/postacute services in this setting, the enrollee will be disenrolled. The
contractor will no longer be financially responsible.) Not covered for NJ FamilyCare Plans B and C. 

  

	 	B.	Inpatient psychiatric services (except for RTCs) for individuals under age 21 and 65 and over – Services that are provided: 

  

	 	1.	Under the direction of a physician; 

  

	 	2.	In a facility or program accredited by the Joint Commission on Accreditation of Health Care Organizations; and 

  

	 	3.	Meet the federal and State requirements. 

  

	 	C.	Intermediate Care Facility/Mental Retardation Services – Items and services furnished in an intermediate care facility for the mentally retarded. Covered for NJ FamilyCare Plan
A only. 

  

	 	D.	Waiver (except Division of Developmental Disabilities Community Care Waiver) and demonstration program services. Covered for NJ FamilyCare Plan A only. 

  

			
	Amended as of July 1, 2004	  	IV-10

	 	C.	Access Standards. The contractor shall ensure that all covered services, that are required on an emergency basis are available to all its enrollees, twenty-four (24) hours per day,
seven (7) days per week, either in the contractor’s own provider network or through arrangements approved by DMAHS. The contractor shall maintain twenty-four (24) hours per day, seven (7) days per week on-call telephone coverage, including
Telecommunication Device for the Deaf (TDD)/Tech Telephone (TT) systems, to advise enrollees of procedures for emergency and urgent care and explain procedures for obtaining non-emergent/non-urgent care during regular business hours within the
enrollment area as well as outside the enrollment area. 

  

	 	D.	Non-Participating Providers. 

  

	 	1.	The contractor shall be responsible for developing and advising its enrollees and where applicable, authorized persons of procedures for obtaining emergency services, including
emergency dental services, when it is not medically feasible for enrollees to receive emergency services from or through a participating provider, or when the time required to reach the participating provider would mean risk of permanent damage to
the enrollee’s health. The contractor shall bear the cost of providing emergency service through non-participating providers. 

  

	 	2.	Non-contracted hospitals providing emergency services to Medicaid or NJ FamilyCare members enrolled in the managed care program shall accept, as payment in full, the amounts that
the non-contracted hospitals would receive from Medicaid for the emergency services and/or any related hospitalization as if the beneficiary were enrolled in fee-for-service Medicaid. 

  

	 	E.	Emergency Care Prior Authorization. Prior authorization shall not be required for emergency services through stabilization. This applies to out-of-network as well as to in-network
providers. 

  

	 	F.	Medical Screenings/Urgent Care. Prior authorization shall not be required for medical screenings or for providing services in urgent care situations at the hospital emergency room.
The hospital emergency room physician may determine the necessity for contacting the PCP or the contractor for information about an enrollee who presents with an urgent condition. 

  

	 	G.	The contractor shall pay for all medical screening services rendered to its enrollees by hospitals and emergency room physicians regardless of the admitting symptoms or discharge
diagnosis. The amount and method of reimbursement for medical screenings shall be subject to negotiation between the contractor and the hospital and directly with non-hospital salaried emergency room physicians and shall include reimbursement for
urgent care and non-urgent care rates. Non- participating hospitals may be reimbursed for hospital costs at Medicaid rates or other mutually agreeable rates for medical screening services. Additional fees for 

  

			
	Amended as of July 1, 2004	  	IV-21

	 	i.	The contractor shall provide to DMAHS documentation as to the efforts made to educate providers with low screening rates. 

  

	 	ii.	The contractor shall implement plans for corrective action with those identified PCPs that describe interventions to be taken to identity and correct deficiencies and impediments to
the screening and how the effectiveness of its interventions will be measured. 

  

	 	e.	On a quarterly basis, the contractor shall submit to DMAHS a report of all lead-burdened children who are receiving treatment and case management services. 

 

	 	f.	Lead Case Management Program. The contractor shall establish a Lead Case Management Program (LCMP) and have written policies and procedures for the enrollment of children with blood
lead levels > 10 μg/dl and members of the same household who are between six months and six years of age, into the contractor’s LCMP. 

  

	 	i.	Lead Case Management shall consist of, at a minimum: 

  

	 	1)	Follow-up of a child in need of lead screening, or who has been identified with an elevated blood lead level > 10 μg/dl. At minimum, follow-up shall include:

  

	 	A)	For a child with an elevated blood lead level > 10 μg/dl, the Plan’s LCM shall ascertain if the blood lead level has been confirmed by a venous blood determination. In
the absence of confirmatory test results, the LCM will arrange for a test. 

  

	 	B)	For a child with a confirmed blood (venous) lead level of > 10 μg/dl, the contractor’s LCM shall notify and provide to the local health department the child’s
name, primary health care provider’s name, the confirmed blood lead level, and any other pertinent information. 

  

	 	2)	 Education of the family about all aspects of lead hazard and toxicity. Materials shall explain the sources of lead exposure, the consequences of 

  

			
	Amended as of July 1, 2004	  	IV-35

	 	 
elevated blood levels, preventive measures, including housekeeping, hygiene, and appropriate nutrition. The reasons why it is necessary to follow a
prescribed medical regimen shall also be explained. 

  

	 	3)	Communication among all interested parties. 

  

	 	4)	Development of a written case management plan with the PCP and the child’s family and other interested parties. The case management plan shall be reviewed and updated on an
ongoing basis. 

  

	 	5)	Coordination of the various aspects of the affected child’s care, e.g., WIC. support groups, and community resources, and 

  

	 	6)	Aggressively pursuing non-compliance with follow-up tests and appointments, and document these activities in the LCMP. 

  

	 	ii.	Active case management may be discontinued if one of the following criteria has been met: 

  

	 	1)	The child has one confirmed blood lead levels < 10 μg/dl drawn and all other children under the age of six years living in the household who have been tested and their
blood levels are < 10 μg/dl, and the sources of lead have been identified and reduced, or 

  

	 	2)	The family has been permanently relocated to a lead-safe house, or 

  

	 	3)	The parent/guardian has given a written refusal of service, or 

  

	 	4)	The LCM is unable to locate the child after a minimum of three documented attempts, using the assistance of County Board of Social Services, and the LHD. The child’s PCP will
be notified in writing. 

  

			
	Amended as of July 1, 2004	  	IV-36

	4.2.7	IMMUNIZATIONS 

  
 with the administration of Methadone, which will remain FFS). neurological evaluations, laboratory testing and radiologic examinations, and any other
diagnostic procedures that are necessary to make the diagnostic determination between a primary MH/SA disorder and an underlying physical disorder, as well as for medical work-ups required for medical clearances prior to the provision of psychiatric
medication or electroconvulsive therapy (ECT), or for transfer to a psychiatric/SA facility. Routine laboratory procedures ordered by treating MH/SA providers in conjunction with MH/SA treatment, for routine blood testing performed in conjunction
with the administration of atypical antipsychotics (see Article 4.1.4B for non-DDD enrollees, are not the responsibility of the contractor. 
  

	 	2.	The contractor shall develop a referral process to be used by its providers which shall include providing a copy of the medical consultation and diagnostic results to the MH/SA
provider. The contractor shall develop procedures to allow for notification of an enrollee’s MH/SA provider of the findings of his/her physical examination and laboratory/radiological tests within twenty-four (24) hours of receipt for urgent
cases and within five business days in non-urgent cases. This notification shall be made by phone with follow-up in writing when feasible. 

  

	 	C.	Pharmacy Services. Except for the drugs specified in Article 4.1.4 (Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are covered by the contractor. This includes
drugs prescribed by the contractor or MH/SA providers. The contractor shall only restrict or require a prior authorization for prescriptions or pharmacy services prescribed by MH/SA providers if one of the following exceptions is demonstrated:

  

	 	1.	The drug prescribed is not related to the treatment of substance abuse/dependency/addiction or mental illness or to any side effects of the psychopharmacological agents. These drugs
are to be prescribed by the contractor’s PCP or specialists in the contractor’s network. 

  

	 	2.	The prescribed drug does not conform to standard rules of the contractor’s pharmacy plan. 

  

	 	3.	The contractor, at its option, may require a prior authorization (PA) process if the number of prescriptions written by the MH/SA provider for MH/SA-related conditions exceed four
(4) per month per enrollee. For drugs that require weekly prescriptions, these prescriptions shall be counted as one per month and not as four separate prescriptions. The contractor’s PA process for the purposes of this section shall require
review and prior approval by DMAHS. 

  

			
	Amended as of July 1, 2004	  	IV-45

	 	g.	Serving as Chairperson of Quality Management Committee; [Note: the medical director may designate another physician to serve as chairperson with prior approval from DMAHS.]

  

	 	h.	Oversight of provider education, in-service training and orientation; 

  

	 	i.	Assuring that adequate staff and resources are available for the provision of proper medical care to enrollees; and 

  

	 	j.	The review and approval of studies and responses to DMAHS concerning QM matters. 

  

	 	3.	Enrollee Rights and Responsibilities. Shall include the right to the Medicaid Fair Hearing Process for Medicaid enrollees. 

  

	 	4.	Medical Record standards shall address both Medical and Dental records. Records shall also contain notation of any cultural/linguistic needs of the enrollee.

  

	 	5.	Provider Credentialing. Before any provider may become part of the contractor’s network, that provider shall be credentialed by the contractor. The contractor must comply with
N.J.A.C. 8:38C-1 et seq. and Standard IX of NJ modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the contractor’s credentialing procedures shall include verification that providers and subcontractors have not been suspended,
debarred, disqualified, terminated or otherwise excluded from Medicaid, Medicare, or any other federal or state health care program. The contractor shall obtain federal and State lists of suspended/debarred providers from the appropriate agencies.

  

	 	6.	Institutional and Agency Provider Credentialing. The contractor shall have written policies and procedures for the initial quality assessment of institutional and agency providers
with which it intends to contract. At a minimum, such procedures shall include confirmation that a provider has been reviewed and approved by a recognized accrediting body and is in good standing with State and federal regulatory bodies. If a
provider has not been approved by a recognized accrediting body, the contractor shall develop and implement standards of participation. For home health agency and hospice agency providers, the contractor shall verify that the providers are licensed
and meet Medicare certification participation requirements. 

  

	 	7.	 Delegation/subcontracting of QAPI activities shall not relieve the contractor of its obligation to perform all QAPI functions. The contractor shall submit a written
request and a plan for active oversight of the QAPI 

  

			
	Amended as of July 1, 2004	  	IV-61

	 	 
its aggregate, enrolled commercial and Medicare population in the State or region (if these data are collected and __ported to DHSS, a copy of the report
should be submitted also to DMAHS) the following clinical indicator measures: 

  

			
	 HEDIS
 Reporting Set
Measures

	  	Report Period
by Contract Year

	 Childhood Immunization Status
	  	annually
	 Adolescent Immunization Status
	  	annually
	 Well-Child Visits in first 15 months of life
	  	annually
	 Well-Child Visits in the 3rd, 4th, 5th and 6th year of
life
	  	annually
	 Adolescent Well-Care Visits
	  	annually
	 Prenatal and Postpartum Care
	  	annually
	 Breast Cancer Screening
	  	annually
	 Cervical Cancer Screening
	  	annually
	 Medical Assistance with Smoking Cessation
	  	annually

  
 Childhood &
Adolescent Immunization HEDIS data for NJ FamilyCare enrollees up to the age of 19 years must be reported separately. 
  

	 	Q.	Quality Improvement Projects (QIPs). The contractor shall participate in QIPs defined annually by the State with input from the contractor. The State will, with input from the
contractor and possibly other MCEs, define measurable improvement goals and QIP-specific measures which shall serve as the focus for each QIP. The contractor shall be responsible for designing and implementing strategies for achieving each
QIP’s objectives. At the beginning of each contract year the contractor shall present a plan for designing and implementing such strategies, which shall receive approval from the State prior to implementation. The contractor shall then submit
semiannual progress reports summarizing performance relative to each of the objectives of each contract year. 

  
 The QIPs shall be completed annually and shall include the areas identified below. The external review organization (ERO) under contract with DHS shall
prepare a final report for year one that will contain data, using State-approved sampling and measurement methodologies, for each of the measures below. Changes in required QIPs shall be defined by the DHS and incorporated into the contract by
amendment. 
  
 For each measure the DHS will identify a baseline
and a compliance standard. Baseline data, target standards, and compliance standards shall be established or updated by the State. 
  
 If DHS determines that the contractor is not in compliance with the requirements of the annual QIP objectives, either based on the contractor’s
progress report or 

  

			
	Amended as of July 1, 2004	  	IV-64

 
he ERO’s report, the contractor shall prepare and submit a corrective action plan for DHS approval. 
  

	 	1.	Well-Child Care (EPSDT) 

  
 The QIP for Well-Child Care shall focus upon achieving compliance with the EPSDT periodicity schedule (See Article 4.2.6) in the following priority
areas: 
  

										
	 Clinical Area

	  	Performance
Standard

	 	 	Minimum
Compliance
Standard

	 	 	Discretionary
Sanction

	 
	 Age-appropriate
	  	 	 	 	 	 	 	 	 
	 Comprehensive exams
	  	 	 	 	 	 	 	 	 
	 (CMS-specified age groups)
	  	 	 	 	 	 	 	 	 
	 	  	80	%	 	60	%	 	60 – 70	%
	 < 1 year old
	  	80	%	 	60	%	 	60 – 70	%
	 1 – 2 years old
	  	80	%	 	65	%	 	60 – 70	%
	 3 – 5 years old (at least 1 visit)
	  	80	%	 	60	%	 	60 – 70	%
	 6 – 9 years old (at least 1 visit)
	  	80	%	 	60	%	 	60 – 70	%
	 10 – 14 years old (at least 1 visit)
	  	80	%	 	60	%	 	60 – 70	%
	 15 – 18 years old (at least 1 visit)
	  	80	%	 	60	%	 	60 – 70	%
	 19 – 20 years old (at least 1 visit)
	  	 	 	 	 	 	 	 	 
	 Immunizations
	  	 	 	 	 	 	 	 	 
	 2 year olds (HEDIS combined rate)
	  	80	%	 	60	%	 	60 – 70	%
	 Annual Denial Visit –
	  	 	 	 	 	 	 	 	 
	 3 – 12 yr olds
	  	80	%	 	60	%	 	60 – 70	%
	 13 – 21 yr olds
	  	80	%	 	60	%	 	60 – 70	%
	 Lead screens (under age 3)
	  	80	%	 	60	%	 	60 – 70	%

  

	 	2.	Prenatal Care and Pregnancy Outcome 

  
 The QIP for Prenatal Care and Pregnancy Outcome shall focus upon achieving improvements in compliance with prenatal care protocols and in obtaining
positive pregnancy outcomes 
  

							
	 Clinical Area

	  	 Target
 Standard

	 	 	Compliance
Standard

	 
	 Initial visit in first trimester or within 6 wks of enrollment
	  	85	%	 	75	%
	 Adequate frequency of prenatal care
	  	85	%	 	75	%
	 Low birth weight babies
	  	 	 	 	 	 

  

			
	Amended as of July 1, 2004	  	IV-65

	 	A.	The contractor shall provide the DMAHS a full network, monthly, on computer diskette in accordance with the specifications provided in Section A.4:l of the Appendices. The network
file shall include an indicator for new additions and deletions and shall include: 

  

	 	1.	Any and all changes in participating primary care providers, including, for example, additions, deletions, or closed panels, must be reported monthly to DMAHS.

  

	 	2.	Any and all changes in participating physician specialists, health care providers, CNPs/CNSs, ancillary providers, and other subcontractors must be reported to DMAHS on a monthly
basis. 

  

	 	B.	DMAHS review of provider network deficiencies will be conducted on a quarterly basis or more frequently as may be required. 

  

	 	C.	The contractor shall provide the HBC with a full network on a monthly basis in accordance with the specifications found in Section A.4.1 of the Appendices. The electronic files
shall be sent to DMAHS, and a copy to the DMAHS’ designee for distribution. 

  

	4.8.4	 PROVIDER DIRECTORY REQUIREMENTS 

  
 The contractor shall prepare a provider directory which shall be presented in the following manner. Fifty (50) copies of the provider directory, and any
updates, shall be provided to the HBC, and ten (10) copies shall be provided to DMAHS at least every six months or within 30 days of an update. 
  

	 	A.	Primary care providers who will serve enrollees listed by 

  

	 	•	County, by city, by specialty 

  

	 	•	Provider name and degree; specialty board eligibility/certification status; office address(es) (actual street address); telephone number; fax number if available; office hours at
each location; indicate if a provider serves enrollees with disabilities and how to receive additional information such as type of disability; hospital affiliations; transportation availability; special appointment instructions if any; languages
spoken; disability access; and any other pertinent information that would assist the enrollee in choosing a PCP. 

  

	 	B.	Contracted specialists and ancillary services providers who will serve enrollees 

  

	 	•	Listed by county, by city, by physician specialty, by non-physician specialty, and by adult specialist and by pediatric specialist for those specialties indicated in Section
4.8.8.C. 

  

			
	Amended as of July 1, 2004	  	IV-98

	 	C.	Subcontractors 

  

	 	•	Provide, at a minimum, a list of all other health care providers by county, by service specialty, and by name. The contractor shall demonstrate its ability to provide all of the
services included under this contract. 

  

	4.8.5	 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES 

  
 The contractor shall develop and enforce credentialing and recredentialing criteria for all provider types which should follow the CMS’ credentialing
criteria, as delineated in the NJ modified QARI/QISMC standards found in Article 4.6.1 and Section B.4.14 of the Appendices, and comply with N.J.A.C. 8:38C-1 et seq. 
  

	4.8.6	 LABORATORY SERVICE PROVIDERS 

  

	 	A.	The contractor shall ensure that all laboratory testing sites providing services under this contract, including those provided by primary care physicians, specialists, other health
care practitioners, hospital labs, and independent laboratories have either a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number, and comply with New Jersey
DHSS disease reporting requirements. Those laboratory service providers with a certificate of waiver shall provide only those tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of
laboratory tests. 

  

	 	1.	The contractor shall provide to DMAHS, on request, copies of certificates that its own laboratory or any other laboratory it conducts business with, has a CLIA certificate for the
services it is performing as fulfillment of requirements in 42 C.F.R. § 493.1809. 

  

	 	2.	If the contractor has its own laboratory, the contractor shall submit at the time of initial contracting a written list of all diagnostic tests performed in its own laboratory if
applicable and those tests which are referred to other laboratories annually and within fifteen (15) working days of any changes. 

  

	 	3.	The contractor shall inform DMAHS and provide a geographic access analysis in accordance with the specifications found in the Appendix, Section A.4.3 if it contracts with a new
laboratory subcontractor 45 days prior to the effective date of the subcontractor’s contract and shall notify DMAHS of a termination of a laboratory subcontractor 90 days prior to the effective date of the subcontractor’s termination. The
contractor shall provide a copy of a new subcontractor’s certificate of waiver or certificate of registration within ten (10) days of operation. 

  

			
	Amended as of July 1, 2004	  	IV-99

	 	3.	Other: 

  

	 	a.	Genetic Testing and Counseling Centers 

  

	 	b.	Hemophilia Treatment Centers 

  

	 	H.	Other Specialty Centers/Providers [Institutional File] 

  
 Contractor should establish relationships with the following providers/centers on a consultant or referral basis. 
  

	 	1.	Spina Bifida Centers/providers 

  

	 	2.	Adult Scoliosis 

  

	 	3.	Autism and Attention Deficits 

  

	 	4.	Spinal Cord Injury 

  

	 	5.	Lead Poisoning Treatment Centers 

  

	 	6.	Child Abuse Regional Diagnostic Centers 

  

	 	7.	County Case Management Units 

  

	 	8.	Psychologists (for clients of DDD) 

  

	 	9.	Physical Medicine (for inpatient rehabilitation services) 

  

	 	10.	Maternal & Fetal Medicine 

  

	 	11.	Medical Toxicology 

  

			
	Amended as of July 1, 2004	  	IV-107

	 	1.	Provider Network Access Standards and Ratios 

  

															
	 Specialty

	  	A - Miles per 2

	  	B - Miles per 1

	  	Min. No. Per County
Except Where Noted

	 	 	Capacity Limit
Per Provider

	 
	 	  	Urban

	  	Non-Urban

	  	Urban

	  	Non-urban

	  	 
	 PCP Children     GP
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	                             FP
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	                             Peds
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	         Adults        GP
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	                             FP
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	                             IM
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	 CNP/CNS
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,000	 
	 CNM
	  	12	  	25	  	6	  	15	  	2	 	 	1:    1,500	 
	 Dentist, Primary Care
	  	6	  	15	  	2	  	10	  	2	 	 	1:    1,500	 
	 Allergy
	  	15	  	25	  	10	  	15	  	2	 	 	1:  75,000	 
	 Anesthesiology
	  	15	  	25	  	10	  	15	  	2	 	 	1:  17,250	 
	 Cardiology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Cardiovascular Disease
	  	15	  	25	  	10	  	15	  	2	 	 	1:166,000	 
	 Chiropractor
	  	15	  	25	  	10	  	15	  	1	 	 	1:  20,000	 
	 Colorectal surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:  30,000	 
	 Dermatology
	  	15	  	25	  	10	  	15	  	2	 	 	1:  75,000	 
	 Emergency Medicine
	  	15	  	25	  	10	  	15	  	2	 	 	1:  19,000	 
	 Endocrinology
	  	15	  	25	  	10	  	15	  	2	 	 	1:143,000	 
	 Endodontia
	  	15	  	25	  	10	  	15	  	1	 (where available)	 	1:  30,000	 
	 Gastroenterology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 General Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:  30,000	 
	 Geriatric Medicine
	  	15	  	25	  	10	  	15	  	1	 	 	1:  10,000	 
	 Hematology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Infectious Disease
	  	15	  	25	  	10	  	15	  	2	 	 	1:125,000	 
	 Neonatology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Nephrology
	  	15	  	25	  	10	  	15	  	2	 	 	1:125,000	 
	 Neurology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Neurological Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:166,000	 
	 Obstetrics/Gynecology
	  	15	  	25	  	10	  	15	  	2	 	 	1:    7,100	 
	 Oncology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Ophthalmology
	  	15	  	25	  	10	  	15	  	2	 	 	1:    60,00	 
	 Optometrist
	  	15	  	25	  	10	  	15	  	2	 	 	1:    8,000	 
	 Oral Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:  20,000	 
	 Orthodontia
	  	15	  	25	  	10	  	15	  	1	 	 	1:  20,000	 
	 Orthopedic Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:  28,000	 
	 Otolaryngology (ENT)
	  	15	  	25	  	10	  	15	  	2	 	 	1:  53,000	 
	 Periodontia
	  	15	  	25	  	10	  	15	  	1	 (where available)	 	1:  30,000	 
	 Physical Medicine
	  	15	  	25	  	10	  	15	  	 	(where applicable)	 	1:  75,000	 
	 Plastic Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:250,000	 
	 Podiatrist
	  	15	  	25	  	10	  	15	  	2	 	 	1:  20,000	 
	 Prosthodontia
	  	15	  	25	  	10	  	15	  	1	 (where available)	 	1:  30,000	 
	 Psychiatrist
	  	15	  	25	  	10	  	15	  	2	 	 	1:  30,000	 
	 Psychologist
	  	15	  	25	  	10	  	15	  	—  	 	 	1:  30,000	 
	 Pulmonary Disease
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Radiation Oncology
	  	15	  	25	  	10	  	15	  	2	 	 	1:100,000	 
	 Radiology
	  	15	  	25	  	10	  	15	  	2	 	 	1:  25,000	 
	 Rheumatology
	  	15	  	25	  	10	  	15	  	2	 	 	1:150,000	 
	 Audiology
	  	12	  	25	  	6	  	15	  	2	 	 	1:100,000	 
	 Thoracic Surgery
	  	15	  	25	  	10	  	15	  	2	 	 	1:150,000	 
	 Urology
	  	15	  	25	  	10	  	15	  	2	 	 	1:  60,000	 
	 Fed Qual Health Co
	  	 	  	 	  	 	  	 	  	1	 	 	1 /county if
available	 
 
	 Hospital
	  	20	  	35	  	10	  	15	  	2	 	 	2 per county
(where applicable	 
)
	 Pharmacies
	  	10	  	15	  	5	  	12	  	 	 	 	1:    1,000	 
	 Laboratory
	  	N/A	  	N/A	  	7	  	12	  	 	 	 	 	 
	 DME/Med Supplies
	  	12	  	25	  	6	  	15	  	1	 	 	1:  50,000	 
	 Hearing Aid
	  	12	  	25	  	6	  	15	  	1	 	 	1:  50,000	 
	 Optical Appliance
	  	12	  	25	  	6	  	15	  	2	 	 	1:  50,000	 

  

			
	Amended as of July 1, 2004	  	IV-108

 of medicine in the following counties: Cape May, Cumberland. Gloucester, Hunterdon,
Salem, Sussex. 
  

	 	b.	Cardiology, pediatric – In-county alternative: adult cardiovascular disease; out of county pediatric referral applies to: Cumberland, Hunterdon, Somerset, Sussex, Warren.

  

	 	c.	Endocrinology, adult – In-county alternative: none, refer out of county for Cape May, Gloucester, Sussex, Warren. 

  

	 	d.	Endocrinology, pediatric – In-county alternative: adult endocrinologist: out of county referral for pediatric endocrinology applies to: Atlantic, Cape May, Cumberland,
Gloucester, Hunterdon, Mercer, Ocean, Salem, Somerset, Sussex, Warren. 

  

	 	e.	Gastroenterology, pediatric – In-county alternative: adult gastroenterologists; out of county referral for pediatric gastroenterology applies to: Atlantic, Burlington, Cape
May, Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem, Sussex, Warren. 

  

	 	f.	General Surgery, pediatric – In-county alternative: adult general surgery; out of county referral for pediatrics applies to: Burlington, Cape May, Cumberland, Gloucester,
Hunterdon, Mercer, Morris, Salem, Somerset, Sussex, Warren. 

  

	 	g.	Geriatrics – In-county alternative: Family Practitioner or Internist; applies to: Cape May, Cumberland, Gloucester, Mercer, Morris, Salem, Somerset, Sussex, Warren.

  

	 	h.	Hematology/Oncology, pediatric – In-county alternative: none; out of county pediatrics referral applies to: Burlington, Cape May, Cumberland, Gloucester, Salem, Somerset,
Warren. 

  

	 	i.	Infectious Disease, pediatric – In-county alternative: Adult infectious disease; out of county pediatric referral applies to: Atlantic, Burlington, Cape May, Cumberland,
Gloucester, Hunterdon, Ocean, Salem, Somerset, Sussex, Warren. 

  

	 	j.	Nephrology, adult – In-county alternative: none; refer out of county for Cape May, Sussex, Warren. 

  

	 	k.	Nephrology, pediatric – In-county alternative; adult nephrologist; out of county pediatric referral applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester,
Hunterdon, Mercer, Monmouth, Ocean, Salem, Somerset, Sussex, Warren. 

  

			
	Amended as of July 1, 2004	  	IV-114

	 	l.	Neonatal/Perinatal medicine – Alternative: none, refer out of county. 

  

	 	m.	Neurology, pediatric – In-county alternative: adult neurology; out of county pediatric referral applies to: Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Sussex,
Warren. 

  

	 	n.	Neurological Surgery – In-county alternative: none; out of county referral applies to: Cape May, Cumberland, Gloucester, Hudson, Salem, Warren. 

  

	 	o.	Plastic Surgery – In-county alternative: none; out of county referral applies to: Cape May, Salem, Sussex, Warren. 

  

	 	p.	Pulmonary Disease, pediatric – In-county alternative: Adult pulmonary disease; out of county pediatric referral applies to: Burlington, Cape May, Cumberland, Gloucester, Ocean,
Warren. 

  

	 	q.	Radiation Oncology – In-county alternative: none; out of county referral applies to: Cape May, Salem. Sussex, Warren. 

  

	 	r.	Rheumatology, pediatric – In-county alternative: adult rheumatology; out of county pediatric referral applies to: all counties except Bergen and Essex.

  

	 	s.	Thoracic surgery – In-county alternative: none, refer out of county for Cape May, Hunterdon, Morris, Sussex, Warren. 

  

	 	4.	Hospitals. For the following counties, the contractor may limit its hospital provider network to one (1) hospital, which must be a full service, acute care hospital including at
least licensed medical-surgical, pediatric, obstetrical, and critical care services: Cape May, Cumberland, Gloucester, Hunterdon, Salem, Somerset, Sussex, and Warren. 

  

	4.8.9 	DENTAL PROVIDER NETWORK REQUIREMENTS 

  

	 	A.	The contractor shall establish and maintain a dental provider network, including primary and specialty care dentists, which is adequate to provide the full scope of benefits. The
contractor shall include general dentists and pediatric dentists as primary care dentists (PCDs). A system whereby the PCD initiates and coordinates any consultations or referrals for specialty care deemed necessary for the treatment and care of the
enrollee is preferred. 

  

	 	B.	The dental provider network shall include sufficient providers able to meet the dental treatment requirements of patients with developmental disabilities. (See Article 4.5.2E for
details.) 

  

			
	Amended as of July 1, 2004	  	IV-115

	 	5.	The contractor shall submit to DMAHS for review and approval prior to implementation any changes required to comply with HIPAA. 

  

	 	G.	The contractor shall submit at least annually or 30 days prior to any changes, lists of names, addresses, ownership/control information of participating providers and
subcontractors, and individuals or entities, which shall be incorporated in this contract. 

  

	 	1.	The contractor shall obtain prior DMAHS review and written approval of any proposed plan for merger, reorganization or change in ownership of the contractor and approval by the
appropriate State regulatory agencies. 

  

	 	2.	The contractor shall comply with Article 4.9.1 G.I to ensure uninterrupted and undiminished services to enrollees, to evaluate the ability of the modified entity to support the
provider network, and to ensure that any such change has no adverse effects on DMAHS1 managed care program and shall
comply with the Departments of Banking and Insurance, and Health and Senior Services statutes and regulations. 

  

	 	H.	The contractor shall demonstrate its ability to provide all of the services included under this contract through the approved network composition and accessibility.

  

	 	I.	The contractor shall not oblige providers to violate their state licensure regulations. 

  

	 	J.	The contractor shall provide its providers and subcontractors with a schedule of fees and relevant policies and procedures at least 30 days prior to implementation.

  

	 	K.	The contractor shall arrange for the distribution of informational materials to all its providers and subcontractors providing services to enrollees, outlining the nature, scope,
and requirements of this contract. 

  

	 	L.	Subcontractor Delegation. The contractor shall monitor any functions and responsibilities it delegates to any subcontractor. The contractor shall be accountable for any and all
functions and responsibilities it delegates to a subcontractor. The contractor shall obtain the prior approval of DMAHS for any such delegation and shall meet the requirements of 42 C.F.R. § 438. 

  

	4.9.2 	CONTRACT SUBMISSION 

  
 The contractor shall submit to DMAHS one complete, fully executed contract for each type of provider, i.e., primary care physician, physician specialist,
non-physician practitioner, hospital and other health care providers/services covered under the benefits package, subcontract and the form contract of any subcontractor’s provider contracts. The use of a signature stamp is not permitted and
shall not be considered a fully executed contract. Contracts shall be submitted with all attachments, appendices, referenced 

  

			
	Amended as of July 1, 2004	  	IV-118

 
documents, and with rate schedules, etc., upon request. A copy of the appropriate completed contract checklist for DHS, DHSS, and DOB shall be attached to each contract form. Regulatory approval and approval by the Department is required for each
provider contract form and subcontract prior to use. Submission of all other contracts shall follow the format and procedures described below: 
  

	 	A.	Copies of the complete fully executed contract with every FQHC. Certification of the continued in force contracts previously submitted will be permitted. 

 

	 	B.	Hospital contracts shall list each specific service to be covered including but not limited to: 

  

	 	1.	Inpatient services; 

  

	 	2.	Anesthesia and whether professional services of anesthesiologists and nurse anesthetists are included; 

  

	 	3.	Emergency room services 

  

	 	a.	Triage fee - whether facility and professional fees are included; 

  

	 	b.	Medical screening fee - whether facility and professional fees are included; 

  

	 	c.	Specific treatment rates for: 

  

	 	(1)	Emergent services 

  

	 	(2)	Urgent services 

  

	 	(3)	Non-urgent services 

  

	 	(4)	Other 

  

	 	d.	Other - must specify 

  

	 	4.	Neonatology - facility and professional fees 

  

	 	5.	Radiology 

  

	 	a	Diagnostic 

  

	 	b.	Therapeutic 

  

	 	c.	Facility fee 

  

	 	d.	Professional services 

  

	 	6.	Laboratory - facility and professional services 

  

	 	7.	Outpatient/clinic services must be specific and address 

  

	 	a.	School-based health service programs 

  

	 	b.	Audiology therapy and therapists 

  

	 	8.	AIDS Centers 

  

	 	9.	Any other specialized service or center of excellence 

  

	 	10.	Hospice services if the hospital has an approved hospice agency that is Medicare certified. 

  

	 	11.	Home Health agency services if hospital has an approved home health agency license from the Department of Health and Senior Services that meets licensing and Medicare certification
participation requirements. 

  

	 	12.	Any other service. 

  

	 	C.	FQHC contracts: 

  

			
	Amended as of July 1, 2004	  	IV-119

	 	C.	The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible persons within the defined enrollment areas in the order in which they apply or are auto-assigned to the
contractor (on a random basis with equal distribution among all participating contractors) without restrictions, within contract limits. Enrollment shall be open at all times except when the contract limits have been met. A contractor shall not deny
enrollment of a person with an SSI disability or New Jersey Care Disabled category who resides outside of the enrollment area. However, such enrollee with a disability shall be required to utilize the contractor’s established provider network.
The contractor shall accept enrollees for enrollment throughout the duration of this contract. 

  

	 	D.	Enrollment timeframe. As of the effective date of enrollment, and until the enrollee is disenrolled from the contractor’s plan, the contractor shall be responsible for the
provision and cost of all care and services covered by the benefits package listed in Article 4.1. Enrollees who become eligible to receive services between the 1st through the end of the month shall be eligible for Managed Care services in that month. When an enrollee is shown on the enrollment roster as covered by a contractor’s plan, the contractor shall
be responsible for providing services to that person from the first day of coverage shown to the last day of the calendar month of the effective date of disenrollment. DMAHS will pay the contractor a capitation rate during this period of time.

  

	 	E.	Hospitalizations. For any eligible person who applies for participation in the contractor’s plan, but who is hospitalized prior to the time coverage under the plan becomes
effective, such coverage shall not commence until the date after such person is discharged from the hospital and DMAHS shall be liable for payment for the hospitalization, including any charges for readmission within forty-eight (48) hours of
discharge for the same diagnosis. If an enrollee’s disenrollment or termination becomes effective during a hospitalization, the contractor shall be liable for hospitalization until the date such person is discharged from the hospital, including
any charges for readmission within forty- eight (48) hours of discharge for the same diagnosis. The contractor shall notify DMAHS within 180 days of initial hospital admission. 

  

	 	F.	Unless otherwise required by statute or regulation, the contractor shall not condition any Medicaid/NJ FamilyCare eligible person’s enrollment upon the performance of any act
or suggest in any way that failure to enroll may result in a loss of Medicaid/NJ FamilyCare benefits. 

  

	 	G.	There shall be no retroactive enrollment in Managed Care. Services for those beneficiaries during any retroactive period will remain fee-for-service, except for individuals eligible
under NJ FamilyCare Plans B, C, D, and H who are not eligible until enrolled in an MCE. Coverage shall continue indefinitely unless this contract expires or is terminated, or the enrollee is no longer eligible or is deleted from the
contractor’s list of eligible enrollees. 

  

			
	Amended as of July 1, 2004	  	V - 7

	 	R.	Complaints and Grievances/Appeals 

  

	 	1.	Procedures for resolving complaints, as approved by the DMAHS; 

  

	 	2.	A description of the grievance/appeal procedures to be used to resolve disputes between a contractor and an enrollee, including: the name, title. or department, address, and
telephone number of the person(s) responsible for assisting enrollees in grievance/appeal resolutions; the time frames and circumstances for expedited and standard grievances; the right to appeal a grievance determination and the procedures for
filing such an appeal; the time frames and circumstances for expedited and standard appeals; the right to designate a representative; a notice that all disputes involving clinical decisions will be made by qualified clinical personnel; and that all
notices of determination will include information about the basis of the decision and further appeal rights, if any; 

  

	 	3.	The contractor shall notify all enrollees in their primary language of their rights to file grievances and appeal grievance decisions by the contractor; 

  

	 	S.	An explanation that Medicaid/NJ FamilyCare Plan A enrollees, and Plans D and H enrollees with a program status code of 380, have the right to a Medicaid Fair Hearing with DMAHS and
the appeal process through the DHSS for Medicaid and NJ FamilyCare enrollees, including instructions on the procedures involved in making such a request; 

  

	 	T.	Title, addresses, phone numbers and a brief description of the contractor’s plan for contractor management/service personnel; 

  

	 	U.	The interpretive, linguistic, and cultural services available through the contractor’s plan; 

  

	 	V.	An explanation of the terms of enrollment in the contractor’s plan, continued enrollment, automatic re-enrollment, disenrollment procedures, time frames for each procedure,
default procedures, enrollee’s rights and responsibilities and causes for which an enrollee shall lose entitlement to receive services under this contract, and what should be done if this occurs; 

  

	 	W.	A statement strongly encouraging the enrollee to obtain a baseline physical and dental examination, and to attend scheduled orientation sessions and other educational and outreach
activities; 

  

	 	X.	A description of the EPSDT program, and language encouraging enrollees to make regular use of preventive medical and dental services; 

  

	 	Y.	Provision of information to enrollees or, where applicable, an authorized person, to assist them in the selection of a PCP; 

  

			
	Amended as of July 1, 2004	  	V - 15

 The contractor’s system and procedure shall be available to both Medicaid beneficiaries and NJ
FamilyCare beneficiaries. All enrollees __ve available the complaint and grievance/appeal process under the contractor’s plan, the Department of Health and Senior Services and, for Medicaid and certain NJ FamilyCare beneficiaries (i.e., Plan A
enrollees and beneficiaries with a PSC of 380 under Plan D), the Medicaid Fair Hearing process. Individuals eligible solely through NJ FamilyCare Plans B, C, D, and H (except for Plan D and H individuals with a program status code of 380), do not
have the right to a Medicaid Fair Hearing. 
  

	 	B.	Complaints. The contractor shall have procedures for receiving, responding to and documenting resolution of enrollee complaints that are received orally and are of a less serious or
formal nature. Complaints that are resolved to the enrollee’s satisfaction within three (3) business days of receipt do not require a formal written response or notification. The contractor shall call back an enrollee within twenty-four hours
of the initial contact if the contractor is unavailable for any reason or the matter cannot be readily resolved during the initial contact. Any complaint that is not resolved within three business days shall be treated as a grievance/appeal, in
accordance with requirements defined in Article 5.15.3. 

  

	 	C.	HBC Coordination. The contractor shall coordinate its efforts with the health benefits coordinator including referring the enrollee to the HBC for assistance as needed in the
management of the complaint/grievance/appeal procedures. 

  

	 	D.	DMAHS Intervention. DMAHS shall have the right to intercede on an enrollee’s behalf at any time during the contractor’s complaint/grievance/appeal process whenever there
is an indication from the enrollee, or, where applicable, authorized person, or the HBC that a serious quality of care issue is not being addressed timely or appropriately. Additionally, the enrollee may be accompanied by a representative of the
enrollee’s choice to any proceedings and grievances/appeals. 

  

	 	E.	Legal Rights. Nothing in this Article shall be construed as removing any legal rights of enrollees under State or federal law, including the right to file judicial actions to
enforce rights. 

  

	5.15.2 	NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE 

  

	 	A.	 The contractor shall provide all enrollees or, where applicable, an authorized person, upon enrollment in the contractor’s plan, and annually thereafter,
pursuant to this contract, with a concise statement of the contractor’s grievance/appeal procedure and the enrollees’ rights to a hearing by the Independent Utilization Review Organization (IURO) per NJAC 8:38-8.7 as well as their right to
pursue the Medicaid Fair Hearing process described in N.J.A.C 10:49-10.1 et seq. The information shall be provided through an annual mailing, a member handbook, or any other method approved by DMAHS. The contractor shall prepare the 

  

			
	Amended as of July 1, 2004	  	V - 36

	 	 
provider performance. Practice guidelines may be included in a separate document. 

  

	 	9.	The contractor’s policies and procedures 

  

	 	10.	PCP responsibilities 

  

	 	11.	Other provider/subcontractors’ responsibilities 

  

	 	12.	Prior authorization and referral procedures 

  

	 	13.	Description of the mechanism by which a provider can appeal a contractor’s service decision through the DHSS’ Independent Utilization Review Organization process

  

	 	14.	Protocol for encounter data element reporting/records 

  

	 	15.	Procedures for screening and referrals for the MH/SA services 

  

	 	16.	Medical records standards 

  

	 	17.	Payment policies 

  

	 	18.	Enrollee rights and responsibilities 

  

	 	B.	Bulletins. The contractor shall develop and disseminate bulletins as needed to incorporate any and all changes to the Provider Manual. All bulletins shall be mailed to the State at
least three (3) calendar days prior to publication or mailing to the providers or as soon as feasible. The Department shall have the right to issue and/or modify the bulletins at any time. If the DHS determines that there are factual errors or
misleading information, the contractor shall be required to issue corrected information in the manner determined by the DHS. 

  

	 	C.	Timeframes. Within twenty (20) calendar days after the contractor places a newly enrolled provider in an active status, the contractor shall furnish the provider with a current
Provider Manual, all related bulletins and the contractor’s methodology for supplying encounter data. 

  

	 	D.	The contractor shall provide a current Provider Manual to the Department annually. All updates of the manual shall also be provided to the Department within 30 days of the revision.

  

	 	E.	The Provider Manual and all policies and procedures shall be reviewed at least annually to ensure that the contractor’s current practices and contract requirements are
reflected in the written policies and procedures. 

  

			
	Amended as of July 1, 2004	  	VI-2

 measured by procedure codes specified in Appendix Section B.7.5 using encounter data. If the contractor
has not achieved the eighty (80) percent participation rate by the end of the twelve-month period, it shall submit a corrective action plan to DMAHS within thirty (30) days of notification by DMAHS of its actual participation rate. DMAHS shall have
the right to conduct a follow-up onsite review and/or impose financial damages for non-compliance. 
  

	 	a.	Mandatory Sanction. Failure of the contractor to achieve the minimum screening rate shall require the following refund of capitation paid: 

  

	 	i.	Achievement of a 50 percent to less than 60 percent EPSDT screening, dental visit and immunization rate (the lowest measured rate of each of the components of EPSDT screening, i.e.,
periodic exam, immunization rate, and dental screening rate, shall be considered to be the rate for EPSDT participation and the basis for the sanction): refund of $1 per enrollee for all enrollees under age 21 not screened. 

 

	 	ii.	Achievement of a 40 percent to less than 50 percent EPSDT screening, dental visit and immunization rate: refund of $2 per enrollee for all enrollees under age 21 not screened.

  

	 	iii.	Achievement of a 30 percent to less than 40 percent EPSDT screening, dental visit and immunization rate: refund of $3 per enrollee for all enrollees under age 21 not screened.

  

	 	iv.	Achievement of less than 30 percent: refund of $4 per enrollee for all enrollees under age 21 not screened. 

  

	 	b.	Discretionary Sanction. The DMAHS shall have the right to impose a financial or administrative sanction if the contractor’s performance screening rate is between sixty (60) -
seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve compliance. 

  

	 	2.	Failure to achieve and maintain the required screening rate shall result in the Local Health Departments being permitted to screen the contractor’s pediatric members. The cost
of these screenings shall be paid by the DMAHS-to the LHD, and the screening cost shall be deducted from the contractor’s capitation rate in addition to the damages imposed as a result of failure to achieve EPSDT performance standards.

  

	 	3.	 Mandatory sanctions may be offset when the contractor demonstrates improved compliance. The Division, in its sole discretion, may reduce the sanction amount by $1
for each twelve (12) point improvement over prior reporting period 

  

			
	Amended as of July 1, 2004	  	VII-29

	 	 
performance rate. Offsets shall not reduce the financial sanction amount to below $1 per enrollee not screened. 

  

	 	B.	Blood Lead Screening 

  

	 	1.	The contractor shall ensure that it has achieved an eighty (80) percent blood lead screening rate of its enrollees under three years of age during a twelve (12)-month contract
period. Blood lead screening is described in Article 4 and shall be measured using encounter data and the DHSS database. If the contractor has not achieved the eighty (80) percent blood lead screening rate by the end of the twelve (12)-month period,
it shall submit a corrective action plan to DMAHS within thirty (30) days of notification by DMAHS of its actual blood lead level screening rate. DMAHS shall have the right to conduct a follow-up onsite review and/or impose financial damages for
non-compliance. 

  

	 	a.	Mandatory sanction. Failure of the contractor to achieve sixty (60) percent screening rate shall require the following refund of capitation paid: 

  

	 	i	Achievement of a 50 percent to less than 60 percent lead screening rate: refund of $2 per enrollee for all enrollees under age 3 not screened. 

  

	 	ii	Achievement of a 40 percent to less than 50 percent lead screening rate: refund of $3 per enrollee for all enrollees under age 3 not screened. 

  

	 	iii	Achievement of a 30 percent to less than 40 percent lead screening rate: refund of $4 per enrollee for all enrollees under age 3 not screened. 

  

	 	iv	Achievement of less than 30 percent lead screening rate: refund of $5 per enrollee for all enrollees under age 3 not screened. 

  

	 	b.	Discretionary sanction. The DMAHS shall have the right to impose a financial or administrative sanction if the contractor’s performance screening rate is between sixty (60)
– seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve compliance. 

  

	 	C.	The contractor must demonstrate continuous quality improvement in achieving the performance standards for EPSDT and lead screenings as stated in Article 4. The Division shall, in
its sole discretion, determine the appropriateness of contractor proposed corrective action and the imposition of any other Financial or administrative sanctions in addition to those set out above. 

  

			
	Amended as of July 1, 2004	  	VII-30

	7.20	CONTRACTOR CERTIFICATIONS 

  

	7.20.1	GENERAL PROVISIONS 

  

	 	A.	With respect to any report, invoice, record, papers, documents, books of account, or other contract-required data submitted to the Department in support of an invoice or documents
submitted to meet contract requirements, including, but not limited to, proofs of insurance and bonding, Lobbying Certifications and Disclosures, Conflict of Interest Disclosure Statements and/or Conflict of Interest Avoidance Plans, pursuant to the
requirements of this contract, the Contractor’s Representative or his/her designee shall certify that the report, invoice, record, papers, documents, books of account or other contract required data is current, accurate, complete and in full
compliance with legal and contractual requirements to the best of that individual’s knowledge and belief. 

  

	 	B.	The contractor shall attest, based on best knowledge, information, and belief, as to the accuracy, completeness and truthfulness of enrollment information, encounter data, provider
networks, marketing materials, provider and beneficiary notifications and educational materials and any other information/documents specified in this contract. 

  

	7.20.2	 CERTIFICATION SUBMISSIONS 

  

	 	A.	Where in this contract there is a requirement that the contractor “certify” or submit a “certification,” such certification shall be in the form of an affidavit
or declaration under penalty of perjury dated and signed by the Contractor’s Representative or his/her designee. 

  

	 	B.	The data must be certified by one of the following: 

  

	 	1.	Chief Executive Officer (CEO) 

  

	 	2.	Chief Financial Office (CFO) 

  

	 	3.	An individual who has delegated authority to sign for, and who reports directly to the contractor’s CEO or CFO. 

  

	 	C.	The contractor shall submit the certification concurrently with the certified data. (See Appendix, Section A.7.1 for certification forms.) 

  

	7.20.3	 ENVIRONMENTAL COMPLIANCE 

  
 The contractor shall comply with all applicable environmental laws, rules, directives, standards, orders, or requirements, including but not limited to,
Section 306 of the Clean Air Act (42 U.S.C § 1857(h)), Section 508 of the Clean Water Act (33 U.S.C. § 1368), Executive Order 11738, and the Environmental Protection Agency (EPA) regulations (40 C.F.R., Part 15) that prohibit the use of
the facilities included on the EPA List of Violating Facilities. 
  

			
	Amended as of July 1, 2004	  	VII-34

 shall include., but not be limited to, utilization information on enrollee encounters with PCPs, children
who have not received an EPSDT examination or a blood lead screening, specialty claims, prescriptions, inpatient stays, and emergency room use. 
  

	 	E.	The contractor shall collect and analyze data to implement effective quality assurance, utilization review, and peer review programs in which physicians and other health care
practitioners participate. The contractor shall review and assess data using statistically valid sampling techniques including, but not limited to, the following: 

  
 Primary care practitioner audits: specialty audits; inpatient mortality audits; quality of care and provider performance
assessments; quality assurance referrals; credentialing and recredentialing; verification of encounter reporting rates; quality assurance committee and subcommittee meeting agendas and minutes; enrollee complaints, grievances, and follow-up actions;
providers identified for trending and sanctioning, including providers with low blood lead screening rates; special quality assurance studies or projects; prospective, concurrent, and retrospective utilization reviews of inpatient hospital stays;
and denials of off-formulary drug requests. 
  

	 	F.	The contractor shall prepare and submit to DMAHS quarterly reports to be reported by hard copy and diskette in a format and software application system determined by DMAHS,
containing summary information on the contractor’s operations for each quarter of the program (See Section A.7 of the Appendices, Tables 1 through 21. Exception – Tables 3A and 3B shall be submitted monthly by the fifteenth (15th) of every month.). These reports shall be received by DMAHS no later than forty-five (45) calendar
days after the end of the quarter. After a grace period of five (5) calendar days, for each calendar day after a due date that DMAHS has not yet received at a prescribed location a report that fulfills the requirements of any one item, assessment
for damages equal to one half month’s negotiated blended capitation rate that would normally be owed by DMAHS to the contractor for one recipient shall be applied. The damages shall be applied as an offset to subsequent payments to the
contractor. 

  
 The contractor shall be responsible
for continued reporting beyond the term of the contract because of lag time in submitting source documents by providers. 
  

	 	G.	The contractor may submit encounter reports daily but must submit encounter reports at least quarterly. However, encounter reports will be processed by DMAHS’ fiscal agent no
more frequently than monthly. All encounters shall be reported to DMAHS within seventy-five (75) days of the end of the quarter in which they are received by the contractor and within one year plus seventy-five (75) days from the date of service.

  

			
	Amended as of July 1, 2004	  	VII-38

	 	H.	The contractor shall annually and at the time changes are made report its staffing positions including the names of supervisory personnel (Director level and above and the QM/UR
personnel), organizational chart, and any position vacancies in these major areas. 

  

	 	I.	DMAHS shall have the right to create additional reporting requirements at any time as required by applicable federal or State laws and regulations, as they exist or may hereafter be
amended and incorporated into this contract. 

  

	 	J.	Reports that shall be submitted on an annual or semi-annual basis, as specified in this contract, shall be due within sixty (60) days of the close of the reporting period, unless
specified otherwise. 

  

	 	K.	MCSA Paid Claims Reconciliation. On a quarterly basis, the contractor shall provide paid claims data, via an encounter data file or separate paid claims file, that meet the HIPAA
format requirements for audit and reconciliation purposes. The contractor shall provide documentation that demonstrates a 100% reconciliation of the amounts paid to the amounts billed to the DMAHS. The paid claims data shall include at a minimum,
claim type, provider type, category of service, diagnosis code (5 digits), procedure/revenue code, Internal Control Number or Patient Account Number under HIPAA, provider ID, dates of services, that will allow the DMAHS to price claims in comparison
to Medicaid fee schedules for evaluation purposes. 

  

	 	L.	Encounter Data Submissions. The contractor shall cooperate with the DMAHS in its review of the status of encounter data submissions to determine needed improvements for accuracy and
completeness of encounter data submissions. With the contract period beginning July 2005, the contractor will be subject to additional sanctions if not in full compliance with encounter data submission standards. 

  

	7.27	FINANCIAL STATEMENTS 

  

	7.27.1	 AUDITED FINANCIAL STATEMENTS (SAP BASIS) 

  

	 	A.	Annual Audit. The contractor shall submit its audited annual financial statements prepared in accordance with Statutory Accounting Principles (SAP) certified by an independent
public accountant no later than June 1 of each year, for the immediately preceding calendar year as well as for any company that is a financial guarantor for the contractor in accordance with N.J.S.A. 8:38-11.6. 

  

	 	B.	Audit of Rate Cell Grouping Costs 

  
 The contractor shall submit, quarterly, reports found in Appendix, Section A in accordance with the “HMO Financial Guide for Reporting Medicaid/NJ
Family Care Rate Cell Grouping Costs” (Appendix, Section B7.3). These reports shall be 
  

			
	Amended as of July 1, 2004	  	VII-39

	8.5.3	 NEWBORN INFANTS 

  
 The contractor shall be reimbursed for newborns from the date of birth through the first 60 days after the birth through the period ending at the end of
the month in which the 60th day falls by a supplemental payment as part of the supplemental maternity payment.
Thereafter, capitation payments will be made prospectively, i.e., only when the baby’s name and ID number are accreted to the Medicaid eligibility file and formally enrolled in the contractor’s plan. 
  

	8.5.4	 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME 

  
 Because costs for pregnancy outcomes were not included in the capitation rates, the contractor shall be paid supplemental payments for pregnancy outcomes
for all eligibility categories. 
  
 Payment for pregnancy outcome
shall be a single, predetermined lump sum payment. This amount shall supplement the existing capitation rate paid. The Department will make a supplemental payment to contractors following pregnancy outcome. For purposes of this Article, pregnancy
outcome shall mean each live birth, still birth or miscarriage occurring at the thirteenth (13th) or greater week of
gestation. This supplemental payment shall reimburse the contractor for its inpatient hospital, antepartum, and postpartum costs incurred in connection with delivery. Costs for care of the baby for the first 60 days after the birth plus through the
end of the month in which the 60th day falls are included (See Section 8.5.3). Regional payment
shall be made by the State to the contractor based on submission of a financial summary report of hospital and/or birthing center claims paid for final pregnancy outcomes. No other services, inpatient hospital or otherwise, rendered prior to final
pregnancy outcome shall qualify or be payable for a maternity supplement. 
  
 The report shall be accompanied by a signed certification form and an electronic file to include: 
  

	 	1.	Paid inpatient hospital/birthing center claims; 

  

	 	2.	Name of mother; 

  

	 	3.	Mother’s Medicaid identification number; 

  

	 	4.	Newborn’s name, if known; 

  

	 	5.	Diagnosis and five-digit ICD-9 codes, including V-codes, specified by DMAHS; and 

  

	 	6.	Place of service. 

  
 The contractor shall continue to submit encounter data that will document each paid claim reported on the financial summary report. The DMAHS will conduct
a reconciliation of these paid claims utilizing encounter data. 
  

			
	Amended as of July 1, 2004	  	VIII-8

	8.5.5	PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS 

  

	 	K.	Hospitalizations. For any eligible person who applies for participation in the contractor’s plan, but who is hospitalized prior to the time coverage under the plan becomes
effective, such coverage shall not commence until the date after such person is discharged from the hospital and DMAHS shall be liable for payment for the hospitalization, including any charges for readmission within forty-eight (48) hours of
discharge for the same diagnosis. If an enrollee’s disenrollment or termination becomes effective during a hospitalization, the contractor shall be liable for hospitalization until the date such person is discharged from the hospital, including
any charges for readmission within forty-eight (48) hours of discharge for the same diagnosis. The contractor must notify DMAHS of these occurrences to facilitate payment to appropriate providers. 

  

	 	L.	Continuation of Benefits. The contractor shall continue benefits for all enrollees for the duration of the contract period for which capitation payments have been made, including
enrollees in an inpatient facility until discharge. The contractor shall notify DMAHS of these occurrences. 

  

	 	M.	Drug Carve-Out Report. The DMAHS will provide the contractor with a monthly electronic file of paid drug claims data for non-dually eligible, ABD enrollees.

  

	 	N.	MCSA Administrative Fee. The Contractor shall receive a monthly administrative fee, PMPM, for its MCSA enrollees, by the fifteenth (15th) day of any month during which health care services will be available to an enrollee. 

  

	 	O.	Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall reimburse the contractor for all claims paid on behalf of MCSA enrollees. The contractor shall submit to DMAHS a
financial summary report of claims paid on behalf of MCSA enrollees on a weekly basis. The report shall be summarized by category of service corresponding to the MCSA benefits and payment dates, accompanied by an electronic file of all individual
claim numbers for which the State is being billed. 

  

	 	P.	MCSA Claims Payment Audits. The contractor shall monitor and audit claims payments to providers to identify payment errors, including duplicate payments, overpayments,
underpayments, and excessive payments. For such payment errors (excluding underpayments), the contractor shall refund DMAHS the overpaid amounts. The contractor shall report the dollar amount of claims with payment errors on a monthly basis, which
is subject to verification by the State. The contractor is responsible for collecting funds due to the State from providers, either through cash payments or through offsets to payments due the providers. 

  

	8.9	CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS 

  

	 	A.	 The contractor shall make advance payments to its providers, capitation, FFS, or other financial reimbursement arrangement, based on a provider’s historical
billing or utilization of services if the contractor’s claims processing systems 

  

			
	Amended as of July 1, 2004	  	VIII-19

	 	 
against the next PIP made to the hospital. An example of how this methodology shall work is as follows: 

  
 EXAMPLE: 
  

													
	 	  	 PIP
 Payment

	 	 	 Claims
 Adjudicated

	  	Reconciliation
Adjustment

	 	 	 Net
 Payment

	  	Balance

	 Aug 1
	  	300,000 	(A)	 	 	  	 	 	 	 	  	 
	 Aug 1
	  	300,000 	(B)	 	 	  	 	 	 	 	  	600,000
	 Aug 1-31
	  	 	 	 	180,000	  	 	 	 	 	  	420,000
	 Sept 1
	  	300,000 	(C)	 	 	  	(120,000	) (A)	 	180,000	  	600,000
	 Sept 1-30
	  	 	 	 	270,000	  	 	 	 	 	  	330,000
	 Oct 1
	  	300,000 	(D)	 	 	  	(30,000	) (B)	 	270,000	  	600,000
	 Oct l -31
	  	 	 	 	320,000	  	 	 	 	 	  	280,000
	 Nov 1
	  	300,000 	(E)	 	 	  	20,000 	(C)	 	320,000	  	600,000

  

	8.10	FEDERALLY QUALIFIED HEALTH CENTERS 

  

	 	A.	Standards for Contractor FQHC Rates. The contractor shall not reimburse FQHCs less than the level and amount of payment that the contractor would make for a similar set of services
if the services were furnished by a non-FQHC. The contractor may pay the FQHCs on a fee-for-service or capitated basis. The contractor shall make payments for primary care equal to, or greater than, the average amounts paid to other primary care
providers. Non-primary care services may be included if mutually agreeable between the contractor and FQHC. For non-primary care services, payments shall be equal to, or greater than, the average amounts paid to other non-primary care providers for
equivalent services. 

  

	 	B.	DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall be paid under a Prospective Payment System (PPS) by DMAHS. At the end of each calendar quarter, the contractor and the
FQHC will complete certain reporting requirements specified that will enable DMAHS to determine PPS reimbursement and compare that to what was actually paid by the contractor to the FQHC. DMAHS will reimburse the FQHC the difference between the PPS
rate per encounter and the payments to the FQHC made by the contractor if the payments by the contractor to the FQHC are less than the PPS rate. In the event of an overpayment, the FQHC shall reimburse DMAHS for payments received from the contractor
that are in excess of the PPS rate. FQHC providers must meet the contractor’s credentialing and program requirements. 

  

	 	C.	Contractor Participation in Reconciliation Process. The contractor shall participate in the reconciliation processes if there is a dispute between what the 

 

			
	Amended as of July 1, 2004	  	VIII-21

 TABLE OF CONTENTS – APPENDICES 
  
 SECTION A REPORTS 
  

			
		
	 A.1.0
	  	 Definitions

		
	 	  	 (no reports)

		
	 A.2.0
	  	 Conditions Precedent

		
	 	  	 (no reports)

		
	 A.3.0
	  	 Managed Care Management Information System

		
	 A.3.1
	  	 Monthly HMO Reconciliation File

		
	 A.4.0
	  	 Provision of Health Care Services

		
	 A.4.1
	  	 Provider Network File

	 A.4.2
	  	 Organ Transplant Procedure

	 A.4.3
	  	 Network Accessibility Analysis

	 A.4.4
	  	 Certification of Contractor Provider Network

		
	 A.5.0
	  	 Enrollee Services

		
	 A.5.1
	  	 Enrollee P-Factor

		
	 A.6.0
	  	 Provider Information

		
	 	  	 (no reports)

		
	 A.7.0
	  	 Terms and Conditions

		
	 A.7.1
	  	 Certifications

	 A.7.1.A
	  	 Certification of Enrollment Information Relating to Payment Under the Medicaid/NJ FamilyCare Programs

	 A.7.1.B
	  	 Certification of Encounter Information Relating to Payment Under the Medicaid/NJ FamilyCare Programs

	 A.7.1.C
	  	Certification of any Information Required by the State and Contained in Contracts, Proposals, and Related Documents Relating to Payments Under the Medicaid/NJ FamilyCare
Programs
	 A.7.1.D
	  	 Certification Regarding Lobbying

  

			
	Amended as of July 1, 2004	  	 

			
	 A.7.2
	  	 Fraud and Abuse

	 A.7.3
	  	 Table 1 – Medicaid Enrollment by PCP

	 A.7.4
	  	 Table 2 – Disenrollment From Plan

	 A.7.5
	  	 Table 3 – Grievance Summary

	 A.7.6
	  	 Table 4 – Claims Lag Report

	 A.7.7
	  	 Table 5 – Hospital-specific Data

	 A.7.8
	  	 Table 6 – Statement of Revenues and Expenses

	 A.7.9
	  	 Table 7 – Stop-Loss Summary

	 A.7.10
	  	 Table 8 – Medicaid Claims Analysis

	 A.7.11
	  	 Table 9 – Health Care Data Elements

	 A.7.12
	  	 Table 10 – Third Party Liability Collections

	 A.7.13
	  	 Table 11 – Provider Additions and Deletions

	 A.7.14
	  	 Table 12 – Referrals Made to the WIC Program

	 A.7.15
	  	 Table 13 – Access to HIV Testing/Treatment for Pregnant Women

	 A.7.16
	  	 Table 14 – EPSDT Services

	 A.7.17
	  	 Table 15 – Pharmacy Lock-In Participants

	 A.7.18
	  	 Table 16 – Ratio of Prior Authorizations Denied to Requested

	 A.7.19
	  	 Table 17 – RESERVED

	 A.7.20
	  	 Table 18 – Federally Qualified Health Center Payments/Encounters

	 A.7.21
	  	 Table 19 – Income Statement by Rate Cell Grouping

	 A.7.22
	  	 Table 20 – Lag Reports

	 A.7.23
	  	 Table 21 – Maternity Outcome Counts

	 A.7.24
	  	 Table 22 – Plan H Invoice Form

		
	 A.8.0
	  	 Financial Provisions

		
	 A.8.1
	  	 Other Coverage Information

	 A.8.2
	  	 Tort/Accident Referral Form

	
	SECTION B REFERENCE MATERIALS
		
	 B.1.0
	  	 Definitions

		
	 	  	 (no reference documents)

		
	 B.2.0
	  	 Conditions Precedent

		
	 B.2.1
	  	 RESERVED

	 B.2.2
	  	 RESERVED

	 B.2.3
	  	 Readiness Review

		
	 B.3.0
	  	 Managed Care Management Information System

		
	 B.3.1
	  	 Monthly Roster Extract File

  

			
	Amended as of July 1, 2004	  	 

			
	 B.3.2
	  	 Managed Care Register File

	 B.3.3
	  	 RESERVED

		
	 B.4.0
	  	 Provision of Health Care Services

		
	 B.4.1
	  	 Benefit Packages

	 B.4.2
	  	 HealthStart Guidelines

	 B.4.3
	  	 RESERVED

	 B.4.4
	  	 RESERVED

	 B.4.5
	  	 Head Start Programs

	 B.4.6
	  	 School-Based Youth Services Programs

	 B.4.7
	  	 Local Health Departments

	 B.4.8
	  	 WIC Referral Forms

	 B.4.9
	  	 Mental Health/Substance Abuse Screening Tools

	 B.4.10
	  	 Centers of Excellence

	 B.4.11
	  	 County Case Management Units/Special Child Health Services

	 B.4.12
	  	 Care Management Flowchart

	 B.4.13
	  	 Ryan White CARE Act Grantees

	 B.4.14
	  	 New Jersey Modified QARI/QISMC Standards

	 B.4.15
	  	 Hysterectomy and Sterilization Procedures and Consent Forms

	 B.4.16
	  	 Child Abuse Regional Diagnostic Centers

	 B.4.17
	  	 DUR Standards

		
	 B.5.0
	  	 Enrollee Services

		
	 B.5.1
	  	 Notification of Newborns

	 B.5.2
	  	 Cost-Sharing Requirements for NJ FamilyCare Plans C, D, & H

		
	 B.6.0
	  	 Provider Information

		
	 	  	 (No reference materials)

		
	 B.7.0
	  	 Terms and Conditions

		
	 B.7.1
	  	 Physician Incentive Plan Provisions

	 B.7.2
	  	 Provider Contract/Subcontract Provisions

	 B.7.3
	  	 Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping Costs

	 B.7.4
	  	 Agreed Upon Procedures – For Rate Cell Cost Reports

	 B.7.5
	  	 EPSDT Related Procedure Codes

	
	 SECTION C CAPITATION RATES

	
	 SECTION D CONTRACTOR’S DOCUMENTATION

		
	 D.1
	  	 Contractor’s QAPI/Utilization Management Plans

	 D.2
	  	 Contractor’s Grievance Process

  

			
	Amended as of July 1, 2004	  	 

			
	 D.3
	  	 Contractor’s Provider Network

	 D.4
	  	 Contractor’s List of Subcontractors

	 D.5
	  	 Contractor’s Supplemental Benefits

	 D.6
	  	 Contractor’s Representative

  

	SECTION 	E     MANAGED CARE SERVICE ADMINISTRATOR (MCSA) ADMINISTRATIVE FEES 

  

			
	Amended as of July 1, 2004	  	 

 ATTACHMENT E 
 Hospital Code List 
  

					
	 Hospital Name

	  	County Location

	  	Codes

	 Ancora Psychiatric Hospital
	  	Atlantic	  	P0101
			
	 Atlantic City Medical Center-City Division
	  	Atlantic	  	H0102
			
	 Atlantic City Medical Center-Mainland Division
	  	Atlantic	  	H0103
			
	 Bacharach Institute for Rehabilitation
	  	Atlantic	  	R0104
			
	 Shore Memorial Hospital
	  	Atlantic	  	H0105
			
	 William B. Kessler Memorial Hospital
	  	Atlantic	  	H0106
			
	 Bergen Regional Medical Center
	  	Bergen	  	H0201
			
	 Christian Health Care Center
	  	Bergen	  	P0202
			
	 Englewood Hospital and Medical Center
	  	Bergen	  	H0203
			
	 Hackensack University Medical Center
	  	Bergen	  	H0204
			
	 Holy Name Hospital
	  	Bergen	  	H0205
			
	 Kessler Institution for Rehabilitation-Kessler North
	  	Bergen	  	R0206
			
	 Pascack Valley Hospital
	  	Bergen	  	H0207
			
	 The Valley Hospital
	  	Bergen	  	H0208
			
	 Lourdes Medical Center of Burlington County
	  	Burlington	  	H0301
			
	 Deborah Heart and Lung Center
	  	Burlington	  	S0302
			
	 Hampton Behavioral Health Center
	  	Burlington	  	P0303
			
	 Marlton Rehabilitation Hospital
	  	Burlington	  	R0304
			
	 Virtua-Memorial Hospital Burlington County
	  	Burlington	  	H0305
			
	 Virtua-West Jersey Hospital-Marlton
	  	Burlington	  	H0306
			
	 Weisman Children’s Rehabilitation Hospital
	  	Burlington	  	R0307
			
	 The Cooper Health System
	  	Camden	  	H0401
			
	 Kennedy Memorial Hospital-UMC Cherry Hill
	  	Camden	  	H0402
			
	 Kennedy Memorial Hospital-UMC Stratford
	  	Camden	  	H0403
			
	 Our Lady of Lourdes Medical Center
	  	Camden	  	H0404
			
	 Virtua West .Jersey Hospital-Berlin
	  	Camden	  	H0405

  

			
	Amended as of July 1, 2004	  	 

					
	 Hospital Name

	  	County Location

	  	Codes

	 Virtua West Jersey Hospital-Voorhees
	  	Camden	  	H0406
			
	 Burdette Tomlin Memorial Hospital
	  	Cape May	  	H0501
			
	 South Jersey Healthcare-Bridgeton Hospital
	  	Cumberland	  	H0601
			
	 South Jersey Healthcare-Vineland Hospital
	  	Cumberland	  	H0602
			
	 Clara Maass Medical Center
	  	Essex	  	H0701
			
	 Columbus Hospital
	  	Essex	  	H0702
			
	 East Orange General Hospital
	  	Essex	  	H0703
			
	 Hospital Center at Orange
	  	Essex	  	H0704
			
	 Irvington General Hospital
	  	Essex	  	H0705
			
	 Kessler Institution for Rehabilitation-Kessler East
	  	Essex	  	R0706
			
	 Kessler Institution for Rehabilitation-Kessler West
	  	Essex	  	R0707
			
	 Newark Beth Israel Medical Center
	  	Essex	  	H0708
			
	 St. Barnabas Medical Center
	  	Essex	  	H0709
			
	 St. James Hospital
	  	Essex	  	H0710
			
	 St. Michael’s Medical Center
	  	Essex	  	H0711
			
	 The Mountainside Hospital
	  	Essex	  	H0712
			
	 UMDNJ-University Hospital
	  	Essex	  	H0713
			
	 VA New Jersey Health Care System-East Orange
	  	Essex	  	V0714
			
	 Essex County Hospital Center
	  	Essex	  	P0715
			
	 Kennedy Memorial Hospitals-UMC Washington Township
	  	Gloucester	  	H0801
			
	 Underwood Memorial Hospital
	  	Gloucester	  	H0802
			
	 Bayonne Medical Center
	  	Hudson	  	H0901
			
	 Christ Hospital
	  	Hudson	  	H0902
			
	 Hudson County Meadowview Hospital
	  	Hudson	  	P0903
			
	 Liberty Health Care System-Greenville Hospital Campus
	  	Hudson	  	H0904
			
	 Liberty Health Care System-Jersey City Medical Center Campus
	  	Hudson	  	H0905
			
	 Liberty Health Care System-Meadowlands Hospital Campus
	  	Hudson	  	H0906
			
	 Palisades Medical Center-New York Presbyterian Health Care System
	  	Hudson	  	H0907

  

			
	Amended as of July 1, 2004	  	 

					
	 Hospital Name

	  	County Location

	  	Codes

	 St. Mary’s Hospital
	  	Hudson	  	H0908
			
	 Hunterdon Medical Center
	  	Hunterdon	  	H1001
			
	 Senator Garrett W. Hagedorn Gero-Psychiatric Hospital
	  	Hunterdon	  	P1002
			
	 Capital Health System-Fuld Campus
	  	Mercer	  	H1101
			
	 Capital Health System-Mercer Campus
	  	Mercer	  	H1102
			
	 University Medical Center at Princeton
	  	Mercer	  	H1103
			
	 Robert Wood Johnson University’ Hospital at Hamilton
	  	Mercer	  	H1104
			
	 St. Francis Medical Center
	  	Mercer	  	H1105
			
	 St. Lawrence Rehabilitation Center
	  	Mercer	  	R1106
			
	 Trenton Psychiatric Hospital
	  	Mercer	  	P1107
			
	 JFK Medical Center
	  	Middlesex	  	H1201
			
	 Raritan Bay Medical Center-Old Bridge
	  	Middlesex	  	H1202
			
	 Raritan Bay Medical Center-Perth Amboy
	  	Middlesex	  	H1203
			
	 Robert Wood Johnson University Hospital-New Brunswick
	  	Middlesex	  	H1204
			
	 St. Peter’s University Hospital
	  	Middlesex	  	H1205
			
	 JFK Johnson Rehabilitation Institute
	  	Middlesex	  	R1206
			
	 University Behavioral HealthCare
	  	Middlesex	  	P1207
			
	 Bayshore Community Hospital
	  	Monmouth	  	H1301
			
	 CentraState Healthcare System
	  	Monmouth	  	H1302
			
	 Jersey Shore University Medical Center
	  	Monmouth	  	H1303
			
	 Monmouth Medical Center
	  	Monmouth	  	H1304
			
	 Riverview Medical Center
	  	Monmouth	  	H1305
			
	 HEALTHSOUTH Rehabilitation Hospital at Tinton Falls
	  	Monmouth	  	R1306
			
	 Chilton Memorial Hospital
	  	Morris	  	H1401
			
	 Morristown Memorial Hospital
	  	Morris	  	H1402
			
	 St. Clare’s Health Services-Denville
	  	Morris	  	H1403
			
	 Greystone Park Psychiatric Hospital
	  	Morris	  	P1404
			
	 Kessler Institute for Rehabilitation Corporation-Kessler Welkind
	  	Morris	  	R1405

  

			
	Amended as of July 1, 2004	  	 

					
	 Hospital Name

	  	County Location

	  	Codes

	 St. Clare’s Hospital-Boonton Township
	  	Morris	  	P1406
			
	 Community Medical Center
	  	Ocean	  	H1501
			
	 Kimball Medical Center
	  	Ocean	  	H1502
			
	 Meridian Health Health-Ocean Medical Center
	  	Ocean	  	H1503
			
	 Southern Ocean County Hospital
	  	Ocean	  	H1504
			
	 HEALTHSOUTH Rehabilitation Hospital of Toms River
	  	Ocean	  	R1505
			
	 St. Barnabas Behavioral Health Network
	  	Ocean	  	P1506
			
	 Barncrt Hospital
	  	Passaic	  	H1601
			
	 Passaic Beth Israel Regional Medical Center
	  	Passaic	  	H1602
			
	 St Joseph’s Hospital and Medical Center-Paterson
	  	Passaic	  	H1603
			
	 St. Joseph’s Wayne Hospital
	  	Passaic	  	H1604
			
	 St. Man’s Hospital-Passaic
	  	Passaic	  	H1605
			
	 South Jersey Healthcare-Elmer Hospital
	  	Salem	  	H1701
			
	 The Memorial Hospital of Salem County
	  	Salem	  	H1702
			
	 Carrier Clinic
	  	Somerset	  	P1801
			
	 The Matheny School and Hospital
	  	Somerset	  	S1802
			
	 Somerset Medical Center
	  	Somerset	  	H1803
			
	 VA New Jersey Health Care System-Lyons
	  	Somerset	  	VI804
			
	 Newton Memorial Hospital
	  	Sussex	  	H1901
			
	 St. Clare’s Hospital/Sussex
	  	Sussex	  	H1902
			
	 Muhlenburg Regional Medical Center
	  	Union	  	H2001
			
	 Overlook Hospital
	  	Union	  	H2002
			
	 Robert Wood Johnson University Hospital at Railway
	  	Union	  	H2003
			
	 Trinitas Hospital-Williamson Street Campus
	  	Union	  	H2004
			
	 Union Hospital
	  	Union	  	H2005
			
	 Children’s Specialized Hospital
	  	Union	  	K2006
			
	 Runnells Specialized Hospital
	  	Union	  	S2007
			
	 Summit Hospital
	  	Union	  	P2008

  

			
	Amended as of July 1, 2004	  	 

					
	 Hospital Name

	  	County Location

	  	Codes

	 Hackettstown Community Hospital
	  	Warren	  	H2101
			
	 Warren Hospital
	  	Warren	  	H2102

  

			
	Amended as of July 1, 2004	  	 

	A.4.2	 Organ Transplant Procedure 

  

			
	Amended as of July 1, 2004	  	 

 DEPARTMENT OF HUMAN SERVICES 
  
 DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES 
  
 ORGAN TRANSPLANTATION BILLING POLICY AND PROCEDURE 
  
 Policy 
  

	1.	Responsibility for Medicaid/NJ FamilyCare HMO beneficiaries’ inpatient hospital costs (donor and recipient) resides with the HMO, with one exception, below.

  

	2.	Exception: Fee-for-Service (FFS) Medicaid will pay for transplant-related donor and recipient inpatient hospital costs for an individual “placed on a transplant list”
(solid organs), or having a physician’s written affirmative decision for transplant (non-solid organs, and other specific circumstances where no transplant list exists), while in the Medicaid FFS program prior to initial enrollment in the
contractor’s plan. 

  

	3.	For individuals already enrolled in an HMO who transfer to another HMO, Medicaid FFS will not pay for the transplant-related costs referenced in number 1, above, regardless of
timing of placement on list, or timing of a written affirmative decision for transplant. The HMOs involved themselves must settle such cases. 

  

	4.	For individuals enrolled in an HMO who briefly (i.e., less than 60 days) return to FFS Medicaid, for any reason, and subsequently return to the HMO, FFS Medicaid will not pay for
any transplant-related costs referenced in number 1, above. The costs remain the responsibility of the HMO. 

  
 Definitions 
  
 Non-solid Organs – includes blood, bone marrow, peripheral stem cells, and umbilical cord cells. 
  
 Organ Procurement and Transplanting Network (OPTN) – a national organ transplantation network administered by the United Network for
Organ Sharing (UNOS) consisting of the national patient organ transplantation waiting list and an organ placement center. 
  
 Solid Organs – vascularizcd organs, including: liver, kidney, pancreas, heart, lung, and intestine. 
  
 United Network for Organ Sharing (UNOS) – a private nonprofit organization under contract with the US Department of Health and Human
Services to administer the Organ Procurement and Transplanting Network (OPTN). UNOS is responsible for the national patient organ transplantation waiting list and the computerized organ allocation system. 
  

			
	Amended as of July 1, 2004	  	 

 Procedures for Billing 
  

	1.	The HMO will submit a completed DMAHS Transplantation Billing Request (FD- 403 – attached) to the DMAHS Office of Utilization Management (OUM). For transplant of solid organs,
The HMO’s submittal must include proof of the date of UNOS entry. This may include a copy of the list with a dated entry, or a copy of a confirmation from the transplant facility indicating that an enrollee has been added to the list. (Patients
should receive confirmation of their placement on the national waiting list from their transplant hospital. UNOS does not send written confirmation of status to patients.) 

  
 For circumstances where there does not exist a centralized list or equivalent (i.e., non-solid organs, related donor, etc.),
the verification process will vary depending on the specific circumstances of the transplant. However, for each transplant, there should exist a physician’s written affirmative decision for transplant. The HMO shall be responsible for providing
documentation to support the date of transplant decision with the fully completed FD-403 request form. 
  

	2.	The DMAHS OUM will be responsible for review and approval of the FD-403, and notification to the HMO of the disposition of the request. 

  

			
	Amended as of July 1, 2004	  	 

 [GRAPHIC] 
  

DEPARTMENT OF HUMAN SERVICES 
  
 DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES 
  
 TRANSPLANTATION BILLING REQUEST 
  

			
	 HMO REQUESTING APROVAL:
	 	 
		
	 HMO CARE MANAGER:
	 	 
		
	 TELEPHONE:
	 	 
		
	 E-MAIL ADDRESS:
	 	 

  

			
	 BENEFICIARY NAME:
	 	 
		
	 BENEFICIARY MEDICAID l.D. NUMBER:
	 	 
		
	 BENEFICIARY ADDRESS:
	 	 
		
	 	 	 
		
	 	 	 
		
	 BENEFICIARY DOB:
	 	 

  

			
	 TYPE OF TRANSPLANT:
	 	 
		
	 TRANSPLANT PROGRAM/FACILITY NAME:
	 	 
		
	 PCP NAME:
	 	 
		
	 PCP ADDRESS:
	 	 
		
	 PCP TELEPHONE:
	 	 

  

			
	 DATE OF UNOS ENTRY (SOLID ORGAN):
	 	 
	 (ATTACH PROOF OF ENTRY)
	 	 
		
	 DATE OF AFFIRMATIVE DECISION:
	 	 
	             (NON-SOLID)
	 	 
		
	 OTHER INSURANCE:
	 	 
		
	 POLICY l.D. NUMBER:
	 	 
		
	 POLICY GROUP NUMBER:
	 	 
		
	FD-403	 	REV: 07/03

  

	A.4.4	 Certification of Contractor Provider Network 

  

			
	Amended as of July 1, 2004	  	 

 CERTIFICATION OF PROVIDER NETWORK REPORT 
  
 I, _____________________________, hereby certify both personally and on behalf 
     (Name & Title of HMO Officer) 
 of ________________ that all of the health care providers
whose names appear 
         (Name of HMO) 
 on the attached and/or transmitted Provider Network Report, dated ____________, 
                                        
                                        
                                   (Date) 
 have signed valid, written contracts with ________________, which are currently in effect 
                                        
                             (Name of HMO) 
 and are similar in all material respects to the sample provider agreements submitted on 
 _____________ to, and approved by, the Division of Medical 
         (Date) 
 Assistance and Health Services, by _________________. I further certify that all of
the 
                                        
                     (Name of HMO) 
 providers
listed have expressly agreed to serve, and are currently serving. New Jersey 
 Medicaid and NJ FamilyCare beneficiaries who enroll in _________________.

                                        
                                        
                 (Name of HMO) 
  
 I certify that the foregoing statements made by me are true, and attest that based on 
 best knowledge, information, and belief as of the date indicated below, all information 
 submitted to DMAHS is accurate, complete, and truthful,
and certify that no material fact 
 has been omitted from this form. I am aware that if any of the foregoing statements made by 
 me are willfully false, _________________, may be subject to the imposition of 
                                        
 (Name of HMO) 
 sanctions and/or liquidated damages. I understand that I must abide by all applicable 
 Federal and State laws for any false claims, statements, or documents, or concealment 
 of a material fact. I have read and am familiar with the contents of this submission. 
  

			
		
	Signature:	 	 

			
		
	Print Name:	 	 

			
		
	Title of HMO Officer:	 	 

			
		
	Name of HMO:	 	 

			
		
	Date:	 	 

  

			
	Amended as of July 1, 2004	  	 

	A.7.1	 Certifications 

  

			
	Amended as of July 1, 2004	  	 

	A.7.1. A	CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM 

  

			
	Amended as of July 1, 2004	  	 

 (Sample Certification Form) 
  
 This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey
Medicaid/NJ FamilyCare program. 
  
 CERTIFICATION OF ENROLLMENT INFORMATION
RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM 
  
 CERTIFICATION 
  
 Pursuant to the contract(s)
between the Department of Human Services and the (name of managed care organization (MCO), provider certifies that: the business entity named on this form is a qualified provider enrolled with and authorized to participate in the New
Jersey Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here.) (Name of MCO) acknowledges that if payment is based on enrollment data, Federal regulations at 42 CFR 438.600
(et. al.) require that the data submitted must be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer.

  
 (Name of MCO) hereby requests payment from the New Jersey Medical
Assistance Program under contracts based on enrollment data submitted and in so doing makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (et.al.). 
  
 (Name of MCO) has reported to DHS for the month of (indicate month
and year) all new enrollments, disenrollments, and any changes in enrollees’ status. (Name of MCO) has reviewed the monthly membership report for the month of (indicate month and year) and I, (enter Name of Chief
Financial Officer, Chief Executive Officer or Name of Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief Executive Officer) attest that based on best knowledge, information, and belief as of the date
indicated below, all information submitted to DHS in this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM. 
  
 I, (enter Name of Chief Financial Officer. Chief Executive Officer or Name of Person Who Reports Directly To And Who Is
Authorized To Sign For Chief Financial Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). 1 UNDERSTAND THAT 1 MUST COMPLY WITH ALL
APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR 

  

			
	Amended as of July 1, 2004	  	 

 
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION. 
  

	
	 
	 (INDICATE NAME AND TITLE
 (CFO, CEO, OR
DELEGATE)
 on behalf of

	
	 
	 (INDICATE NAME OF BUSINESS ENTITY)

	
	 
	 DATE

  

			
	Amended as of July 1, 2004	  	 

	A.7.1.B	 CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM 

  

			
	Amended as of July 1, 2004	  	 

 (Sample Certification Form) 
  
 This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey
Medicaid/NJ FamilyCare program. 
  
 CERTIFICATION OF ENCOUNTER INFORMATION
RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM 
  
 CERTIFICATION 
  
 Pursuant to the contract(s)
between the Department of Human Services and the (name of managed care organization (MCO)), provider certifies that: the business entity named on this form is a qualified provider enrolled with and authorized to participate in the New Jersey
Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here.) (Name of MCO) acknowledges that if payment is based on encounter data, Federal regulations at 42 CFR 438.600 (et. al.) require
that the data submitted must be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer. 
  
 (Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program
under contracts based on encounter data submitted and in so doing makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (et.al.). 
  
 (Name of MCO) has reported to DHS for the month of (indicate month
and year) all new encounters (indicate type of data – inpatient hospital, outpatient hospital, physician, etc.). (Name of MCO) has reviewed the encounter data for the month of (indicate month and year) and I, (enter
Name of Chief Financial Officer, Chief Executive Officer or Name of Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief Executive Officer) attest that based on best knowledge, information, and belief
as of the date indicated below, all information submitted to DHS in this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM. 
  
 I, (enter Name of Chief Financial Officer, Chief Executive Officer or
Name of Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO).
I UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR 

  

			
	Amended as of July 1, 2004	  	 

 
CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION. 
  

	
	
	 
	 (INDICATE NAME AND TITLE
 (CFO, CEO, OR
DELEGATE)
 on behalf of

	
	 
	 (INDICATE NAME OF BUSINESS ENTITY)

	
	 
	 DATE

  

			
	Amended as of July 1, 2004	  	 

	A.7.1.C	 CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE
PROGRAM 

  

			
	Amended as of July 1, 2004	  	 

 (Sample Certification Form) 
  
 This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey
Medicaid/NJ FamilyCare program. 
  
 CERTIFICATION OF ANY INFORMATION REQUIRED BY
THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM 
  
 CERTIFICATION 
  
 Pursuant to the contract(s) between the Department of Human Services and (name of managed care organization (MCO)). provider certifies that: the business entity
named on this form is a qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here.) (Name of MCO)
acknowledges that if payment is based on any information required by the State and contained in contracts, proposals, and related documents, Federal regulations at 42 CFR 438.600 (et. al.) require that the data submitted must be certified by a Chief
Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer. 
  
 (Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under contracts based on any information
required by the State and contained in contracts, proposals, and related documents submitted and in so doing makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600
(et.al.). 
  
 (Name of MCO) has reported to the DHS for
the period of (indicate dates) all information required by the State and contained in contracts, proposals, and related documents submitted. (Name of MCO) has reviewed the information submitted for the period of (indicate dates)
and I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief Executive Officer) attest that based on best
knowledge, information, and belief as of the date indicated below, all information submitted to DHS is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM. 
  
 I, (enter Name of Chief Financial Officer, Chief Executive Officer or
Name of Person Who Reports Directly To And Who Is Authorized To Sign For Chief Financial Officer, Chief Executive Officer) ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO).
I UNDERSTAND THAT I 

  

			
	Amended as of July 1, 2004	  	 

 
MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM
FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION. 
  

	
	
	 
	 (INDICATE NAME AND TITLE
 (CFO, CEO, OR DELEGATE)
 on behalf of

	
	 
	 (INDICATE NAME OF BUSINESS ENTITY)

	
	 
	 DATE

  

			
	Amended as of July 1, 2004	  	 

	A.7.1.D	 Certification Regarding Lobbying 

  
 The contractor must sign and return the form on the following page. 
  

			
	Amended as of July 1, 2004

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