Document:

Exhibit 10.1

AIR COMMERCIAL REAL ESTATE ASSOCIATION 

STANDARD INDUSTRIAL/COMMERCIAL MULTI-TENANT LEASE - NET

 

1.          Basic Provisions ("Basic Provisions").

 

	
 

	
1.1 

	
Parties:

	This Lease ("Lease"), dated for reference purposes only  	August 1, 2013 	 	,

	
 is made by and between  

	
T. Drive Partners, LP

	
	 		("Lessor")

	
and  

	AXT, Inc.

	
 

	
 

	
 

	
("Lessee"), (collectively the "Parties", or individually a "Party").

 

 1.2(a)  Premises: That certain portion of the Project (as defined below), including all improvements therein or to be provided by Lessor 

	
under the terms of this Lease, commonly known by the street address of  

	
4281 Technology Drive

	   	,

	
located in the City of  

	
Fremont

	, 	County of  	Alameda 	, 	
State of

	
California 

	
,

	
 with zip code  

	94538	, 	as outlined on Exhibit	"A" 	 attached hereto ("Premises")

	
and generally described as (describe briefly the nature of the Premises):  

	
20, 767 square footage portion (including

	
4 , 844 square feet of storage space "SP1" on Exhibit A)

	
 

 

In addition to Lessee's rights to use and occupy the Premises as hereinafter specified, Lessee shall have non-exclusive rights to any utility raceways of the building containing the Premises ("Building") and to the common Areas (as defined in Paragraph 2.7 below), but shall not have any rights to the roof or exterior walls of the Building or to any other buildings in the Project. The Premises, the Building, the Common Areas, the land upon which they are located, along with all other buildings and improvements thereon, are herein collectively referred to as the "Project." (See also Paragraph 2) 

 

	
 

	1.2(b)  	Parking:	 See Item #55 	 unreserved vehicle parking spaces. (See also Paragraph 2.6)

 

	
 

	1.3	Term:	two (2)	 years and  	none (0)	
months ("Original Term")

 

	
commencing  

	
December 1, 2013

	
 ("Commencement Date") and ending  

	
November 30, 2015

("Expiration Date"). (See also Paragraph 3)

 

 1.4          Early Possession: If the Premises are available Lessee may have non-exclusive possession of the Premises commencing 

	
Lessee is currently in possession  

	
 ("Early Possession Date").

(See also Paragraphs 3.2 and 3.3)

 

		
1.5 

	
Base Rent:   

	$     10, 656.00	 per month ("Base Rent"), payable on the  	first (1st)

	
day of each month commencing  

	
December 1, 2013

	  (See Paragraph

52) (See also Paragraph 4)

	
o

	
If this box is checked, there are provisions in this Lease for the Base Rent to be adjusted. See Paragraph  

	

	

 

		
1.6 

	Lessee's Share of Common Area Operating Expenses:  	
 thrity-one

	 percent (31     %) ("Lessee's Share").

 

In the event that the size of the Premises and/or the Project are modified during the term of this Lease, Lessor shall recalculate Lessee's Share to reflect such modification. Tenant shall pay its pro-rata for Operating expenses monthly for the lease term.

 

 1.7         Base Rent and Other Monies Paid Upon Execution:

 

	
 

	
(a)

	
Base Rent: $_____________________________ for the period N/A                                                                                                                       .

	 	(b) 	Common Area Operating Expenses: $_____________________________ for the period ___________________________________.
	 	(c)	Security Deposit: $_______________________________  ("Security Deposit")(on file).(See also Paragraph 5)
	 	(d) 	Other: $10, 000.00                                  for Security Deposit on file with Lessor                                                                                                            
	 		________________________________________________________________________________________________________.
	 	(e)	
Total Due Upon Execution of this Lease: $0.00                                                                        .

 

	
 

	
1.8  

	
Agreed Use:  

	design/manufacture/office/warehouse/distribution .
	 	 	 	 

	
 

	
 . (See also Paragraph 6)

 

1.9       Insuring Party. Lessor is the "Insuring Party". (See also Paragraph 8)

 

	
 

	
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1.10     Real Estate Brokers: (See also Paragraph 15 and 25)

 

(a)            Representation: The following real estate brokers (the "Brokers") and brokerage relationships exist in this transaction (check applicable boxes):

 

	
o

	
N/A                                                                                                                                                    represents Lessor exclusively ("Lessor's Broker");

	
o

	N/A                                                                                                                                                    represents Lessee exclusively ("Lessee's Broker"); or

	
o

	N/A                                                                                                                                                    represents both Lessor and Lessee ("Dual Agency").

 

(b)            Payment to Brokers: Upon execution and delivery of this Lease by both Parties, Lessor shall pay to the Brokers for the brokerage services rendered by the Brokers the fee agreed to in the attached a separate written agreement or if no such agreement is attached, the sum of________ or_______% of the total Base Rent payable for the Original Term, the sum of_______ or_______ of the total Base Rent payable during any period of time that the Lessee occupies the Premises subsequent to the Original Term, and/or the sum of_______ or_______ % of the purchase price in the event that the Lessee or anyone affiliated with Lessee acquires from Lessor any rights to the Premises.

 

		
1.11

	
Guarantor. The obligations of the Lessee under this Lease are to be guaranteed by  

	N/A
	 	
 

	
 

	
 ("Guarantor"). (See also Paragraph 37)

		
1.12

	
Attachments. Attached hereto are the following, all of which constitute a part of this Lease:

 

	
o

	
an Addendum consisting of Paragraphs_______________ through______________ ;

	
þ

	
a site plan depicting the Premises Exhibit A|

	
o

	
a site plan depicting the Project;

	
o

	
a current set of the Rules and Regulations for the Project;

	
o

	
a current set of the Rules and Regulations adopted by the owners' association;

	
o

	
a Work Letter;

	
o

	
other (specify); Exhibit E: Common Area Operating Expense Exclusions

 

2.            Premises.

 

2.1            Letting. Lessor hereby leases to Lessee, and Lessee hereby leases from Lessor, the Premises, for the term, at the rental, and upon all of the terms, covenants and conditions set forth in this Lease. While the approximate square footage of the Premises may have been used in the marketing of the Premises for purposes of comparison, the Base Rent stated herein is NOT tied to square footage and is not subject to adjustment should the actual size be determined to be different. NOTE: Lessee is advised to verify the actual size prior to executing this Lease.

 

2.2            Condition. Lessor shall deliver that portion of the Premises contained within the Building ('Unit") to Lessee broom clean and free of debris on the Commencement Date or the Early Possession Date, whichever first occurs ("Start Date"), and, so long as the required service contracts described in Paragraph 7.1(b) below are obtained by Lessee and in effect within thirty days following the Start Date, warrants that the existing electrical, plumbing, fire sprinkler, lighting, heating, ventilating and air conditioning systems ("HVAC"), loading doors, sump pumps, if any, and all other such elements in the Unit, other than those constructed by Lessee, shall be in good operating condition on said date, that the structural elements of the roof, bearing walls and foundation of the Unit shall be free of material defects, and that the Unit does not contain hazardous levels of any mold or fungi defined as toxic under applicable state or federal law. If a non-compliance with such warranty exists as of the Start Date, or if one of such systems or elements should malfunction or fail within the appropriate warranty period, Lessor shall, as Lessor's sole obligation with respect to such matter, except as otherwise provided in this Lease, promptly after receipt of written notice from Lessee setting forth with specificity the nature and extent of such non-compliance, malfunction or failure, rectify same at Lessor's expense. The warranty periods shall be as follows: (i) 6 months as to the HVAC systems, and (ii) 30 days as to the remaining systems and other elements of the Unit. If Lessee does not give Lessor the required notice within the appropriate warranty period, correction of any such non-compliance, malfunction or failure shall be the obligation of Lessee at Lessee's sole cost and expense (except for the repairs to the fire sprinkler systems, roof, foundations, and/or bearing walls - see Paragraph 7).

 

2.3            Compliance. Lessor warrants that to the best of its knowledge the improvements on the Premises and the Common Areas comply with the building codes that were in effect at the time that each such improvement, or portion thereof, was constructed, and also with all applicable laws, covenants or restrictions of record, regulations, and ordinances in effect on the Start Date ("Applicable Requirements"). Said warranty does not apply to the use to which Lessee will put the Premises, modifications which may be required by the Americans with Disabilities Act or any similar laws as a result of Lessee's use (see Paragraph 49), or to any Alterations or Utility Installations (as defined in Paragraph 7.3(a)) made or to be made by Lessee. NOTE: Lessee is responsible for determining whether or not the Applicable Requirements and especially the zoning are appropriate for Lessee's intended use, and acknowledges that past uses of the Premises may no longer be allowed. If the Premises do not comply with said warranty, Lessor shall, except as otherwise provided, promptly after receipt of written notice from Lessee setting forth with specificity the nature and extent of such non-compliance, rectify the same at Lessor's expense. If Lessee does not give Lessor written notice of a non-compliance with this warranty within 6 months following the Start Date, correction of that non-compliance shall be the obligation of Lessee at Lessee's sole cost and expense. If the Applicable Requirements are hereafter changed so as to require during the term of this Lease the construction of an addition to or an alteration of the Unit, Premises and/or Building, the remediation of any Hazardous Substance, or the reinforcement or other physical modification of the Unit, Premises and/or Building ("Capital Expenditure"), Lessor and Lessee shall allocate the cost of such work as follows:

 

	
 

	
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(a)            Subject to Paragraph 2.3(c) below, if such Capital Expenditures are required as a result of the specific and unique use of the Premises by Lessee as compared with uses by tenants in general, Lessee shall be fully responsible for the cost thereof, provided, however that if such Capital Expenditure is required during the last 2 years of this Lease and the cost thereof exceeds 6 months' Base Rent, Lessee may instead terminate this Lease unless Lessor notifies Lessee, in writing, within 10 days after receipt of Lessee's termination notice that Lessor has elected to pay the difference between the actual cost thereof and the amount equal to 6 months' Base Rent. If Lessee elects termination, Lessee shall immediately cease the use of the Premises which requires such Capital Expenditure and deliver to Lessor written notice specifying a termination date at least 90 days thereafter. Such termination date shall, however, in no event be earlier than the last day that Lessee could legally utilize the Premises without commencing such Capital Expenditure.

 

(b)            If such Capital Expenditure is not the result of the specific and unique use of the Premises by Lessee (such as, governmentally mandated seismic modifications), then Lessor shall pay for such Capital Expenditure and Lessee shall only be obligated to pay, each month during the remainder of the term of this Lease or any extension thereof, on the date that on which the Base Rent is due, an amount equal to 1/144th of the portion of such costs reasonably attributable to the Premises. Lessee shall pay Interest on the balance but may prepay its obligation at any time. If, however, such Capital Expenditure is required during the last 2-years 0 It10fl"khs of this Lease or if Lessor reasonably determines that it is not economically feasible to pay its share thereof, Lessor shall have the option to terminate this Lease upon 90 days prior written notice to Lessee unless Lessee notifies Lessor, in writing, within 10 days after receipt of Lessor's termination notice that Lessee will pay for such Capital Expenditure. If Lessor does not elect to terminate, and fails to tender its share of any such Capital Expenditure, Lessee may advance such funds and deduct same, with Interest, from Rent until Lessor's share of such costs have been fully paid. If Lessee is unable to finance Lessor's share, or if the balance of the Rent due and payable for the remainder of this Lease is not sufficient to fully reimburse Lessee on an offset basis, Lessee shall have the right to terminate this Lease upon 30 days written notice to Lessor.

 

(c)            Notwithstanding the above, the provisions concerning Capital Expenditures are intended to apply only to non-voluntary, unexpected, and new Applicable Requirements. If the Capital Expenditures are instead triggered by Lessee as a result of an actual or proposed change in use, change in intensity of use, or modification to the Premises then, and in that event, Lessee shall either: (i) immediately cease such changed use or intensity of use and/or take such other steps as may be necessary to eliminate the requirement for such Capital Expenditure, or (ii) complete such Capital Expenditure at its own expense. Lessee shall not have any right to terminate this Lease.

 

2.4          Acknowledgements. Lessee acknowledges that: (a) it has been given an opportunity to inspect and measure the Premises, (b) it has been advised by Lessor and/or Brokers to satisfy itself with respect to the size and condition of the Premises (including but not limited to the electrical, HVAC and fire sprinkler systems, security, environmental aspects, and compliance with Applicable Requirements and the Americans with Disabilities Act), and their suitability for Lessee's intended use, (c) Lessee has made such investigation as it deems necessary with reference to such matters and assumes all responsibility therefor as the same relate to its occupancy of the Premises, (d) it is not relying on any representation as to the size of the Premises made by Brokers or Lessor, (e) the square footage of the Premises was not material to Lessee's decision to lease the Premises and pay the Rent stated herein, and (f) neither Lessor, Lessor's agents, nor Brokers have made any oral or written representations or warranties with respect to said matters other than as set forth in this Lease. In addition, Lessor acknowledges that: (i) Brokers have made no representations, promises or warranties concerning Lessee's ability to honor the Lease or suitability to occupy the Premises, and (ii) it is Lessor's sole responsibility to investigate the financial capability and/or suitability of all proposed tenants.

 

2.5           Lessee as Prior Owner/Occupant. The warranties made by Lessor in Paragraph 2 shall be of no force or effect if immediately prior to the Start Date Lessee was the owner or occupant of the Premises. In such event, Lessee shall be responsible for any neeessary corrective work.

 

2.6          Vehicle Parking. Lessee shall be entitled to use the number of parking spaces specified in Paragraph 1.2(b) on those portions of the Common Areas designated from time to time by Lessor for parking. Lessee shall not use more parking spaces than said number. Said parking spaces shall be used for parking by vehicles no larger than full-size passenger automobiles or pick-up trucks, herein called "Permitted Size Vehicles." Lessor may regulate the loading and unloading of vehicles by adopting Rules and Regulations as provided in Paragraph 2.9. No vehicles other than Permitted Size Vehicles may be parked in the Common Area without the prior written permission of Lessor. In addition:

 

(a)            Lessee shall not permit or allow any vehicles that belong to or are controlled by Lessee or Lessee's employees, suppliers, shippers, customers, contractors or invitees to be loaded, unloaded, or parked in areas other than those designated by Lessor for such activities.

 

(b)          Lessee shall not service or store any vehicles in the Common Areas.

 

(c)            If Lessee permits or allows any of the prohibited activities described in this Paragraph 2.6, then Lessor shall have the right, without notice, in addition to such other rights and remedies that it may have, to remove or tow away the vehicle involved and charge the cost to Lessee, which cost shall be immediately payable upon demand by Lessor.

 

2.7           Common Areas - Definition. The term "Common Areas" is defined as all areas and facilities outside the Premises and within the exterior boundary line of the Project and interior utility raceways and installations within the Unit that are provided and designated by the Lessor from time to time for the general non-exclusive use of Lessor, Lessee and other tenants of the Project and their respective employees, suppliers, shippers, customers, contractors and invitees, including parking areas, loading and unloading areas, trash areas, roadways, walkways, driveways and landscaped areas.

 

	
 

	
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2.8           Common Areas - Lessee's Rights. Lessor grants to Lessee, for the benefit of Lessee and its employees, suppliers, shippers, contractors, customers and invitees, during the term of this Lease, the non-exclusive right to use, in common with others entitled to such use, the Common Areas as they exist from time to time, subject to any rights, powers, and privileges reserved by Lessor under the terms hereof or under the terms of any rules and regulations or restrictions governing the use of the Project. Under no circumstances shall the right herein granted to use the Common Areas be deemed to include the right to store any property, temporarily or permanently, in the Common Areas. Any such storage shall be permitted only by the prior written consent of Lessor or Lessor's designated agent, which consent may be revoked at any time. In the event that any unauthorized storage shall occur then Lessor shall have the right, without notice, in addition to such other rights and remedies that it may have, to remove the property and charge the cost to Lessee, which cost shall be immediately payable upon demand by Lessor.

 

2.9           Common Areas - Rules and Regulations. Lessor or such other person(s) as Lessor may appoint shall have the exclusive control and management of the Common Areas and shall have the right, from time to time, to establish, modify, amend and enforce reasonable rules and regulations ("Rules and Regulations") for the management, safety, care, and cleanliness of the grounds, the parking and unloading of vehicles and the preservation of good order, as well as for the convenience of other occupants or tenants of the Building and the Project and their invitees. Lessee agrees to abide by and conform to all such Rules and Regulations, and shall use its best efforts to cause its employees, suppliers, shippers, customers, contractors and invitees to so abide and conform. Lessor shall not be responsible to Lessee for the non-compliance with said Rules and Regulations by other tenants of the Project.

 

2.10          Common Areas - Changes. Lessor shall have the right, in Lessor's sole discretion, from time to time:

 

(a)          To make changes to the Common Areas, including, without limitation, changes in the location, size, shape and number of driveways, entrances, parking spaces, parking areas, loading and unloading areas, ingress, egress, direction of traffic, landscaped areas, walkways and utility raceways;

 

(b)          To close temporarily any of the Common Areas for maintenance purposes so long as reasonable access to the Premises remains available;

 

(c)          To designate other land outside the boundaries of the Project to be a part of the Common Areas;

 

(d)          To add additional buildings and improvements to the Common Areas;

 

(e)          To use the Common Areas while engaged in making additional improvements, repairs or alterations to the Project, or any portion thereof; and

 

(f)          To do and perform such other acts and make such other changes in, to or with respect to the Common Areas and Project as Lessor may, in the exercise of sound business judgment, deem to be appropriate.

 

3.            Term.

 

3.1          Term. The Commencement Date, Expiration Date and Original Term of this Lease are as specified in Paragraph 1.3.

 

3.2          Early Possession. Any provision herein granting Lessee Early Possession of the Premises is subject to and conditioned upon the Premises being available for such possession prior to the Commencement Date. Any grant of Early Possession only conveys a non-exclusive right to occupy the Premises. If Lessee totally or partially occupies the Premises prior to the Commencement Date, the obligation to pay Base Rent shall be abated for the period of such Early Possession. All other terms of this Lease (including but not limited to the obligations to pay Lessee's Share of Common Area Operating Expenses, Real Property Taxes and insurance premiums and to maintain the Premises) shall be in effect during such period. Any such Early Possession shall not affect the Expiration Date.

 

3.3          Delay In Possession. Lessor agrees to use its best commercially reasonable efforts to deliver possession of the Premises to Lessee by the Commencement Date. If, despite said efforts, Lessor is unable to deliver possession by such date, Lessor shall not be subject to any liability therefor, nor shall such failure affect the validity of this Lease or change the Expiration Date. Lessee shall not, however, be obligated to pay Rent or perform its other obligations until Lessor delivers possession of the Premises and any period of rent abatement that Lessee would otherwise have enjoyed shall run from the date of delivery of possession and continue for a period equal to what Lessee would otherwise have enjoyed under the terms hereof, but minus any days of delay caused by the acts or omissions of Lessee. If possession is not delivered within 60 days after the Commencement Date, as the same may be extended under the terms of any Work Letter executed by Parties, Lessee may, at its option, by notice in writing within 10 days after the end of such 60 day period, cancel this Lease, in which event the Parties shall be discharged from all obligations hereunder. If such written notice is not received by Lessor within said 10 day period, Lessee's right to cancel shall terminate. If possession of the Premises is not delivered within 120 days after the Commencement Date, this Lease shall terminate unless other agreements are reached between Lessor and Lessee, in writing.

 

3.4          Lessee Compliance. Lessor shall not be required to tender possession of the Premises to Lessee until Lessee complies with its obligation to provide evidence of insurance (Paragraph 8.5). Pending delivery of such evidence, Lessee shall be required to perform all of its obligations under this Lease from and after the Start Date, including the payment of Rent, notwithstanding Lessor's election to withhold possession pending receipt of such evidence of insurance. Further, if Lessee is required to perform any other conditions prior to or concurrent with the Start Date, the Start Date shall occur but Lessor may elect to withhold possession until such conditions are satisfied.

 

	
 

	
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4.            Rent.

 

4.1            Rent Defined. All monetary obligations of Lessee to Lessor under the terms of this Lease (except for the Security Deposit) are deemed to be rent ("Rent").

 

4.2            Common Area Operating Expenses. Lessee shall pay to Lessor during the term hereof, in addition to the Base Rent, Lessee's Share (as specified in Paragraph 1.6) of all Common Area Operating Expenses, as hereinafter defined, during each calendar year of the term of this Lease, in accordance with the following provisions:

 

(a)          "Common Area Operating Expenses" are defined, for purposes of this Lease, as all costs incurred by Lessor relating to the ownership and operation of the Project, including, but not limited to, the following:

 

(i)          The operation, repair and maintenance, in neat, clean, good order and condition, and if necessary the replacement, of the following:

 

(aa)       The Common Areas and Common Area improvements, including parking areas, loading and unloading areas, trash areas, roadways, parkways, walkways, driveways, landscaped areas, bumpers, irrigation systems, Common Area lighting facilities, fences and gates, elevators, roofs, exterior walls of the buildings, building systems and roof drainage systems.

 

(bb)      Exterior signs and any tenant directories. 

 

(cc)      Any fire sprinkler systems.

 

(dd)      All other areas and improvements that are within the exterior boundaries of the Project but outside of the Premises and/or any other space occupied by a tenant.

 

(ii)         The cost of water, gas, electricity and telephone to service the Common Areas and any utilities not separately metered.

 

(iii)        The cost of trash disposal, pest control services, property management, security services, owners' association dues and fees, the cost to repaint the exterior of any structures and the cost of any environmental inspections.

 

(iv)    Reserves set aside for maintenance, repair and/or replacement of Common Area improvements and equipment.

 

(v)         Real Property Taxes (as defined in Paragraph 10).

 

(vi)       The cost of the premiums for the insurance maintained by Lessor pursuant to Paragraph 8.

 

(vii)      Any deductible portion of an insured loss concerning the Building or the Common Areas not to exceed $10,000.

 

(viii) Auditors, accountants and attorneys' fees and costs related to the operation, maintenance, repair and replacement of the Project.

 

(ix)        The cost of any capital improvement to the Building or the Project not covered under the provisions of Paragraph 2.3 provided; however, that Lessor shall allocate the cost of any such capital improvement over a 12 year period the useful life of the capital item and Lessee shall not be required to pay more than Lessee's Share of 1/144th a fraction, the numerator of which is one and the denominator of which is the number of months in the useful life of the item, of the cost of such capital improvement in any given month .

 

(x)         The cost of any other services to be provided by Lessor that are stated elsewhere in this Lease to be a Common Area Operating Expense.

 

Notwithstanding anything to the contrary in this Lease, Common Area Operating Expenses shall not include the costs set forth on Exhibit E, attached hereto.

 

(b)      Any Common Area Operating Expenses and Real Property Taxes that are specifically attributable to the Unit, the Building or to any other building in the Project or to the operation, repair and maintenance thereof, shall be allocated entirely to such Unit, Building, or other building. However, any Common Area Operating Expenses and Real Property Taxes that are not specifically attributable to the Building or to any other building or to the operation, repair and maintenance thereof, shall be equitably allocated by Lessor to all buildings in the Project.

 

(c)      The inclusion of the improvements, facilities and services set forth in Subparagraph 4.2(a) shall not be deemed to impose an obligation upon Lessor to either have said improvements or facilities or to provide those services unless the Project already has the same, Lessor already provides the services, or Lessor has agreed elsewhere in this Lease to provide the same or some of them.

 

(d)      Lessee's Share of Common Area Operating Expenses is payable monthly on the same day as the Base Rent is due hereunder. The amount of such payments shall be based on Lessor's estimate of the annual Common Area Operating Expenses. Within 60 days after the end of each calender year during the term and for one (1) year thereafter written request (but not more than once each year) Lessor shall deliver to Lessee a reasonably detailed statement showing Lessee's Share of the actual Common Area Operating Expenses for the preceding year. If Lessee's payments during such year exceed Lessee's Share, Lessor shall credit the amount of such over-payment against Lessee's future payments. If Lessee's payments during such year were less than Lessee's Share, Lessee shall pay to Lessor the amount of the deficiency within 10 days after delivery by Lessor to Lessee of the statement.

 

(e)       Common Area Operating Expenses shall not include any expenses paid by any tenant directly to third parties, or as to which Lessor is otherwise reimbursed by any third party, other tenant, or insurance proceeds.

 

	
 

	
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(f)       Lessee may review Lessor's books and records relating to Common Area Operating Expenses in order to verify the accuracy of all amounts charged to Lessee, provided that: (i) Lessee specifically designates the fiscal year(s) that Lessee intends to audit, which request shall be made in writing within ninety (90) days of receipt of the applicable expense statement; and (ii) such audit will be conducted only during regular business hours at the office where Lessor maintains such records and only after Lessee gives Lessor thirty (30) days prior notice. Lessee shall deliver to Landlord a copy of the results of such audit within fifteen (15) days of it receipt by Lessee. Any overpayment or underpayment of Lessee's Share of Common Area Operating Expenses revealed by such audit shall be adjusted by the parties by payment by Lessee, in case of any underpayment, or payment by Lessor or credit to Lessee, as designated by Lessor, in case of any overpayment, within thirty (30) days after Lessor's receipt of Lessee's audit results. If Lessee's audit disclosed that Lessee's Share of Common Area Operating Expenses has been overstated by ten percent (10%) or more, Lessor shall pay the reasonable cost of such audit.

 

4.3       Payment. Lessee shall cause payment of Rent to be received by Lessor in lawful money of the United States, without offset or deduction (except as specifically permitted in this Lease), on or before the day on which it is due. All monetary amounts shall be rounded to the nearest whole dollar. In the event that any invoice prepared by Lessor is inaccurate such inaccuracy shall not constitute a waiver and Lessee shall be obligated to pay the amount set forth in this Lease. Rent for any period during the term hereof which is for less than one full calendar month shall be prorated based upon the actual number of days of said month. Payment of Rent shall be made to Lessor at its address stated herein or to such other persons or place as Lessor may from time to time designate in writing. Acceptance of a payment which is less than the amount then due shall not be a waiver of Lessor's rights to the balance of such Rent, regardless of Lessor's endorsement of any check so stating. In the event that any check, draft, or other instrument of payment given by Lessee to Lessor is dishonored for any reason, Lessee agrees to pay to Lessor the sum of $25 in addition to any Late Charge and Lessor, at its option, may require all future Rent be paid by cashier's check. Payments will be applied first to accrued late charges and attorney's fees, second to accrued interest, then to Base Rent and Common Area Operating Expenses, and any remaining amount to any other outstanding charges or costs.

 

5.           Security Deposit. Lessee shall deposit with Lessor upon execution hereof the Security Deposit as security for Lessee's faithful performance of its obligations under this Lease. If Lessee fails to pay Rent, or otherwise Defaults under this Lease, Lessor may use, apply or retain all or any portion of said Security Deposit for the payment of any amount already due Lessor, for Rents which will be due in the future, and/ or to reimburse or compensate Lessor for any liability, expense, loss or damage which Lessor may suffer or incur by reason thereof. If Lessor uses or applies all or any portion of the Security Deposit, Lessee shall within 10 days after written request therefor deposit monies with Lessor sufficient to restore said Security Deposit to the full amount required by this Lease. If the Base Rent increases during the term of this Lease, Lessee shall, upon written request from Lessor, deposit additional monies with Lessor so that the total amount of the Security Deposit shall at all times bear the same proportion to the increased Base Rent as the initial Security Deposit bore to the initial Base Rent. Should the Agreed Use be amended to accommodate a material change in the business of Lessee or to accommodate a sublessee or assignee, Lessor shall have the right to increase the Security Deposit to the extent necessary, in Lessor's reasonable judgment, to account for any increased wear and tear that the Premises may suffer as a result thereof. If a change in control of Lessee occurs during this Lease and following such change the financial condition of Lessee is, in Lessor's reasonable judgment, significantly reduced, Lessee shall deposit such additional monies with Lessor as shall be sufficient to cause the Security Deposit to be at a commercially reasonable level based on such change in financial condition. Lessor shall not be required to keep the Security Deposit separate from its general accounts. Within 90 days after the expiration or termination of this Lease, Lessor shall return that portion of the Security Deposit not used or applied by Lessor. No part of the Security Deposit shall be considered to be held in trust, to bear interest or to be prepayment for any monies to be paid by Lessee under this Lease.

 

6.            Use.

 

6.1          Use. Lessee shall use and occupy the Premises only for the Agreed Use, or any other legal use which is reasonably comparable thereto, and for no other purpose. Lessee shall not use or permit the use of the Premises in a manner that is unlawful, creates damage, waste or a nuisance, or that disturbs occupants of or causes damage to neighboring premises or properties. Other than guide, signal and seeing eye dogs, Lessee shall not keep or allow in the Premises any pets, animals, birds, fish, or reptiles. Lessor shall not unreasonably withhold or delay its consent to any written request for a modification of the Agreed Use, so long as the same will not impair the structural integrity of the Building or the mechanical or electrical systems therein, and/or is not significantly more burdensome to the Project. If Lessor elects to withhold consent, Lessor shall within 7 days after such request give written notification of same, which notice shall include an explanation of Lessor's objections to the change in the Agreed Use.

 

	
 

	
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6.2          Hazardous Substances.

 

(a)       Reportable Uses Require Consent. The term "Hazardous Substance" as used in this Lease shall mean any product, substance, or waste whose presence, use, manufacture, disposal, transportation, or release, either by itself or in combination with other materials expected to be on the Premises, is either: (i) potentially injurious to the public health, safety or welfare, the environment or the Premises, (ii) regulated or monitored by any governmental authority, or (iii) a basis for potential liability of Lessor to any governmental agency or third party under any applicable statute or common law theory. Hazardous Substances shall include, but not be limited to, hydrocarbons, petroleum, gasoline, and/or crude oil or any products, by-products or fractions thereof. Lessee shall not engage in any activity in or on the Premises which constitutes a Reportable Use of Hazardous Substances without the express prior written consent of Lessor and timely compliance (at Lessee's expense) with all Applicable Requirements. Notwithstanding the foregoing, Lessor is aware that Lessee may use or store Hazardous Substances from time to time in connection with Lessee's use of the Premises, and this is acceptable to Lessor as long as Lessee's usage is fully compliant with all applicable City, County, and other governmental guidelines and regulations. "Reportable Use" shall mean (i) the installation or use of any above or below ground storage tank, (ii) the generation, possession, storage, use, transportation, or disposal of a Hazardous Substance that requires a permit from, or with respect to which a report, notice, registration or business plan is required to be filed with, any governmental authority, and/or (iii) the presence at the Premises of a Hazardous Substance with respect to which any Applicable Requirements requires that a notice be given to persons entering or occupying the Premises or neighboring properties. Notwithstanding the foregoing, Lessee may use any ordinary and customary materials reasonably required to be used in the normal course of the Agreed Use, ordinary office supplies (copier toner, liquid paper, glue, etc.) and common household cleaning materials, so long as such use is in compliance with all Applicable Requirements, is not a Reportable Use, and does not expose the Premises or neighboring property to any meaningful risk of contamination or damage or expose Lessor to any liability therefor. In addition, Lessor may condition its consent to any Reportable Use upon receiving such additional assurances as Lessor reasonably deems necessary to protect itself, the public, the Premises and/or the environment against damage, contamination, injury and/or liability, including, but not limited to, the installation (and removal on or before Lease expiration or termination) of protective modifications (such as concrete encasements) and/or increasing the Security Deposit.

 

(b)          Duty to Inform Lessor. If Lessee knows, or has reasonable cause to believe, that a Hazardous Substance has come to be located in, on, under or about the Premises, other than as previously consented to by Lessor, Lessee shall immediately give written notice of such fact to Lessor, and provide Lessor with a copy of any report, notice, claim or other documentation which it has concerning the presence of such Hazardous Substance.

 

(c)          Lessee Remediation. Lessee shall not cause or permit any Hazardous Substance to be spilled or released in, on, under, or about the Premises (including through the plumbing or sanitary sewer system) and shall promptly, at Lessee's expense, comply with all Applicable Requirements and take all investigatory and/or remedial action reasonably recommended, whether or not formally ordered or required, for the cleanup of any contamination of, and for the maintenance, security and/or monitoring of the Premises or neighboring properties, that was caused or materially contributed to by Lessee, or pertaining to or involving any Hazardous Substance brought onto the Premises during the term of this Lease, by or for Lessee, or any third party.

 

(d)          Lessee Indemnification. Lessee shall indemnify, defend and hold Lessor, its agents, employees, lenders and ground lessor, if any, harmless from and against any and all loss of rents and/or damages, liabilities, judgments, claims, expenses, penalties, and attorneys' and consultants' fees arising out of or involving any Hazardous Substance brought onto the Premises by or for Lessee, or any third party (provided, however, that Lessee shall have no liability under this Lease with respect to underground migration of any Hazardous Substance under the Premises from areas outside of the Project not caused or contributed to by Lessee). Lessee's obligations shall include, but not be limited to, the effects of any contamination or injury to person, property or the environment created or suffered by Lessee, and the cost of investigation, removal, remediation, restoration and/or abatement, and shall survive the expiration or termination of this Lease. No termination, cancellation or release agreement entered into by Lessor and Lessee shall release Lessee from its obligations under this Lease with respect to Hazardous Substances, unless specifically so agreed by Lessor in writing at the time of such agreement.

 

(e)          Lessor Indemnification. Except as otherwise provided in paragraph 8.7, Lessor and its successors and assigns shall indemnify, defend, reimburse and hold Lessee, its employees and lenders, harmless from and against any and all environmental damages, including the cost of remediation, which are suffered as a direct result of Hazardous Substances on the Premises prior to Lessee taking possession or which are caused by the gross negligence or willful misconduct of Lessor, its agents or employees. Lessor's obligations, as and when required by the Applicable Requirements, shall include, but not be limited to, the cost of investigation, removal, remediation, restoration and/or abatement, and shall survive the expiration or termination of this Lease.

 

(f)           Investigations and Remediations. Lessor shall retain the responsibility and pay for any investigations or remediation measures required by governmental entities having jurisdiction with respect to the existence of Hazardous Substances on the Premises prior to the Lessee taking possession, unless such remediation measure is required as a result of Lessee's use (including "Alterations", as defined in paragraph 7.3(a) below) of the Premises, in which event Lessee shall be responsible for such payment. Lessee shall cooperate fully in any such activities at the request of Lessor, including allowing Lessor and Lessor's agents to have reasonable access to the Premises at reasonable times in order to carry out Lessor's investigative and remedial responsibilities.

 

	
 

	
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(g)          Lessor Termination Option. If a Hazardous Substance Condition (see Paragraph 9.1(e)) occurs during the term of this Lease, unless Lessee is legally responsible therefor (in which case Lessee shall make the investigation and remediation thereof required by the Applicable Requirements and this Lease shall continue in full force and effect, but subject to Lessor's rights under Paragraph 6.2(d) and Paragraph 13), Lessor may, at Lessor's option, either (i) investigate and remediate such Hazardous Substance Condition, if required, as soon as reasonably possible at Lessor's expense, in which event this Lease shall continue in full force and effect, or (ii) if the estimated cost to remediate such condition exceeds 12 times the then monthly Base Rent or $100,000, whichever is greater, give written notice to Lessee, within 30 days after receipt by Lessor of knowledge of the occurrence of such Hazardous Substance Condition, of Lessor's desire to terminate this Lease as of the date 60 days following the date of such notice. In the event Lessor elects to give a termination notice, Lessee may, within 10 days thereafter, give written notice to Lessor of Lessee's commitment to pay the amount by which the cost of the remediation of such Hazardous Substance Condition exceeds an amount equal to 12 times the then monthly Base Rent or $100,000, whichever is greater. Lessee shall provide Lessor with said funds or satisfactory assurance thereof within 30 days following such commitment. In such event, this Lease shall continue in full force and effect, and Lessor shall proceed to make such remediation as soon as reasonably possible after the required funds are available. If Lessee does not give such notice and provide the required funds or assurance thereof within the time provided, this Lease shall terminate as of the date specified in Lessor's notice of termination.

 

6.3          Lessee's Compliance with Applicable Requirements. Except as otherwise provided in this Lease, Lessee shall, at Lessee's sole expense, fully, diligently and in a timely manner, materially comply with all Applicable Requirements, the requirements of any applicable fire insurance underwriter or rating bureau, and the recommendations of Lessor's engineers and/or consultants which relate in any manner to such Requirements, without regard to whether said Requirements are now in effect or become effective after the Start Date. Lessee shall, within 10 days after receipt of Lessor's written request, provide Lessor with copies of all permits and other documents, and other information evidencing Lessee's compliance with any Applicable Requirements specified by Lessor, and shall immediately upon receipt, notify Lessor in writing (with copies of any documents involved) of any threatened or actual claim, notice, citation, warning, complaint or report pertaining to or involving the failure of Lessee or the Premises to comply with any Applicable Requirements. Likewise, Lessee shall immediately give written notice to Lessor of: (i) any water damage to the Premises and any suspected seepage, pooling, dampness or other condition conducive to the production of mold; or (ii) any mustiness or other odors that might indicate the presence of mold in the Premises.

 

6.4          Inspection; Compliance. Lessor and Lessor's "Lender" (as defined in Paragraph 30) and consultants shall have the right to enter into Premises at any time, in the case of an emergency, and otherwise at reasonable times after reasonable notice, for the purpose of inspecting the condition of the Premises and for verifying compliance by Lessee with this Lease. The cost of any such inspections shall be paid by Lessor, unless a violation of Applicable Requirements, or a Hazardous Substance Condition (see Paragraph 9.1) is found to exist or be imminent, or the inspection is requested or ordered by a governmental authority. In such case, Lessee shall upon request reimburse Lessor for the cost of such inspection, so long as such inspection is reasonably related to the violation or contamination. In addition, Lessee shall provide copies of all relevant material safety data sheets (MSDS) to Lessor within 10 days of the receipt of written request therefor.

 

7.             Maintenance; Repairs, Utility Installations; Trade Fixtures and Alterations.

 

7.1     Lessee's Obligations.

 

(a)                In General. Subject to the provisions of Paragraph 2.2 (Condition), 2.3 (Compliance), 6.3 (Lessee's Compliance with Applicable Requirements), 7.2 (Lessor's Obligations), 9 (Damage or Destruction), and 14 (Condemnation), Lessee shall, at Lessee's sole expense, keep the Premises, Utility Installations (intended for Lessee's exclusive use, no matter where located), and Alterations in good order, condition and repair (whether or not the portion of the Premises requiring repairs, or the means of repairing the same, are reasonably or readily accessible to Lessee, and whether or not the need for such repairs occurs as a result of Lessee's use, any prior use, the elements or the age of such portion of the Premises), including, but not limited to, all equipment or facilities, such as plumbing, HVAC equipment, electrical, lighting facilities, boilers, pressure vessels, fixtures, interior walls, interior surfaces of exterior walls, ceilings, floors, windows, doors, plate glass, and skylights but excluding any items which are the responsibility of Lessor pursuant to Paragraph 7.2. Lessee, in keeping the Premises in good order, condition and repair, shall exercise and perform good maintenance practices, specifically including the procurement and maintenance of the service contracts required by Paragraph 7.1(b) below. Lessee's obligations shall include restorations, replacements or renewals when necessary to keep the Premises and all improvements thereon or a part thereof in good order, condition and state of repair.

 

(b)               Service Contracts. Lessee shall, at Lessee's sole expense, procure and maintain contracts, with copies to Lessor, in customary form and substance for, and with contractors specializing and experienced in the maintenance of the following equipment and improvements, if any, if and when installed on the Premises: (i) HVAC equipment, (ii) boiler and pressure vessels, and (iii) clarifiers. However, Lessor reserves the right, upon notice to Lessee, to procure and maintain any or all of such service contracts, and Lessee shall reimburse Lessor, upon demand, for the cost thereof.

 

(c)               Failure to Perform. If Lessee fails to perform Lessee's obligations under this Paragraph 7.1, Lessor may enter upon the Premises after 10 days' prior written notice to Lessee (except in the case of an emergency, in which case no notice shall be required), perform such obligations on Lessee's behalf, and put the Premises in good order, condition and repair, and Lessee shall promptly pay to Lessor a sum equal to 115% of the cost thereof.

 

(d)               Replacement. Subject to Lessee's indemnification of Lessor as set forth in Paragraph 8.7 below, and without relieving Lessee of liability resulting from Lessee's failure to exercise and perform good maintenance practices, if an item described in Paragraph 7.1(b) cannot be repaired other than at a cost which is in excess of 50% of the cost of replacing such item, then such item shall be replaced by Lessor, and the cost thereof shall be prorated between the Parties and Lessee shall only be obligated to pay, each month during the remainder of the term of this Lease, on the date on which Base Rent is due, an amount equal to the product of multiplying the cost of such replacement by a fraction, the numerator of which is one, and the denominator of which is 144 (ie. 1/144th of the cost per month). Lessee shall pay Interest on the unamortized balance but may prepay its obligation at any time.

 

	
 

	
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7.2          Lessor's Obligations. Subject to the provisions of Paragraphs 2.2 (Condition), 2.3 (Compliance), 4.2 (Common Area Operating Expenses), 6 (Use), 7.1 (Lessee's Obligations), 9 (Damage or Destruction) and 14 (Condemnation), Lessor, subject to reimbursement pursuant to Paragraph 4.2, shall keep in good order, condition and repair the foundations, exterior walls, structural condition of interior bearing walls, exterior roof, fire sprinkler system, Common Area fire alarm and/or smoke detection systems, fire hydrants, parking lots, walkways, parkways, driveways, landscaping, fences, signs and utility systems serving the Common Areas and all parts thereof, as well as providing the services for which there is a Common Area Operating Expense pursuant to Paragraph 4.2. Lessor shall not be obligated to paint the exterior or interior surfaces of exterior walls nor shall Lessor be obligated to maintain, repair or replace windows, doors or plate glass of the Premises. Lessee expressly waives the benefit of any statute now or hereafter in effect to the extent it is inconsistent with the terms of this Lease.

 

7.3          Utility Installations; Trade Fixtures; Alterations.

 

(a)          Definitions. The term "Utility Installations" refers to all floor and window coverings, air and/or vacuum lines, power panels, electrical distribution, security and fire protection systems, communication cabling, lighting fixtures, HVAC equipment, plumbing, and fencing in or on the Premises. The term "Trade Fixtures" shall mean Lessee's machinery and equipment that can be removed without doing material damage to the Premises. The term "Alterations" shall mean any modification of the improvements, other than Utility Installations or Trade Fixtures, whether by addition or deletion. "Lessee Owned Alterations and/or Utility Installations" are defined as Alterations and/or Utility Installations made by Lessee that are not yet owned by Lessor pursuant to Paragraph 7.4(a).

 

(b)          Consent. Lessee shall not make any Alterations or Utility Installations to the Premises without Lessor's prior written consent. Lessee may, however, make non-structural Alterations or Utility Installations to the interior of the Premises (excluding the roof) without such consent but upon notice to Lessor, as long as they are not visible from the outside, do not involve puncturing, relocating or removing the roof or any existing walls, will not affect the electrical, plumbing, HVAC, and/or life safety systems, and the cumulative cost thereof during this Lease as extended does not exceed a sum equal to 3 month's Base Rent in the aggregate or a sum equal to one month's Base Rent in any one year. Notwithstanding the foregoing, Lessee shall not make or permit any roof penetrations and/or install anything on the roof without the prior written approval of Lessor. Lessor may, as a precondition to granting such approval, require Lessee to utilize a contractor chosen and/or approved by Lessor. Any Alterations or Utility Installations that Lessee shall desire to make and which require the consent of the Lessor shall be presented to Lessor in written form with detailed plans. Consent shall be deemed conditioned upon Lessee's: (i) acquiring all applicable governmental permits, (ii) furnishing Lessor with copies of both the permits and the plans and specifications prior to commencement of the work, and (iii) compliance with all conditions of said permits and other Applicable Requirements in a prompt and expeditious manner. Any Alterations or Utility Installations shall be performed in a workmanlike manner with good and sufficient materials. Lessee shall promptly upon completion furnish Lessor with as-built plans and specifications. For work which costs an amount in excess of one month's Base Rent, Lessor may condition its consent upon Lessee providing a lien and completion bond in an amount equal to 150% of the estimated cost of such Alteration or Utility Installation and/or upon Lessee's posting an additional Security Deposit with Lessor.

 

(c)          Liens; Bonds. Lessee shall pay, when due, all claims for labor or materials furnished or alleged to have been furnished to or for Lessee at or for use on the Premises, which claims are or may be secured by any mechanic's or materialman's lien against the Premises or any interest therein. Lessee shall give Lessor not less than 10 days notice prior to the commencement of any work in, on or about the Premises, and Lessor shall have the right to post notices of non-responsibility. If Lessee shall contest the validity of any such lien, claim or demand, then Lessee shall, at its sole expense defend and protect itself, Lessor and the Premises against the same and shall pay and satisfy any such adverse judgment that may be rendered thereon before the enforcement thereof. If Lessor shall require, Lessee shall furnish a surety bond in an amount equal to 150% of the amount of such contested lien, claim or demand, indemnifying Lessor against liability for the same. If Lessor elects to participate in any such action, Lessee shall pay Lessor's attorneys' fees and costs.

 

7.4          Ownership; Removal; Surrender; and Restoration.

 

(a)          Ownership. Subject to Lessor's right to require removal or elect ownership as hereinafter provided, all Alterations and Utility Installations made by Lessee shall be the property of Lessee, but considered a part of the Premises. Lessor may, at any time, elect in writing to be the owner of all or any specified part of the Lessee Owned Alterations and Utility Installations. Unless otherwise instructed per paragraph 7.4(b) hereof, ail Lessee Owned Alterations and Utility Installations shall, at the expiration or termination of this Lease, become the property of Lessor and be surrendered by Lessee with the Premises.

 

(b)          Removal. By delivery to Lessee of written notice from Lessor not earlier than 90 and not later than 30 days prior to the end of the term of this Lease, Lessor may require that any or all Lessee Owned Alterations or Utility Installations be removed by the expiration or termination of this Lease. Lessor may require the removal at any time of all or any part of any Lessee Owned Alterations or Utility Installations made without the required consent.

 

(c)          Surrender; Restoration. Lessee shall surrender the Premises by the Expiration Date or any earlier termination date, with all of the improvements, parts and surfaces thereof broom clean and free of debris, and in good operating order, condition and state of repair, ordinary wear and tear excepted. "Ordinary wear and tear" shall not include any damage or deterioration that would have been prevented by good maintenance practice. Notwithstanding the foregoing, if this Lease is for 12 months or less, then Lessee shall surrender the Premises in the same condition as delivered to Lessee on the Start Date with NO allowance for ordinary wear and tear. Lessee shall repair any damage occasioned by the installation, maintenance or removal of Trade Fixtures, Lessee owned Alterations and/or Utility Installations, furnishings, and equipment as well as the removal of any storage tank installed by or for Lessee. Lessee shall also completely remove from the Premises any and all Hazardous Substances brought onto the Premises by or for Lessee, or any third party (except Hazardous Substances which were deposited via underground migration from areas outside of the Project) even if such removal would require Lessee to perform or pay for work that exceeds statutory requirements. Trade Fixtures shall remain the property of Lessee and shall be removed by Lessee. Any personal property of Lessee not removed on or before the Expiration Date or any earlier termination date shall be deemed to have been abandoned by Lessee and may be disposed of or retained by Lessor as Lessor may desire. The failure by Lessee to timely vacate the Premises pursuant to this Paragraph 7.4(c) without the express written consent of Lessor shall constitute a holdover under the provisions of Paragraph 26 below. 

 

	
 

	
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8.         Insurance; Indemnity.

 

8.1          Payment of Premiums. The cost of the premiums for the insurance policies required to be carried by Lessor, pursuant to Paragraphs 8.2(b), 8.3(a) and 8.3(b), shall be a Common Area Operating Expense. Premiums for policy periods commencing prior to, or extending beyond, the term of this Lease shall be prorated to coincide with the corresponding Start Date or Expiration Date.

 

8.2          Liability Insurance.

 

(a)          Carried by Lessee. Lessee shall obtain and keep in force a Commercial General Liability policy of insurance protecting Lessee and Lessor as an additional insured against claims for bodily injury, personal injury and property damage based upon or arising out of the ownership, use, occupancy or maintenance of the Premises and all areas appurtenant thereto. Such insurance shall be on an occurrence basis providing single limit coverage in an amount not less than $1,000,000 per occurrence with an annual aggregate of not less than $2,000,000. Lessee shall add Lessor as an additional insured by means of an endorsement at least as broad as the Insurance Service Organization's "Additional Insured-Managers or Lessors of Premises" Endorsement. The policy shall not contain any intra-insured exclusions as between insured persons or organizations, but shall include coverage for liability assumed under this Lease as an "insured contract" for the performance of Lessee's indemnity obligations under this Lease. The limits of said insurance shall not, however, limit the liability of Lessee nor relieve Lessee of any obligation hereunder. Lessee shall provide an endorsement on its liability policy(ies) which provides that its insurance shall be primary to and not contributory with any similar insurance carried by Lessor, whose insurance shall be considered excess insurance only.

 

(b)          Carried by Lessor. Lessor shall maintain liability insurance as described in Paragraph 8.2(a), in addition to, and not in lieu of, the insurance required to be maintained by Lessee. Lessee shall not be named as an additional insured therein.

 

8.3          Property Insurance - Building, Improvements and Rental Value.

 

(a)          Building and Improvements. Lessor shall obtain and keep in force a policy or policies of insurance in the name of Lessor, with loss payable to Lessor, any ground-lessor, and to any Lender insuring loss or damage to the Project Premises. The amount of such insurance shall be equal to the full insurable replacement cost of the Project Premises, as the same shall exist from time to time, or the amount required by any Lender, but in no event more than the commercially reasonable and available insurable value thereof. Lessee Owned Alterations and Utility Installations, Trade Fixtures, and Lessee's personal property shall be insured by Lessee not by Lessor. If the coverage is available and commercially appropriate, such policy or policies shall insure against all risks of direct physical loss or damage (except the perils of flood and/or earthquake unless required by a Lender), including coverage for debris removal and the enforcement of any Applicable Requirements requiring the upgrading, demolition, reconstruction or replacement of any portion of the Premises as the result of a covered loss. Said policy or policies shall also contain an agreed valuation provision in lieu of any coinsurance clause, waiver of subrogation, and inflation guard protection causing an increase in the annual property insurance coverage amount by a factor of not less than the adjusted U.S. Department of Labor Consumer Price Index for All Urban Consumers for the city nearest to where the Premises are located. If such insurance coverage has a deductible clause, the deductible amount shall not exceed $5,000 $1,000 per occurrence.

 

(b)          Rental Value. Lessor shall also obtain and keep in force a policy or policies in the name of Lessor with loss payable to Lessor and any Lender, insuring the loss of the full Rent for one year with and including, only if required by Lessor's lender, an extended period of indemnity for an additional 180 days ("Rental Value insurance"). Said insurance shall contain an agreed valuation provision in lieu of any coinsurance clause, and the amount of coverage shall be adjusted annually to reflect the projected Rent otherwise payable by Lessee, for the next 12 month period.

 

(c)          Adjacent Premises. Lessee shall pay for any increase in the premiums for the property insurance of the Building and for the Common Areas or other buildings in the Project if said increase is caused by Lessee's acts, omissions, use or occupancy of the Premises.

 

(d)          Lessee's Improvements. Since Lessor is the Insuring Party, Lessor shall not be required to insure Lessee Owned Alterations and Utility Installations unless the item in question has become the property of Lessor under the terms of this Lease. 

 

8.4      Lessee's Property; Business Interruption Insurance; Worker's Compensation Insurance,

 

(a)      Property Damage. Lessee shall obtain and maintain insurance coverage on all of Lessee's personal property, Trade Fixtures, and Lessee Owned Alterations and Utility Installations. Such insurance shall be full replacement cost coverage with a deductible of not to exceed $10,000 $1,000 per occurrence. The proceeds from any such insurance shall be used by Lessee for the replacement of personal property, Trade Fixtures and Lessee Owned Alterations and Utility Installations.

 

	
 

	
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(b)            Business Interruption. Lessee shall obtain and maintain loss of income and extra expense insurance in amounts as will reimburse Lessee for direct or indirect loss of earnings attributable to all perils commonly insured against by prudent lessees in the business of Lessee or attributable to prevention of access to the Premises as a result of such perils.

 

(c)            Worker's Compensation Insurance. Lessee shall obtain and maintain Workers Compensation Insurance in such amount as may be required by Applicable Requirements. Such policy shall include a Waiver of Subrogation endorsement. Lessee shall provide Lessor with a copy of such endorsement along with the certificate of insurance or copy of the policy required by paragraph 8.5.

 

(d)            No Representation of Adequate Coverage. Lessor makes no representation that the limits or forms of coverage of insurance specified herein are adequate to cover Lessee's property, business operations or obligations under this Lease.

 

8.5          Insurance Policies. Insurance required herein shall be by companies maintaining during the policy term a "General Policyholders Rating" of at least A-, VII, as set forth in the most current issue of "Best's Insurance Guide", or such other rating as may be required by a Lender. Lessee shall not do or permit to be done anything which invalidates the required insurance policies. Lessee shall, prior to the Start Date, deliver to Lessor certified copies of policies of such insurance or certificates with copies of the required endorsements evidencing the existence and amounts of the required insurance. No such policy shall be cancelable or subject to modification except after 30 days prior written notice to Lessor. Lessee shall, at least 10 days prior to the expiration of such policies, furnish Lessor with evidence of renewals or "insurance binders" evidencing renewal thereof, or Lessor may order such insurance and charge the cost thereof to Lessee, which amount shall be payable by Lessee to Lessor upon demand. Such policies shall be for a term of at least one year, or the length of the remaining term of this Lease, whichever is less. If either Party shall fail to procure and maintain the insurance required to be carried by it, the other Party may, but shall not be required to, procure and maintain the same.

 

8.6          Waiver of Subrogation. Without affecting any other rights or remedies Not withstanding anything to the contrary herein, Lessee and Lessor each hereby release and relieve the other, and waive their entire right to recover damages against the other, for loss of or damage to its property arising out of or incident to the perils required to be insured against herein. The effect of such releases and waivers is not limited by the amount of insurance carried or required, or by any deductibles applicable hereto. The Parties agree to have their respective property damage insurance carriers waive any right to subrogation that such companies may have against Lessor or Lessee, as the case may be, so long as the insurance is not invalidated thereby.

 

8.7          Indemnity. Except for Lessor's gross negligence or willful misconduct Of violation of this Lease, Lessee shall indemnify, protect, defend and hold harmless the Premises, Lessor and its agents, Lessor's master or ground lessor, partners and Lenders, from and against any and all claims, loss of rents and/or damages, liens, judgments, penalties, attorneys' and consultants' fees, expenses and/or liabilities arising out of, involving, or in connection with, the use and/or occupancy of the Premises by Lessee. If any action or proceeding is brought against Lessor by reason of any of the foregoing matters, Lessee shall upon notice defend the same at Lessee's expense by counsel reasonably satisfactory to Lessor and Lessor shall cooperate with Lessee in such defense. Lessor need not have first paid any such claim in order to be defended or indemnified.

 

8.8          Exemption of Lessor and its Agents from Liability. Notwithstanding Except to the extent due to the negligence or breach of this Lease OP violation of this Lease by Lessor or its agents, neither Lessor nor its agents shall be liable under any circumstances for: (i) injury or damage to the person or goods, wares, merchandise or other properly of Lessee, Lessee's employees, contractors, invitees, customers, or any other person in or about the Premises, whether such damage or injury is caused by or results from fire, steam, electricity, gas, water or rain, indoor air quality, the presence of mold or from the breakage, leakage, obstruction or other defects of pipes, fire sprinklers, wires, appliances, plumbing, HVAC or lighting fixtures, or from any other cause, whether the said injury or damage results from conditions arising upon the Premises or upon other portions of the Building, or from other sources or places, (ii) any damages arising from any act or neglect of any other tenant of Lessor or from the failure of Lessor or its agents to enforce the provisions of any other lease in the Project, or (iii) injury to Lessee's business or for any loss of income or profit therefrom. Instead, it is intended that Lessee's sole recourse in the event of such damages or injury be to file a claim on the insurance policy(ies) that Lessee is required to maintain pursuant to the provisions of paragraph 8. 

 

8.9          Failure to Provide Insurance. Lessee acknowledges that any failure on its part to obtain or maintain the insurance required herein will expose Lessor to risks and potentially cause Lessor to incur costs not contemplated by this Lease, the extent of which will be extremely difficult to ascertain. Accordingly, for any month or portion thereof that Lessee does not maintain the required insurance and/or does not provide Lessor with the required binders or certificates evidencing the existence of the required insurance, the Base Rent shall be automatically increased, without any requirement for notice to Lessee, by an amount equal to 10% of the then existing Base Rent or $100, whichever is greater. The parties agree that such increase in Base Rent represents fair and reasonable compensation for the additional risk/costs that Lessor will incur by reason of Lessee's failure to maintain the required insurance. Such increase in Base Rent shall in no event constitute a waiver of Lessee's Default or Breach with respect to the failure to maintain such insurance, prevent the exercise of any of the other rights and remedies granted hereunder, nor relieve Lessee of its obligation to maintain the insurance specified in this Lease.

 

9.            Damage or Destruction.

 

9.1       Definitions.

 

(a)       "Premises Partial Damage" shall mean damage or destruction to the improvements on the Premises, other than Lessee Owned Alterations and Utility Installations, which can reasonably be repaired in 3 months or less from the date of the damage or destruction, and the cost thereof does not exceed a sum equal to 6 month's Base Rent. Lessor shall notify Lessee in writing within 30 days from the date of the damage or destruction as to whether or not the damage is Partial or Total. Notwithstanding the foregoing, Premises Partial Damage shall not include damage to windows, doors, and/or other similar items which Lessee has the responsibility to repair or replace pursuant to the provisions of Paragraph 7.1.

 

	
 

	
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(b)          "Premises Total Destruction" shall mean damage or destruction to the improvements on the Premises, other than Lessee Owned Alterations and Utility Installations and Trade Fixtures, which cannot reasonably be repaired in 3 months or less from the date of the damage or destruction and/or the cost thereof exceeds a sum equal to 6 month's Base Rent. Lessor shall notify Lessee in writing within 30 days from the date of the damage or destruction as to whether or not the damage is Partial or Total.

 

(c)          "Insured Loss" shall mean damage or destruction to improvements on the Premises, other than Lessee Owned Alterations and Utility Installations and Trade Fixtures, which was caused by an event required to be covered by the insurance described in Paragraph 8.3(a), irrespective of any deductible amounts or coverage limits involved.

 

(d)          "Replacement Cost" shall mean the cost to repair or rebuild the improvements owned by Lessor at the time of the occurrence to their condition existing immediately prior thereto, including demolition, debris removal and upgrading required by the operation of Applicable Requirements, and without deduction for depreciation.

 

(e)          "Hazardous Substance Condition" shall mean the occurrence or discovery of a condition involving the presence of, or a contamination by, a Hazardous Substance, in, on, or under the Premises which requires restoration.

 

9.2          Partial Damage - Insured Loss. If a Premises Partial Damage that is an Insured Loss occurs, then Lessor shall, at Lessor's expense, repair such damage (but not Lessee's Trade Fixtures or Lessee Owned Alterations and Utility Installations) as soon as reasonably possible and this Lease shall continue in full force and effect; provided, however, that Lessee shall, at Lessor's election, make the repair of any damage or destruction the total cost to repair of which is $10,000 or less, and, in such event, Lessor shall make any applicable insurance proceeds-available-to Lessee on a reasonable basis for that purpose. Notwithstanding the foregoing, if the required insurance was not in force or the insurance proceeds are not sufficient to effect such repair, the Insuring Party shall promptly contribute the shortage in proceeds as and when required to complete said repairs. In the event, however, such shortage was due to the fact that, by reason of the unique nature of the improvements, full replacement cost insurance coverage was not commercially reasonable and available, Lessor shall have no obligation to pay for the shortage in insurance proceeds or to fully restore the unique aspects of the Premises unless Lessee provides Lessor with the funds to cover same, or adequate assurance thereof, within 10 days following receipt of written notice of such shortage and request therefor. If Lessor receives said funds or adequate assurance thereof within said 10 day period, the party responsible for making the repairs shall complete them as soon as reasonably possible and this Lease shall remain in full force and effect. If such funds or assurance are not received, Lessor may nevertheless elect by written notice to Lessee within 10 days thereafter to: (i) make such restoration and repair as is commercially reasonable with Lessor paying any shortage in proceeds, in which case this Lease shall remain in full force and effect, or (ii) have this Lease terminate 30 days thereafter. Lessee shall not be entitled to reimbursement of any funds contributed by Lessee to repair any such damage or destruction. Premises Partial Damage due to flood or earthquake shall be subject to Paragraph 9.3, notwithstanding that there may be some insurance coverage, but the net proceeds of any such insurance shall be made available for the repairs if made by either Party.

 

9.3          Partial Damage - Uninsured Loss. If a Premises Partial Damage that is not an Insured Loss occurs, unless caused by a negligent or willful act of Lessee (in which event Lessee shall make the repairs at Lessee's expense), Lessor may either: (i) repair such damage as soon as reasonably possible at Lessor's expense, in which event this Lease shall continue in full force and effect, or (ii) terminate this Lease by giving written notice to Lessee within 30 days after receipt by Lessor of knowledge of the occurrence of such damage. Such termination shall be effective 60 days following the date of such notice. In the event Lessor elects to terminate this Lease, Lessee shall have the right within 10 days after receipt of the termination notice to give written notice to Lessor of Lessee's commitment to pay for the repair of such damage without reimbursement from Lessor. Lessee shall provide Lessor with said funds or satisfactory assurance thereof within 30 days after making such commitment. In such event this Lease shall continue in full force and effect, and Lessor shall proceed to make such repairs as soon as reasonably possible after the required funds are available. If Lessee does not make the required commitment, this Lease shall terminate as of the date specified in the termination notice. Notwithstanding anything to the contrary herein, this Lease shall not terminate upon a casualty (except a Premises Total Destruction, if requested by Lessee) If Lessor actually intends to restore the casualty damage.

 

9.4          Total Destruction. Notwithstanding any other provision hereof, if a Premises Total Destruction occurs, this Lease shall terminate 60 days following such Destruction. If the damage or destruction was caused by the gross negligence or willful misconduct of Lessee, Lessor shall have the right to recover Lessor's damages from Lessee, except as provided in Paragraph 8.6.

 

9.5          Damage Near End of Term. If at any time during the last 6 months of this Lease there is damage for which the cost to repair exceeds one month's Base Rent, whether or not an Insured Loss, Lessor may terminate this Lease effective 60 days following the date of occurrence of such damage by giving a written termination notice to Lessee within 30 days after the date of occurrence of such damage. Notwithstanding the foregoing, if Lessee at that time has an exercisable option to extend this Lease or to purchase the Premises, then Lessee may preserve this Lease by, (a) exercising such option and (b) providing Lessor with any shortage in insurance proceeds (or adequate assurance thereof) needed to make the repairs on or before the earlier of (i) the date which is 10 days after Lessee's receipt of Lessor's written notice purporting to terminate this Lease, or (ii) the day prior to the date upon which such option expires. If Lessee duly exercises such option during such period and provides Lessor with funds (or adequate assurance thereof) to cover any shortage in insurance proceeds, Lessor shall, at Lessor's commercially reasonable expense, repair such damage as soon as reasonably possible and this Lease shall continue in full force and effect. If Lessee fails to exercise such option and provide such funds or assurance during such period, then this Lease shall terminate on the date specified in the termination notice and Lessee's option shall be extinguished.

 

	
 

	
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9.6          Abatement of Rent; Lessee's Remedies.

 

(a)          Abatement. In the event of Premises Partial Damage or Premises Total Destruction or a Hazardous Substance Condition for which Lessee is not responsible under this Lease, the Rent payable by Lessee for the period required for the repair, remediation or restoration of such damage shall be abated in proportion to the degree to which Lessee's use of the Premises is impaired, but not to exceed the proceeds received from the Rental Value insurance. All other obligations of Lessee hereunder shall be performed by Lessee, and Lessor shall have no liability for any such damage, destruction, remediation, repair or restoration except as provided herein.

 

(b)            Remedies. If Lessor is obligated to repair or restore the Premises and does not commence, in a substantial and meaningful way, such repair or restoration within 90 days after such obligation shall accrue, Lessee may, at any time prior to the commencement of such repair or restoration, give written notice to Lessor and to any Lenders of which Lessee has actual notice, of Lessee's election to terminate this Lease on a date not less than 60 days following the giving of such notice. If Lessee gives such notice and such repair or restoration is not commenced within 30 days thereafter, this Lease shall terminate as of the date specified in said notice. If the repair or restoration is commenced within such 30 days, this Lease shall continue in full force and effect. "Commence" shall mean either the unconditional authorization of the preparation of the required plans, or the beginning of the actual work on the Premises, which shall be pursued diligently to completion, whichever first occurs.

 

9.7          Termination; Advance Payments. Upon termination of this Lease pursuant to Paragraph 6.2(g) or Paragraph 9, an equitable adjustment shall be made concerning advance Base Rent and any other advance payments made by Lessee to Lessor. Lessor shall, in addition, return to Lessee so much of Lessee's Security Deposit as has not been, or is not then required to be, used by Lessor.

 

10.       Real Property Taxes.

 

10.1       Definition. As used herein, the term "Real Property Taxes" shall include any form of assessment; real estate, general, special, ordinary or extraordinary, or rental levy or tax (other than inheritance, personal income or estate taxes); improvement bond; and/or license fee imposed upon or levied against any legal or equitable interest of Lessor in the Project, Lessor's right to other income therefrom, and/or Lessor's business of leasing, by any authority having the direct or indirect power to tax and where the funds are generated with reference to the Project address and where the proceeds so generated are to be applied by the city, county or other local taxing authority of a jurisdiction within which the Project is located. The term "Real Property Taxes" shall also include any tax, fee, levy, assessment or charge, or any increase therein: (i) imposed by reason of events occurring during the term of this Lease, including but not limited to, a change in the ownership of the Project, provided, however, that Real Property Tax increases attributable to any change in Ownership of the Premises shall be limited to one (1) change in ownership, and in no event shall such increases in Peal Property Taxes exceed One Thousand Dollars ($1,000) per month, (ii) a change in the improvements thereon, and/or (iii) levied or assessed on machinery or equipment provided by Lessor to Lessee pursuant to this Lease. In calculating Real Property Taxes for any calendar year, the Real Property Taxes for any real estate tax year shall be included in the calculation of Real Property Taxes for such calendar year based upon the number of days which such calendar year and tax year have in common.

 

10.2       Payment of Taxes. Except as otherwise provided in Paragraph 10.3, Lessor shall pay the Real Property Taxes applicable to the Project, and said payments shall be included in the calculation of Common Area Operating Expenses in accordance with the provisions of Paragraph 4.2.

 

10.3       Additional Improvements. Common Area Operating Expenses shall not include Real Property Taxes specified in the tax assessor's records and work sheets as being caused by additional improvements placed upon the Project by other lessees or by Lessor for the exclusive enjoyment of such other lessees. Notwithstanding Paragraph 10.2 hereof, Lessee shall, however, pay to Lessor at the time Common Area Operating Expenses are payable under Paragraph 4.2, the entirety of any increase in Real Property Taxes if assessed solely by reason of Alterations, Trade Fixtures or Utility Installations placed upon the Premises by Lessee or at Lessee's request or by reason of any alterations or improvements to the Premises made by Lessor subsequent to the execution of this Lease by the Parties.

 

10.4       Joint Assessment. If the Building is not separately assessed, Real Property Taxes allocated to the Building shall be an equitable proportion of the Real Property Taxes for all of the land and improvements included within the tax parcel assessed, such proportion to be determined by Lessor from the respective valuations assigned in the assessor's work sheets or such other information as may be reasonably available. Lessor's reasonable determination thereof, in good faith, shall be conclusive.

 

10.5       Personal Property Taxes. Lessee shall pay prior to delinquency all taxes assessed against and levied upon Lessee Owned Alterations and Utility Installations, Trade Fixtures, furnishings, equipment and all personal property of Lessee contained in the Premises. When possible, Lessee shall cause its Lessee Owned Alterations and Utility Installations, Trade Fixtures, furnishings, equipment and all other personal property to be assessed and billed separately from the real property of Lessor. If any of Lessee's said property shall be assessed with Lessor's real property, Lessee shall pay Lessor the taxes attributable to Lessee's property within 10 days after receipt of a written statement setting forth the taxes applicable to Lessee's property.

 

	
 

	
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11.          Utilities and Services. Lessee shall pay for all water, gas, heat, light, power, telephone, trash disposal and other utilities arid services supplied to the Premises, together with any taxes thereon. Notwithstanding the provisions of Paragraph 4.2, if at any time in Lessor's sole judgment, Lessor determines that Lessee is using a disproportionate amount of water, electricity or other commonly metered utilities, or that Lessee is generating such a large volume of trash as to require an increase in the size of the trash receptacle and/or an increase in the number of times per month that it is emptied, then Lessor may increase Lessee's Base Rent by an amount equal to such increased costs. There shall be no abatement of Rent and Lessor shall not be liable in any respect whatsoever for the inadequacy, stoppage, interruption or discontinuance of any utility or service due to riot, strike, labor dispute, breakdown, accident, repair or other cause beyond Lessor's reasonable control or in cooperation with governmental request or directions.

 

12.          Assignment and Subletting.

 

12.1 Lessor's Consent Required.

 

(a)          Lessee shall not voluntarily or by operation of law assign, transfer, mortgage or encumber (collectively, "assign or assignment") or sublet all or any part of Lessee's interest in this Lease or in the Premises without Lessor's prior written consent.

 

(b)         Unless Lessee is a corporation and its stock is publicly traded on a national stock exchange, a change in the control of Lessee shall constitute an assignment requiring consent. The transfer, on a cumulative basis, of 25% or more of the voting control of Lessee shall constitute a change in control for this purpose.

 

(c)     The Involvement of Lessee or its assets in any transaction, or series of transactions (by way of merger, sale, acquisition, financing, transfer, leveraged buy out or otherwise), whether or not a formal assignment or hypothecation of this Lease or Lessee's assets occurs, which results or will result in a reduction of the Net Worth of Lessee by an amount greater than 25% of such Net Worth as it was represented at the time of the execution of this Lease-er at the time of the most recent assignment to which Lessor has consented, or as it exists immediately prior to said may withhold its consent. "Not Worth of Lessee" shall mean the net worth of Lessee (excluding any guarantors) established under generally accepted accounting principles.

 

(d)         An assignment or subletting without consent shall, at Lessor's option, be a Default curable after notice per Paragraph 13.1(c), or a noncurable Breach without the necessity of any notice and grace period. If Lessor elects to treat such unapproved assignment or subletting as a noncurable Breach, Lessor may either: (i) terminate this Lease, or (ii) upon 30 days written notice, increase the monthly Base Rent to 110% of the Base Rent then in effect. Further, in the event of such Breach and rental adjustment, (i) the purchase price of any option to purchase the Premises held by Lessee shall be subject to similar adjustment to 110% of the price previously in effect, and (ii) all fixed and non-fixed rental adjustments scheduled during the remainder of the Lease term shall be increased to 110% of the scheduled adjusted rent.

 

(e)          Lessee's remedy for any breach of Paragraph 12.1 by Lessor shall be limited to compensatory damages and/or injunctive

 

(f)          Lessor may reasonably withhold consent to a proposed assignment or subletting if Lessee is in Default at the time consent is requested.

 

(g)         Notwithstanding the foregoing, allowing a de minimis portion of the Premises, ie. 20 square feet or less, to be used by a third party vendor in connection with the installation of a vending machine or payphone shall not constitute a subletting.

 

12.2        Terms and Conditions Applicable to Assignment and Subletting.

 

(a)          Regardless of Lessor's consent, no assignment or subletting shall: (i) be effective without the express written assumption by such assignee or sublessee of the obligations of Lessee under this Lease, (ii) release Lessee of any obligations hereunder, or (iii) alter the primary liability of Lessee for the payment of Rent or for the performance of any other obligations to be performed by Lessee.

 

(b)          Lessor may accept Rent or performance of Lessee's obligations from any person other than Lessee pending approval or disapproval of an assignment. Neither a delay in the approval or disapproval of such assignment nor the acceptance of Rent or performance shall constitute a waiver or estoppel of Lessor's right to exercise its remedies for Lessee's Default or Breach.

 

(c)          Lessor's consent to any assignment or subletting shall not constitute consent to any subsequent assignment or

subletting.

 

(d)          In the event of any Default or Breach by Lessee, Lessor may proceed directly against Lessee, any Guarantors or anyone else responsible for the performance of Lessee's obligations under this Lease, including any assignee or sublessee, without first exhausting Lessor's remedies against any other person or entity responsible therefore to Lessor, or any security held by Lessor.

 

(e)          Each request for consent to an assignment or subletting shall be in writing, accompanied by information relevant to Lessor's determination as to the financial and operational responsibility and appropriateness of the proposed assignee or sublessee, including but not limited to the intended use and/or required modification of the Premises, if any, together with a fee of $500 as consideration for Lessor's considering and processing said request. Lessee agrees to provide Lessor with such other or additional information and/or documentation as may be reasonably requested. (See also Paragraph 36)

 

(f)          Any assignee of, or sublessee under, this Lease shall, by reason of accepting such assignment, entering into such sublease, or entering into possession of the Premises or any portion thereof, be deemed to have assumed and agreed to conform and comply with each and every term, covenant, condition and obligation herein to be observed or performed by Lessee during the term of said assignment or sublease, other than such obligations as are contrary to or inconsistent with provisions of an assignment or sublease to which Lessor has specifically consented to in writing.

 

	
 

	
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(g) Lessor's consent to any assignment or subletting shall not transfer to the assignee or sublessee any Option granted to the original Lessee by this Lease unless such transfer is specifically consented to by Lessor in writing.; provided, however, "that the foregoing shall not apply to any permitted transfer, pursuant to Section 12.4 (See Paragraph 39.2)

 

12.3           Additional Terms and Conditions Applicable to Subletting. The following terms and conditions shall apply to any subletting by Lessee of all or any part of the Premises and shall be deemed included in all subleases under this Lease whether or not expressly incorporated therein:

 

(a)          Lessee hereby assigns and transfers to Lessor all of Lessee's interest in all Rent payable on any sublease, and Lessor may collect such Rent and apply same toward Lessee's obligations under this Lease; provided, however, that until a Breach shall occur in the performance of Lessee's obligations, Lessee may collect said Rent. In the event that the amount collected by Lessor exceeds Lessee's then outstanding obligations any such excess shall be refunded to Lessee. Lessor shall not, by reason of the foregoing or any assignment of such sublease, nor by reason of the collection of Rent, be deemed liable to the sublessee for any failure of Lessee to perform and comply with any of Lessee's obligations to such sublessee. Lessee hereby irrevocably authorizes and directs any such sublessee, upon receipt of a written notice from Lessor stating that a Breach exists in the performance of Lessee's obligations under this Lease, to pay to Lessor all Rent due and to become due under the sublease. Sublessee shall rely upon any such notice from Lessor and shall pay all Rents to Lessor without any obligation or right to inquire as to whether such Breach exists, notwithstanding any claim from Lessee to the contrary.

 

(b)         In the event of a Breach by Lessee, Lessor may, at its option, require sublessee to attorn to Lessor, in which event Lessor shall undertake the obligations of the sublessor under such sublease from the time of the exercise of said option to the expiration of such sublease; provided, however, Lessor shall not be liable for any prepaid rents or security deposit paid by such sublessee to such sublessor or for any prior Defaults or Breaches of such sublessor.

 

(c)          Any matter requiring the consent of the sublessor under a sublease shall also require the consent of Lessor.

 

(d)          No sublessee shall further assign or sublet all or any part of the Premises without Lessor's prior written consent.

 

(e)          Lessor shall deliver a copy of any notice of Default or Breach by Lessee to the sublessee, who shall have the right to cure the Default of Lessee within the grace period, if any, specified in such notice. The sublessee shall have a right of reimbursement and offset from and against Lessee for any such Defaults cured by the sublessee.

 

12.4            Notwithstanding anything to the contrary in this Article 12, Lessee shall have the right to assign this Lease or sublet all or a portion of the Premises, without the requirement of obtaining Lessor's consent, to entity (a) with which Lessee is merged or consolidated, (b) which acquires all or substantially all of Lessee's assets, or (c) which control, is controlled by or is under common control with Lessee (collectively "Permitted Transfers"); provided, however, that Lessee shall (i) prove written notice of any Permitted Transfer to Lessor within ten (10) business days after the effective date thereof, (ii) unless Lessee does not survive a merger transaction, remain primarily liable under this Lease; and (iii) upon Lessor's written request provide a copy of any assignment and assumption document to Lessor under which such transferee agrees to be bound by all the terms and conditions of this Lease.

 

13.               Default; Breach; Remedies.

 

13.1       Default; Breach. A "Default" is defined as a failure by the Lessee to comply with or perform any of the terms, covenants, conditions or Rules and Regulations under this Lease. A "Breach" is defined as the occurrence of one or more of the following Defaults, and the failure of Lessee to cure such Default within any applicable grace period:

 

(a)          The abandonment of the Premises; or the vacating of the Premises without providing a commercially reasonable level of security, or where the coverage of the property insurance described in Paragraph 8.3 is jeopardized as a result thereof, or without providing reasonable assurances to minimize potential vandalism.

 

(b)            The failure of Lessee to make any payment of Rent or any Security Deposit required to be made by Lessee hereunder, whether to Lessor or to a third party, when due, to provide reasonable evidence of insurance or surety bond, or to fulfill any obligation under this Lease which endangers or threatens life or property, where such failure continues for a period of 3 business days following written notice to Lessee. THE ACCEPTANCE BY LESSOR OF A PARTIAL PAYMENT OF RENT OR SECURITY DEPOSIT SHALL NOT CONSTITUTE A WAIVER OF ANY OF LESSOR'S RIGHTS, INCLUDING LESSOR'S RIGHT TO RECOVER POSSESSION OF THE PREMISES.

 

(c)          The failure-of Lessee to allow Lesser and/or its agents access to the Premises or the commission of waste, act or acts constituting public or private nuisance, and/or an illegal activity on the Premises by Lessee, where such actions continue for a period of 3 business days following written notice to Lessee.

 

(d)          The failure by Lessee to provide (i) reasonable written evidence of compliance with Applicable Requirements, (ii) the service contracts, (iii) the rescission of an unauthorized assignment or subletting, (iv) an Estoppel Certificate or financial statements, (v) a requested subordination, (vi) evidence concerning any guaranty and/or Guarantor, (vii) any document requested under Paragraph 41, (viii) material data safety sheets (MSDS), or (ix) any other documentation or information which Lessor may reasonably require of Lessee under the terms of this Lease, where any such failure continues for a period of 10 days following written notice to Lessee.

 

	
 

	
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(e)          A Default by Lessee as to the terms, covenants, conditions or provisions of this Lease, or of the rules adopted under Paragraph 2.9 hereof, other than those described in subparagraphs 13.1(a), (b), (c) or (d), above, where such Default continues for a period of 30 days after written notice; provided, however, that if the nature of Lessee's Default is such that more than 30 days are reasonably required for its cure, then it shall not be deemed to be a Breach if Lessee commences such cure within said 30 day period and thereafter diligently prosecutes such cure to completion.

 

(f)          The occurrence of any of the following events: (i) the making of any general arrangement or assignment for the benefit of creditors; (ii) becoming a "debtor" as defined in 11 U.S.C. § 101 or any successor statute thereto (unless, in the case of a petition filed against Lessee, the same is dismissed within 60 days); (iii) the appointment of a trustee or receiver to take possession of substantially all of Lessee's assets located at the Premises or of Lessee's interest in this Lease, where possession is not restored to Lessee within 30 days; or (iv) the attachment, execution or other judicial seizure of substantially all of Lessee's assets located at the Premises or of Lessee's interest in this Lease, where such seizure is not discharged within 30 days; provided, however, in the event that any provision of this subparagraph is contrary to any applicable law, such provision shall be of no force or effect, and not affect the validity of the remaining provisions.

 

(g)          The discovery that any financial statement of Lessee or of any Guarantor given to Lessor was materially false.

 

(h)          If the performance of Lessee's obligations under this Lease is guaranteed: (i) the death of a Guarantor, (ii) the termination of a Guarantor's liability with respect to this Lease other than in accordance with the terms of such guaranty, (iii) a Guarantor's becoming insolvent or the subject of a bankruptcy filing, (iv) a Guarantor's refusal to honor the guaranty, or (v) a Guarantor's breach of its guaranty obligation on an anticipatory basis, and Lessee's failure, within 60 days following written notice of any such event, to provide written alternative assurance or security, which, when coupled with the then existing resources of Lessee, equals or exceeds the combined financial resources of Lessee and the Guarantors that existed at the time of execution of this Lease.

 

13.2         Remedies. If Lessee fails to perform any of its affirmative duties or obligations, within 10 days after written notice (or in case of an emergency, without notice), Lessor may, at its option, perform such duty or obligation on Lessee's behalf, including but not limited to the obtaining of reasonably required bonds, insurance policies, or governmental licenses, permits or approvals. Lessee shall pay to Lessor an amount equal to 115% of the costs and expenses incurred by Lessor in such performance upon receipt of an invoice therefor. In the event of a Breach, Lessor may, with or without further notice or demand, and without limiting Lessor in the exercise of any right or remedy which Lessor may have by reason of such Breach:

 

(a)          Terminate Lessee's right to possession of the Premises by any lawful means, in which case this Lease shall terminate and Lessee shall immediately surrender possession to Lessor. In such event Lessor shall be entitled to recover from Lessee: (i) the unpaid Rent which had been earned at the time of termination; (ii) the worth at the time of award of the amount by which the unpaid rent which would have been earned after termination until the time of award exceeds the amount of such rental loss that the Lessee proves could have been reasonably avoided; (iii) the worth at the time of award of the amount by which the unpaid rent for the balance of the term after the time of award exceeds the amount of such rental loss that the Lessee proves could be reasonably avoided; and (iv) any other amount necessary to compensate Lessor for all the detriment proximately caused by the Lessee's failure to perform its obligations under this Lease or which in the ordinary course of things would be likely to result therefrom, including but not limited to the cost of recovering possession of the Premises, expenses of reletting, including necessary renovation and alteration of the Premises, reasonable attorneys' fees, and that portion of any leasing commission paid by Lessor in connection with this Lease applicable to the unexpired term of this Lease. The worth at the time of award of the amount referred to in provision (iii) of the immediately preceding sentence shall be computed by discounting such amount at the discount rate of the Federal Reserve Bank of the District within which the Premises are located at the time of award plus one percent. Efforts by Lessor to mitigate damages caused by Lessee's Breach of this Lease shall not waive Lessor's right to recover any damages to which Lessor is otherwise entitled. If termination of this Lease is obtained through the provisional remedy of unlawful detainer, Lessor shall have the right to recover in such proceeding any unpaid Rent and damages as are recoverable therein, or Lessor may reserve the right to recover all or any part thereof in a separate suit. If a notice and grace period required under Paragraph 13.1 was not previously given, a notice to pay rent or quit, or to perform or quit given to Lessee under the unlawful detainer statute shall also not constitute the notice required by Paragraph 13.1. In such case, the applicable grace period required by Paragraph 13.1 and the unlawful detainer statute shall run concurrently, and the failure of Lessee to cure the Default within the greater of the two such grace periods shall constitute both an unlawful detainer and a Breach of this Lease entitling Lessor to-the remedies provided for in this Lease and/or by said statute.

 

(b)          Continue the Lease and Lessee's right to possession and recover the Rent as it becomes due, in which event Lessee may sublet or assign, subject only to reasonable limitations. Acts of maintenance, efforts to relet, and/or the appointment of a receiver to protect the Lessor's interests, shall not constitute a termination of the Lessee's right to possession.

 

(c)          Pursue any other remedy now or hereafter available under the laws or judicial decisions of the state wherein the Premises are located. The expiration or termination of this Lease and/or the termination of Lessee's right to possession shall not relieve Lessee from liability under any indemnity provisions of this Lease as to matters occurring or accruing during the term hereof or by reason of Lessee's occupancy of the Premises.

 

	
 

	
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13.3       Inducement Recapture. Any agreement for free or abated rent or other charges, or for the giving or paying by Lessor to or for Lessee of any cash or other bonus, inducement or consideration for Lessee's entering into this Lease, all of which concessions are hereinafter referred to as "Inducement Provisions", shall be deemed condition upon Lessee's full and faithful performance of all of the terms, covenants and conditions of this Lease. Upon Breach of this Lease by Lease, any such Inducement Provision shall automatically be deemed from this Lease and of no further force or effect, and any rent, other charge, bonus, inducement or consideration therefore abated, given or paid by Lessor under such an Inducement Provision shall be immediately due and payable by Lessee to Lessor, notwithstanding any subsequent cure of said Breach by Lessee. The acceptance by Lessor of rent or the cure of the Breach which initiated the operation of this paragraph shall not be deemed a waiver by Lessor of the provisions of this paragraph unless specifically so stated in writing by Lessor at the time of such acceptance.

 

13.4           Late Charges. Lessee hereby acknowledges that late payment by Lessee of Rent will cause Lessor to incur costs not contemplated by this Lease, the exact amount of which will be extremely difficult to ascertain. Such costs include, but are not limited to, processing and accounting charges, and late charges which may be imposed upon Lessor by any Lender. Accordingly, if any Rent shall not be received by Lessor within 5 days after such amount shall be due, then, without any requirement for notice to Lessee, Lessee shall immediately pay to Lessor a one-time late charge equal to 10% of each such overdue amount or $100, whichever is greater. The parties hereby agree that such late charge represents a fair and reasonable estimate of the costs Lessor will incur by reason of such late payment. Acceptance of such late charge by Lessor shall in no event constitute a waiver of Lessee's Default or Breach with respect to such overdue amount, nor prevent the exercise of any of the other rights and remedies granted hereunder. In the event that a late charge is payable hereunder, whether or not collected, for 3 consecutive installments of Base Rent, then notwithstanding any provision of this Lease to the contrary, Base Rent shall, at Lessor's option, become due and payable quarterly in advance.

 

13.5          Interest. Any monetary payment due Lessor hereunder, other than late charges, not received by Lessor, when due as to scheduled payments (such as Base Rent) or within 30 days following the date on which it was due for non-scheduled payment, shall bear interest from the date when due, as to scheduled payments, or the 31st day after it was due as to non-scheduled payments. The interest ("Interest") charged shall be computed at the rate of 10% per annum but shall not exceed the maximum rate allowed by law. Interest is payable in addition to the potential late charge provided for in Paragraph 13.4.

 

13.6          Breach by Lessor.

 

(a)          Notice of Breach. Lessor shall not be deemed in breach of this Lease unless Lessor fails within a reasonable time to perform an obligation required to be performed by Lessor. For purposes of this Paragraph, a reasonable time shall in no event be less than 30 days after receipt by Lessor, and any Lender whose name and address shall have been furnished Lessee in writing for such purpose, of written notice specifying wherein such obligation of Lessor has not been performed; provided, however, that if the nature of Lessor's obligation is such that more than 30 days are reasonably required for its performance, then Lessor shall not be in breach if performance is commenced within such 30 day period and thereafter diligently pursued to completion.

 

(b)          Performance by Lessee on Behalf of Lessor. In the event that neither Lessor nor Lender cures said breach within 30 days after receipt of said notice, or if having commenced said cure they do not diligently pursue it to completion, then Lessee may elect to cure said breach at Lessee's expense and offset from Rent the actual and reasonable cost to perform such cure, provided however, that such offset shall not exceed an amount equal to the greater of one month's Base Rent or the Security Deposit, reserving Lessee's right to reimbursement from Lessor for any such expense in excess of such offset. Lessee shall document the cost of said cure and supply said documentation to Lessor.

 

14.               Condemnation. If the Premises or any portion thereof are taken under the power of eminent domain or sold under the threat of the exercise of said power (collectively "Condemnation"), this Lease shall terminate as to the part taken as of the date the condemning authority takes title or possession, whichever first occurs. If more than 10% of the floor area of the Unit, or more than 25% of the parking spaces is taken by Condemnation, Lessee may, at Lessee's option, to be exercised in writing within 10 days after Lessor shall have given Lessee written notice of such taking (or in the absence of such notice, within 10 days after the condemning authority shall have taken possession) terminate this Lease as of the date the condemning authority takes such possession. If Lessee does not terminate this Lease in accordance with the foregoing, this Lease shall remain in full force and effect as to the portion of the Premises remaining, except that the Base Rent shall be reduced in proportion to the reduction in utility of the Premises caused by such Condemnation. Condemnation awards and/or payments shall be the property of Lessor, whether such award shall be made as compensation for diminution in value of the leasehold, the value of the part taken, or for severance damages; provided, however, that Lessee shall be entitled to any compensation paid by the condemnor for Lessee's relocation expenses, loss of business goodwill and/or Trade Fixtures, without regard to whether or not this Lease is terminated pursuant to the provisions of this Paragraph. All Alterations and Utility Installations made to the Premises by Lessee, for purposes of Condemnation only, shall be considered the property of the Lessee and Lessee shall be entitled to any and all compensation which is payable therefor. In the event that this Lease is not terminated by reason of the Condemnation, Lessor shall repair any damage to the Premises caused by such Condemnation.

 

15.              Brokerage Fees.

 

15.1          Additional Commission. In addition to the payments owed pursuant to Paragraph 1.10 above, and unless Lessor and the Brokers otherwise agree in writing, Lessor agrees that: (a) if Lessee exercises any Option, (b) if Lessee or anyone affiliated with Lessee acquires from Lessor any rights to the Premises or other premises owned by Lessor and located within the Project, (c) if Lessee remains in possession of the Premises, with the consent of Lessor, after the expiration of this Lease, or (d) if Base Rent is increased, whether by agreement or operation of an escalation clause herein, then, Lessor shall pay Brokers a fee in accordance with the fee schedule of the Brokers in effect at the time the Lease was executed.

 

15.2          Assumption of Obligations. Any buyer or transferee of Lessor's interest in this Lease shall be deemed to have assumed Lessor's obligation hereunder. Brokers shall be third party beneficiaries of the provisions of Paragraphs 1.10, 15, 22 and 31. If Lessor fails to pay to Brokers any amounts due as and for brokerage fees pertaining to this Lease when due, then such amounts shall accrue Interest. In addition, if Lessor fails to pay any amounts to Lessee's Broker when due, Lessee's Broker may send written notice to Lessor and Lessee of such failure and if Lessor fails to pay such amounts within 10 days after said notice, Lessee shall pay said monies to its Broker and offset such amounts against Rent. In addition, Lessee's Broker shall be deemed to be a third party beneficiary of any commission agreement entered into by and/or between Lessor and Lessor's Broker for the limited purpose of collecting any brokerage fee owed.

 

	
 

	
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15.3       Representations and Indemnities of Broker Relationships. Lessee and Lessor each represent and warrant to the other that it has had no dealings with any person, firm, broker or finder (other than the Brokers, if any) in connection with this Lease, and that no one other than said named Brokers is entitled to any commission or finder's fee in connection herewith. Lessee and Lessor do each hereby agree to indemnify, protect, defend and hold the other harmless from and against liability for compensation or charges which may be claimed by any such unnamed broker, finder or other similar party by reason of any dealings or actions of the indemnifying Party, including any costs, expenses, attorneys' fees reasonably incurred with respect thereto. 16. Estoppel Certificates.

 

(a)          Each Party (as "Responding Party") shall within 10 days after written notice from the other Party (the "Requesting Party") execute, acknowledge and deliver to the Requesting Party a statement in writing in form similar to the then most current "Estoppel Certificate" form published by the AIR Commercial Real Estate Association, plus such additional information, confirmation and/or statements as may be reasonably requested by the Requesting Party.

 

(b)          If the Responding Party shall fail to execute or deliver the Estoppel Certificate within such 10 day period, the Requesting Party may execute an Estoppel Certificate stating that: (i) the Lease is in full force and effect without modification except as may be represented by the Requesting Party, (ii) there are no uncured defaults in the Requesting Party's performance, and (iii) if Lessor is the Requesting Party, not more than one month's rent has been paid in advance. Prospective purchasers and encumbrancers may rely upon the Requesting Party's Estoppel Certificate, and the Responding Party shall be estopped from denying the truth of the facts contained in said Certificate. In addition, Lessee acknowledges that any failure on its part to provide such an Estoppel Certificate will expose Lessor to risks and potentially cause Lessor to incur costs not contemplated by this Lease, the extent of which will be extremely difficult to ascertain. Accordingly, should the Lessee fail to execute and/or deliver a requested Estoppel Certificate in a timely fashion the monthly Base Rent shall be automatically increased, without any requirement for notice to Lessee, by an amount equal to 10% of the then existing Base Rent or $100, whichever is greater for remainder of the Lease. The Parties agree that such increase in Base Rent represents fair and reasonable compensation for the additional risk/costs that Lessor will incur by reason of Lesse's failure to provide the Estoppel Certificate. Such increase in Base Rent shall in no event constitute a waiver of Lessee's Default or Breach with respect to the failure to provide the Estoppel Certificate nor prevent the exercise of any of the other rights and remedies granted hereunder.

 

(c) If Lessor desires to finance, refinance, or sell the Premises, or any part thereof, Lessee and all Guarantors shall within 10 days after written notice from Lessor deliver to any potential lender or purchaser designated by Lessor such financial statements as may be reasonably required by such lender or purchaser, including but not limited to Lessee's financial statements for the past 3 years. All such financial statements shall be received by Lessor and such lender or purchaser in confidence and shall be used only for the purposes herein set forth.

 

17.               Definition of Lessor. The term "Lessor" as used herein shall mean the owner or owners at the time in question of the fee title to the Premises, or, if this is a sublease, of the Lessee's interest in the prior lease. In the event of a transfer of Lessor's title or interest in the Premises or this Lease, Lessor shall deliver to the transferee or assignee (in cash or by credit) any unused Security Deposit held by Lessor. Upon such transfer or assignment and delivery of the Security Deposit, as aforesaid, the prior Lessor shall be relieved of all liability with respect to the obligations and/or covenants under this Lease thereafter to be performed by the Lessor. Subject to the foregoing, the obligations and/or covenants in this Lease to be performed by the Lessor shall be binding only upon the Lessor as hereinabove defined.

 

18.               Severability. The invalidity of any provision of this Lease, as determined by a court of competent jurisdiction, shall in no way affect the validity of any other provision hereof.

 

19.                Days. Unless otherwise specifically indicated to the contrary, the word "days" as used in this Lease shall mean and refer to calendar days.

 

20.               Limitation on Liability. The obligations of Lessor under this Lease shall not constitute personal obligations of Lessor, or its partners, members, directors, officers or shareholders, and Lessee shall look to the Premises, and to no other assets of Lessor, for the satisfaction of any liability of Lessor with respect to this Lease, and shall not seek recourse against Lessor's partners, members, directors, officers or shareholders, or any of their personal assets for such satisfaction.

 

21.                Time of Essence. Time is of the essence with respect to the performance of all obligations to be performed or observed by the Parties under this Lease.

 

22.                No Prior or Other Agreements; Broker Disclaimer. This Lease contains all agreements between the Parties with respect to any matter mentioned herein, and no other prior or contemporaneous agreement or understanding shall be effective. Lessor and Lessee each represents and warrants to the Brokers that it has made, and is relying solely upon, its own investigation as to the nature, quality, character and financial responsibility of the other Party to this Lease and as to the use, nature, quality and character of the Premises. Brokers have no responsibility with respect thereto or with respect to any default or breach hereof by either Party.

 

23.               Notices.

 

23.1  Notice Requirements. All notices required or permitted by this Lease or applicable law shall be in writing and may be delivered in person (by hand or by courier) or may be sent by regular, certified or registered mail or U.S. Postal Service Express Mail, with postage prepaid, or by facsimile transmission, and shall be deemed sufficiently given if served in a manner specified in this Paragraph 23. The addresses noted adjacent to a Party's signature on this Lease shall be that Party's address for delivery or mailing of notices. Either Party may by written notice to the other specify a different address for notice, except that upon Lessee's taking possession of the Premises, the Premises shall constitute Lessee's address for notice. A copy of all notices to Lessor shall be concurrently transmitted to such party or parties at such addresses as Lessor may from time to time hereafter designate in writing.

 

	
 

	
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23.2  Date of Notice. Any notice sent by registered or certified mail, return receipt requested, shall be deemed given on the date of delivery shown on the receipt card, or if no delivery date is shown, the postmark thereon. If sent by regular mail the notice shall be deemed given 72 hours after the same is addressed as required herein and mailed with postage prepaid. Notices delivered by United States Express Mail or overnight courier that guarantees next day delivery shall be deemed given 24 hours after delivery of the same to the Postal Service or courier. Notices transmitted by facsimile transmission or similar means shall be deemed delivered upon telephone confirmation of receipt (confirmation report from fax machine is sufficient), provided a copy is also delivered via delivery or mail. If notice is received on a Saturday, Sunday or legal holiday, it shall be deemed received on the next business day.

 

24.               Waivers.

 

(a)                No waiver by Lessor of the Default or Breach of any term, covenant or condition hereof by Lessee, shall be deemed a waiver of any other term, covenant or condition hereof, or of any subsequent Default or Breach by Lessee of the same or of any other term, covenant or condition hereof. Lessor's consent to, or approval of, any act shall not be deemed to render unnecessary the obtaining of Lessor's consent to, or approval of, any subsequent or similar act by Lessee, or be construed as the basis of an estoppel to enforce the provision or provisions of this Lease requiring such consent.

 

(b)              The acceptance of Rent by Lessor shall not be a waiver of any Default or Breach by Lessee. Any payment by Lessee may be accepted by Lessor on account of moneys or damages due Lessor, notwithstanding any qualifying statements or conditions made by Lessee in connection therewith, which such statements and/or conditions shall be of no force or effect whatsoever unless specifically agreed to in writing by Lessor at or before the time of deposit of such payment.

 

(c)               THE PARTIES AGREE THAT THE TERMS OF THIS LEASE SHALL GOVERN WITH REGARD TO ALL MATTERS RELATED THERETO AND HEREBY WAIVE THE PROVISIONS OF ANY PRESENT OR FUTURE STATUTE TO THE EXTENT THAT SUCH STATUTE IS INCONSISTENT WITH THIS LEASE.

 

25.               Disclosures Regarding The Nature of a Real Estate Agency Relationship.

 

(a)                When entering into a discussion with a real estate agent regarding a real estate transaction, a Lessor or Lessee should from the outset understand what type of agency relationship or representation it has with the agent or agents in the transaction. Lessor and Lessee acknowledge being advised by the Brokers in this transaction, as follows:

 

(i)          Lessor's Agent. A Lessor's agent under a listing agreement with the Lessor acts as the agent for the Lessor only. A Lessor's agent or subagent has the following affirmative obligations: To the Lessor: A fiduciary duty of utmost care, integrity, honesty, and loyalty in dealings with the Lessor. To the Lessee and the Lessor: (a) Diligent exercise of reasonable skills and care in performance of the agent's duties, (b) A duty of honest and fair dealing and good faith, (c) A duty to disclose all facts known to the agent materially affecting the value or desirability of the property that are not known to, or within the diligent attention and observation of, the Parties. An agent is not obligated to reveal to either Party any confidential information obtained from the other Party which does not involve the affirmative duties set forth above.

 

(ii)          Lessee's Agent. An agent can agree to act as agent for the Lessee only. In these situations, the agent is not the Lessor's agent, even if by agreement the agent may receive compensation for services rendered, either in full or in part from the Lessor. An agent acting only for a Lessee has the following affirmative obligations. To the Lessee: A fiduciary duty of utmost care, integrity, honesty, and loyalty in dealings with the Lessee. To the Lessee and the Lessor: (a) Diligent exercise of reasonable skills and care in performance of the agent's duties, (b) A duty of honest and fair dealing and good faith, (c) A duty to disclose all facts known to the agent materially affecting the value or desirability of the property that are not known to, or within the diligent attention and observation of, the Parties. An agent is not obligated to reveal to either Party any confidential information obtained from the other Party which does not involve the affirmative duties set forth above.

 

(iii)        Agent Representing Both Lessor and Lessee. A real estate agent, either acting directly or through one or more associate licenses, can legally be the agent of both the Lessor and the Lessee in a transaction, but only with the knowledge and consent of both the Lessor and the Lessee. In a dual agency situation, the agent has the following affirmative obligations to both the Lessor and the Lessee: (a) A fiduciary duty of utmost care, integrity, honesty and loyalty in the dealings with either Lessor or the Lessee, (b) Other duties to the Lessor and the Lessee as stated above in subparagraphs (i) or (ii). In representing both Lessor and Lessee, the agent may not without the express permission of the respective Party, disclose to the other Party that the Lessor will accept rent in an amount less than that indicated in the listing or that the Lessee is willing to pay a higher rent than that offered. The above duties of the agent in a real estate transaction do not relieve a Lessor or Lessee from the responsibility to protect their own interests. Lessor and Lessee should carefully read all agreements to assure that they adequately express their understanding of the transaction. A real estate agent is a person qualified to advise about real estate. If legal or tax advice is desired, consult a competent professional.

 

(b)                Brokers have no responsibility with respect to any Default or Breach hereof by either Party. The Parties agree that no lawsuit or other legal proceeding involving any breach of duty, error or omission relating to this Lease may be brought against Broker more than one year after the Start Date and that the liability (including court costs and attorneys' fees), of any Broker with respect to any such lawsuit and/or legal proceeding shall not exceed the fee received by such Broker pursuant to this Lease; provided, however, that the foregoing limitation on each Broker's liability shall not be applicable to any gross negligence or willful misconduct of such Broker.

 

	
 

	
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(c)                Lessor and Lessee agree to identify to Brokers as "Confidential" any communication or information given Brokers that is considered by such Party to be confidential.

 

26.                No Right To Holdover. Lessee has no right to retain possession of the Premises or any part thereof beyond the expiration or termination of this Lease. In the event that Lessee holds over, then the Base Rent shall be increased to 150% of the Base Rent applicable immediately preceding the expiration or termination. Nothing contained herein shall be construed as consent by Lessor to any holding over by Lessee.

 

27.                Cumulative Remedies. No remedy or election hereunder shall be deemed exclusive but shall, wherever possible, be cumulative with all other remedies at law or in equity.

 

28.                Covenants and Conditions; Construction of Agreement. All provisions of this Lease to be observed or performed by Lessee are both covenants and conditions. In construing this Lease, all headings and titles are for the convenience of the Parties only and shall not be considered a part of this Lease. Whenever required by the context, the singular shall include the plural and vice versa. This Lease shall not be construed as if prepared by one of the Parties, but rather according to its fair meaning as a whole, as if both Parties had prepared it.

 

29.               Binding Effect; Choice of Law. This Lease shall be binding upon the parties, their personal representatives, successors and assigns and be governed by the laws of the State in which the Premises are located. Any litigation between the Parties hereto concerning this Lease shall be initiated in the county in which the Premises are located.

 

30.               Subordination; Attornment; Non-Disturbance.

 

30.1             Subordination. This Lease and any Option granted hereby shall be subject and subordinate to any ground lease, mortgage, deed of trust, or other hypothecation or security device (collectively, "Security Device"), now or hereafter placed upon the Premises, to any and all advances made on the security thereof, and to all renewals, modifications, and extensions thereof. Lessee agrees that the holders of any such Security Devices (in this Lease together referred to as "Lender") shall have no liability or obligation to perform any of the obligations of Lessor under this Lease. Any Lender may elect to have this Lease and/or any Option granted hereby superior to the lien of its Security Device by giving written notice thereof to Lessee, whereupon this Lease and such Options shall be deemed prior to such Security Device, notwithstanding the relative dates of the documentation or recordation thereof.

 

30.2            Attornment. In the event that Lessor transfers title to the Premises, or the Premises are acquired by another upon the foreclosure or termination of a Security Devise to which this Lease is subordinated (i) Lessee shall, subject to the non-disturbance provisions of Paragraph 30.3, attorn to such new owner, and upon request, enter into a new lease, containing all of the terms and provisions of this Lease, with such new owner for the remainder of the term hereof, or, at the election of the new owner, this Lease will automatically become a new lease between Lessee and such new owner, and (ii) Lessor shall thereafter be relieved of any further obligations hereunder and such new owner shall assume all of Lessor's obligations, except that such new owner shall not: (a) be liable for any act or omission of any prior lessor or with respect to events occurring prior to acquisition of ownership; (b) be subject to any offsets or defenses which Lessee might have against any prior lessor, (c) be bound by prepayment of more than one month's rent, or (d) be liable for the return of any security deposit paid to any prior lessor which was not paid or credited to such new owner.

 

30.3            Non-Disturbance. With respect to Security Devices entered into by Lessor after the execution of this Lease, Lessee's subordination of this Lease shall be subject to receiving a commercially reasonable non-disturbance agreement (a "Non-Disturbance Agreement") from the Lender which Non-Disturbance Agreement provides that Lessee's possession of the Premises, and this Lease, including any options to extend the term hereof, will not be disturbed so long as Lessee is not in Breach hereof and attorns to the record owner of the Premises. Further, within 60 days after the execution of this Lease, Lessor shall, if requested by Lessee, use its commercially reasonable efforts to obtain a Non-Disturbance Agreement from the holder of any pre-existing Security Device which is secured by the Premises. In the event that Lessor is unable to provide the Non-Disturbance Agreement within said 60 days, then Lessee may, at Lessee's option, directly contact Lender and attempt to negotiate for the execution and delivery of a Non-Disturbance Agreement.

 

30.4            Self-Executing. The agreements contained in this Paragraph 30 shall be effective without the execution of any further documents; provided, however, that, upon written request from Lessor or a Lender in connection with a sale, financing or refinancing of the Premises, Lessee and Lessor shall execute such further writings as may be reasonably required to separately document any subordination, attornment and/or Non-Disturbance Agreement provided for herein.

 

31.               Attorneys' Fees. If any Party or Broker brings an action or proceeding involving the Premises whether founded in tort, contract or equity, or to declare rights hereunder, the Prevailing Party (as hereafter defined) in any such proceeding, action, or appeal thereon, shall be entitled to reasonable attorneys' fees. Such fees may be awarded in the same suit or recovered in a separate suit, whether or not such action or proceeding is pursued to decision or judgment. The term, "Prevailing Party" shall include, without limitation, a Party or Broker who substantially obtains or defeats the relief sought, as the case may be, whether by compromise, settlement, judgment, or the abandonment by the other Party or Broker of its claim or defense. The attorneys' fees award shall not be computed in accordance with any court fee schedule, but shall be such as to fully reimburse all attorneys' fees reasonably incurred. In addition, Lessor shall be entitled to attorneys' fees, costs and expenses incurred in the preparation and service of notices of Default and consultations in connection therewith, whether or not a legal action is subsequently commenced in connection with such Default or resulting Breach ($200 is a reasonable minimum per occurrence for such services and consultation).

 

	
 

	
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32.               Lessor's Access; Showing Premises; Repairs. Lessor and Lessor's agents shall have the right to enter the Premises at any time, in the case of an emergency, and otherwise at reasonable times after reasonable prior notice for the purpose of showing the same to prospective purchasers, lenders, or tenants, and making such alterations, repairs, improvements or additions to the Premises as Lessor may deem necessary or desirable and the erecting, using and maintaining of utilities, services, pipes and conduits through the Premises and/or other premises as long as there is no material adverse effect on Lessee's use of the Premises. All such activities shall be without abatement of rent or liability to Lessee.

 

33.               Auctions. Lessee shall not conduct, nor permit to be conducted, any auction upon the Premises without Lessor's prior written consent. Lessor shall not be obligated to exercise any standard of reasonableness in determining whether to permit an auction.

 

34.                Signs. Lessor may place on the Premises ordinary "For Sale" signs at any time and ordinary "For Lease" signs during the last 6 months of the term hereof. Except for ordinary "For Sublease" signs which may be placed only on the Premises, Lessee shall not place any sign upon the Project without Lessor's prior written consent. All signs must comply with all Applicable Requirements.

 

35.               Termination; Merger. Unless specifically stated otherwise in writing by Lessor, the voluntary or other surrender of this Lease by Lessee, the mutual termination or cancellation hereof, or a termination hereof by Lessor for Breach by Lessee, shall automatically terminate any sublease or lesser estate in the Premises; provided, however, that Lessor may elect to continue any one or all existing subtenancies. Lessor's failure within 10 days following any such event to elect to the contrary by written notice to the holder of any such lesser interest, shall constitute Lessor's election to have such event constitute the termination of such interest.

 

36.               Consents. Except as otherwise provided herein, wherever in this Lease the consent of a Party is required to an act by or for the other Party, such consent shall not be unreasonably withheld or delayed. Lessor's actual reasonable costs and expenses (including but not limited to architects', attorneys', engineers' and other consultants' fees) incurred in the consideration of, or response to, a request by Lessee for any Lessor consent, including but not limited to consents to an assignment, a subletting or the presence or use of a Hazardous Substance, shall be paid by Lessee upon receipt of an invoice and supporting documentation therefor. Lessor's consent to any act, assignment or subletting shall not constitute an acknowledgment that no Default or Breach by Lessee of this Lease exists, nor shall such consent be deemed a waiver of any then existing Default or Breach, except as may be otherwise specifically stated in writing by Lessor at the time of such consent. The failure to specify herein any particular condition to Lessor's consent shall not preclude the imposition by Lessor at the time of consent of such further or other conditions as are then reasonable with reference to the particular matter for which consent is being given. In the event that either Party disagrees with any determination made by the other hereunder and reasonably requests the reasons for such determination, the determining party shall furnish its reasons in writing and in reasonable detail within 10 business days following such request.

 

37.               Guarantor.

 

37.1          Execution. The Guarantors, if any, shall each execute a guaranty in the form most recently published by the AIR Commercial Real Estate Association.

 

37.2          Default. It shall constitute a Default of the Lessee if any Guarantor fails or refuses, upon request to provide: (a) evidence of the execution of the guaranty, including the authority of the party signing on Guarantor's behalf to obligate Guarantor, and in the case of a corporate Guarantor, a certified copy of a resolution of its board of directors authorizing the making of such guaranty, (b) current financial statements, (c) an Estoppel Certificate, or (d) written confirmation that the guaranty is still in effect.

 

38.               Quiet Possession. Subject to payment by Lessee of the Rent and performance of all of the covenants, conditions and provisions on Lessee's part to be observed and performed under this Lease, Lessee shall have quiet possession and quiet enjoyment of the Premises during the term hereof.

 

39.                Options. If Lessee is granted any option, as defined below, then the following provisions shall apply.

 

39.1          Definition. "Option" shall mean: (a) the right to extend or reduce the term of or renew this Lease or to extend or reduce the term of or renew any lease that Lessee has on other property of Lessor; (b) the right of first refusal or first offer to lease either the Premises or other property of Lessor; (c) the right to purchase, the right of first offer to purchase or the right of first refusal to purchase the Premises or other property of Lessor.

 

39.2          Options Personal To Original Lessee. Any Option granted to Lessee in this Lease is personal to the original Lessee and Lessor, and any transferee under a permitted transfer, pursuant to section 12.4, and cannot be assigned or exercised by anyone other than said original Lessee, and only while the original Lessee is in full possession of the Promises and, if requested by Lessor with Lessee certifying that Lessee has no intention of thereafter assigning or subletting.

 

39.3          Multiple Options. In the event that Lessee has any multiple Options to extend or renew this Lease, a later Option cannot be exercised unless the prior Options have been validly exercised.

 

39.4           Effect of Default on Options.

 

(a)          Lessee shall have no right to exercise an Option: (i) during the period commencing with the giving of any notice of Default and continuing until said Breach or Default is cured, or (ii) during the period of time any Rent is unpaid (without regard to whether notice thereof is given Lessee), (iii) during the time Lessee is in Breach of this Lease, or  (iv) in the event that Lessee has been given 3 or more notices of separate Default, whether or not the Default are cured, during the 12 month period immediately preceding the exercise of the option.

 

(b)         The period of time within which an Option may be exercised shall not be extended or enlarged by reason of Lessee's inability to exercise an Option because of the provisions of Paragraph 39.4(a).

 

	
 

	
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(c)       An Option shall terminate and be of no further force or effect, notwithstanding Lessee's due and timely exercise of the Option, if, after such exercise and prior to the commencement of the extended term or completion of the purchase, (i) Lessee fails to pay Rent for a period of 30 days after such Rent becomes due (without any necessity of Lessor to give notice thereof),or (ii) if Lessee commits a Breach of this Lease.

 

40.                Security Measures. Lessee hereby acknowledges that the Rent payable to Lessor hereunder does not include the cost of guard service or other security measures, and that Lessor shall have no obligation whatsoever to provide same. Lessee assumes all responsibility for the protection of the Premises, Lessee, its agents and invitees and their property from the acts of third parties.

 

41.                Reservations. Lessor reserves the right: (i) to grant, without the consent or joinder of Lessee, such easements, rights and dedications that Lessor deems necessary, (ii) to cause the recordation of parcel maps and restrictions, and (iii) to create and/or install new utility raceways, so long as such easements, rights, dedications, maps, restrictions, and utility raceways do not unreasonably interfere with the use of the Premises by Lessee. Lessee agrees to sign any documents reasonably requested by Lessor to effectuate such rights.

 

42.                Performance Under Protest. . If at any time a dispute shall arise as to any amount or sum of money to be paid by one Party to the other under the provisions hereof, the Party against whom the obligation to pay the money is asserted shall have the right to make payment "under protest" and such payment shall not be regarded as a voluntary payment and there shall survive the right on the part of said Party to institute suit for recovery of such sum. If it shall be adjudged that there was no legal obligation on the part of said Party to pay such sum or any part thereof, said Party shall be entitled to recover such sum or so much thereof as it was not legally required to pay. A Party who does not initiate suit for the recovery of sums paid "under protest" within 6 months shall be deemed to have waived its right to protest such payment.

 

43.               Authority; Multiple Parties; Execution.

 

(a)        If either Party hereto is a corporation, trust, limited liability company, partnership, or similar entity, such entity represents and warrants that each individual executing this Lease on behalf of such entity represents and warrants that he or she is duly authorized to execute and deliver this Lease on its behalf. Each Party shall, within 30 days after request, deliver to the other Party satisfactory evidence of such authority.

 

(b)       If this Lease is executed by more than one person or entity as "Lessee", each such person or entity shall be jointly and severally liable hereunder. It is agreed that any one of the named Lessees shall be empowered to execute any amendment to this Lease, or other document ancillary thereto and bind all of the named Lessees, and Lessor may rely on the same as if all of the named Lessees had executed such document.

 

(c)       This Lease may be executed by the Parties in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

 

44.              Conflict. Any conflict between the printed provisions of this Lease and the typewritten or handwritten provisions shall be controlled by the typewritten or handwritten provisions.

 

45.               Offer. Preparation of this Lease by either party or their agent and submission of same to the other Party shall not be deemed an offer to lease to the other Party. This Lease is not intended to be binding until executed and delivered by all Parties hereto.

 

46.               Amendments. This Lease may be modified only in writing, signed by the Parties in interest at the time of the modification. As long as they do not materially change Lessee's obligations hereunder, Lessee agrees to make such reasonable non-monetary modifications to this Lease as may be reasonably required by a Lender in connection with the obtaining of normal financing or refinancing of the Premises.

 

47.              Waiver of Jury Trial. THE PARTIES HEREBY WAIVE THEIR RESPECTIVE RIGHTS TO TRIAL BY JURY IN ANY ACTION OR PROCEEDING INVOLVING THE PROPERTY OR ARISING OUT OF THIS AGREEMENT.

 

48.               Arbitration of Disputes. An Addendum requiring the Arbitration of all disputes between the Parties and/or Brokers arising out of this Lease o is ü is not attached to this Lease.

 

49.               Americans with Disabilities Act. Since compliance with the Americans with Disabilities Act (ADA) is dependent upon Lessee's specific use of the Premises, Lessor makes no warranty or representation as to whether or not the Premises comply with ADA or any similar legislation. In the event that Lessee's specific use of the Premises requires modifications or additions to the Premises in order to be in ADA compliance, Lessee agrees to make any such necessary modifications and/or additions at Lessee's expense.

 

50A.       Renewal Options. One (1) two (2) year option to renew. The base rent for the option term shall be $0.70 per foot per month for the 20,767 square feet and shall increase by 4% annually starting with the second year of the extension term. Tenant my elect to relinquish the storage space "SP1" and lease only 15,923 square feet. The option may only be exercised by Lessee providing Lessor with irrevocable written notice not less than one hundred and fifty (150) days and not more than one hundred and eighty (180) days prior to expiration.

 

51.           Restrooms/Common Areas. Lessee shall be responsible to maintain, at its sole cost, any common areas or restrooms used AXT, until such time as any portion of the remaining vacant space is re-leased.

 

	
 

	
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52.           Annual Increase. I3ase Rent shall increase to $11,035 per month starting with 13th month of Lease.

 

53A.       Termination Agreement. Lessor and Lessee acknowledge that Lessee is in possession of the premises pursuant to the existing lease dated June 26, 200& and Lessee has duly exercised its Termination Agreement pursuant to article 53 of said lease and this lease shall supersede and replace the existing lease effective December 1, 2013.

 

54.                Parking and Signage. Lessee may maintain their current signage. There are +/-200 parking spaces for the entire building. Lessee's allotment of 60 parking spaces is based on Lessee's prorata percentage share of occupancy of the entire building. Lessee may use available, additional parking for its employees and guests; however, Lessor shall have the right to restrict and reserve parking spaces to accommodate new tenant(s) based on their prorata share of occupancy. All parking shall be subject to all applicable governmental rules and regulations.

 

55.               Tenant Improvements. Lessor shall provide Lessee with a not to exceed $12,000 tenant improvement allowance to be used by Lessee at its reasonable discretion to repair sinks, clean floors and carpets, wash windows, repair air conditioning and other reasonable improvements. Such allowance shall be paid to Lessee within 30 days of Lessee's request. Lessee accepts the space in AS-IS condition and is all ready occupying the space pursuant to existing lease. Lessor shall give a minimum of 90 days prior to any new tenant renovations and work closely with tenant to minimize tenant disruptions. Lessor shall have no obligation to demise the relinquished space or construct any wall or any other construction to relinquished space until Lessor leases said space.

 

LESSOR AND LESSEE HAVE CAREFULLY READ AND REVIEWED THIS LEASE AND EACH TERM AND PROVISION CONTAINED HEREIN, AND BY THE EXECUTION OF THIS LEASE SHOW THEIR INFORMED AND VOLUNTARY CONSENT THERETO. THE PARTIES HEREBY AGREE THAT, AT THE TIME THIS LEASE IS EXECUTED, THE TERMS OF THIS LEASE ARE COMMERCIALLY REASONABLE AND EFFECTUATE THE INTENT AND PURPOSE OF LESSOR AND LESSEE WITH RESPECT TO THE PREMISES.

 

ATTENTION: NO REPRESENTATION OR RECOMMENDATION IS MADE BY THE AIR COMMERCIAL REAL ESTATE ASSOCIATION OR BY ANY BROKER AS TO THE LEGAL SUFFICIENCY, LEGAL EFFECT, OR TAX CONSEQUENCES OF THIS LEASE OR THE TRANSACTION TO WHICH IT RELATES. THE PARTIES ARE URGED TO:

 

1.                   SEEK ADVICE OF COUNSEL AS TO THE LEGAL AND TAX CONSEQUENCES OF THIS LEASE.

 

2.                   RETAIN APPROPRIATE CONSULTANTS TO REVIEW AND INVESTIGATE THE CONDITION OF THE PREMISES. SAID INVESTIGATION SHOULD INCLUDE BUT NOT BE LIMITED TO: THE POSSIBLE PRESENCE OF HAZARDOUS SUBSTANCES, THE ZONING OF THE PREMISES, THE STRUCTURAL INTEGRITY, THE CONDITION OF THE ROOF AND OPERATING SYSTEMS, COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT AND THE SUITABILITY OF THE PREMISES FOR LESSEE'S INTENDED USE.

 

WARNING: IF THE PREMISES ARE LOCATED IN A STATE OTHER THAN CALIFORNIA, CERTAIN PROVISIONS OF THE LEASE MAY NEED TO BE REVISED TO COMPLY WITH THE LAWS OF THE STATE IN WHICH THE PREMISES ARE LOCATED.

The parties hereto have executed this Lease at the place and on the dates specified above their respective signatures.

 

	
Executed at:

	 	
 

	
Executed at:

	 
	On:	 	
 

	
On:

	 
	
By LESSOR:

	 	
 

	
By LESSEE:

	 
	  	 		 	 
	  	 		 	 

 

	By:	  		By:	  
	Name Printed:	  		Name Printed:	 
	Title:	  		Title:	 

 

	By:	  		By:	  
	Name Printed:	  		Name Printed:	  
	Title:	  		Title:	  
	
Address:

	   		
Address:

	  
	   	  		 	   
	   	  		  	  

 

	
 

	
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©1999 - AIR COMMERCIAL REAL ESTATE; ASSOCIATION

	
Telephone(___)

	
 

	
 

	
Telephone(___)

	 
	
Facsimile:(___)

	
 

	
 

	
Facsimile:(___)

	 
	
Email:

	
 

	
 

	
Email:

	 
	Email:	 		
Email:

	 
	
Federal ID No.

	 		
Federal ID No.

	 
	
BROKER:

	 		
BROKER:

	 
	  	  		 	 
	  	 		 	 

 

	Attn:	 		Attn:	 
	Title:	 		Title:	 
	Address:	 		Address:	 
	  	 		 	 

 

	
Telephone(___)

	
 

	
 

	
Telephone(___)

	 
	
Facsimile:(___)

	
 

	
 

	
Facsimile:(___)

	 
	
Email:

	
 

	
 

	
Email:

	 
	Email:	 		
Email:

	 
	
Federal ID No.

	 		
Federal ID No.

	 

	
Broker/Agent DRE License #:

	 		
Broker/Agent DRE License #:

	 
	  	 		 	 
	  	 		 	 

NOTICE: These forms are often modified to meet changing requirements of law and industry needs. Always write or call to make sure you are utilizing the most current form: AIR Commercial Real Estate Association, 800 W 6th Street, Suite 800, Los Angeles, CA 90017. Telephone No. (213) 687-8777. Fax No.: (213) 687-8616.

 

©Copyright 1999 By AIR Commercial Real Estate Association. 

All rights reserved. No part of these works may be reproduced in any form without permission in writing.

 

	
 

	
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EXHIBIT E

 

Common Area Operating Expense Exclusions As used in the Lease, the term "Common Area Operating Expenses" shall not include the following:

 

	1.	marketing costs, costs of leasing commissions, renovations, attorneys' fees and other costs and expenses incurred in connection with negotiations, disputes or litigation with present or prospective tenants or other occupants of the Project;

 

	2.	any expense to the extent resulting from the gross negligence or willful misconduct of Lessor, its agents, contractors or employees;.

 

	3.	interest, principal,- points and fees on debts or amortization on any mortgage or mortgages or any other debt instrument encumbering the Project;

 

	4.	the original costs of constructing the Project and depreciation of any such expenses;

 

	5.	expenses to the extent Lessor is reimbursed by another source, including without limitation replacement of any items covered by warranties;

 

	6.	expenses for the defense of Lessor's title to the Project;

 

	7.	charitable or political contributions;

 

	8.	costs to correct any latent defects in the design, construction or equipment of the Building;

 

	9.	any expenses incurred in repair, restoration or other work necessitated by fire or other casualty, save and except deductibles to the extent expressly permitted in the Lease; and

 

	10.	rental on ground leases or other underlying leases.

 

	 	   
	
 

	
Initialsex10_1.htm

Exhibit 10.1

 

CONTRACT BETWEEN

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

and

TRIPLE-S SALUD, INC.

(Contractor)

 

to

 

ADMINISTER THE PROVISION OF THE PHYSICAL HEALTH COMPONENT OF 

THE MI SALUD PROGRAM

 

 

	Contract No.:	2014-000047
	Account Number:	300-5805-TPA
	Service Regions:	ALL NINE SERVICE REGIONS OF MISALUD

 

  

  

  

 

TABLE OF CONTENTS

 

	
ARTICLE 1

	
GENERAL PROVISIONS

	
10

	  	  	  	  
	  	
1.2

	
Background

	
11

	  	  	  	  
	  	
1.3

	
Groups Eligible for Services Under MI Salud

	
12

	  	  	  	  
	  	
1.4

	
Service Regions

	
14

	  	  	  	  
	  	
1.5

	
Delegation of Authority

	
14

	  	  	  	  
	  	
1.6

	
Availability of Funds

	
14

	  	  	  	  
	
ARTICLE 2

	
DEFINITIONS

	
14

	  	  	  	  
	
ARTICLE 3

	
ACRONYMS

	
33

	  	  	  	  
	
ARTICLE 4

	
ASES RESPONSIBILITIES

	
35

	  	  	  	  
	  	
4.1

	
General Provision

	
35

	  	  	  	  
	  	
4.3

	
Eligibility

	
36

	  	  	  	  
	  	
4.4

	
Enrollment Process

	
37

	  	  	  	  
	  	
4.5

	
Disenrollment Responsibilities of ASES

	
40

	  	  	  	  
	  	
4.6

	
Enrollee Services and Marketing

	
42

	  	  	  	  
	  	
4.7

	
Covered Services

	
42

	  	  	  	  
	  	
4.8

	
Provider Network

	
43

	  	  	  	  
	  	
4.9

	
Quality Monitoring

	
43

	  	  	  	  
	  	
4.10

	
Coordination with Contractor’s Key Staff

	
44

	  	  	  	  
	  	
4.11

	
Information Systems and Reporting

	
44

	  	  	  	  
	  	
4.12

	
Readiness Review

	
46

	  	  	  	  
	
ARTICLE 5

	
CONTRACTOR RESPONSIBILITIES

	
47

	  	  	  	  
	  	
5.1

	
General Provisions

	
47

	  	  	  	  
	  	
5.2

	
Enrollment Responsibilities of the Contractor

	
48

	  	  	  	  
	  	
5.3

	
Selection and Change of a Primary Medical Group (“PMG”) and Primary Care Physician (“PCP”)

	
53

	  	  	  	  
	  	
5.4

	
Disenrollment Responsibilities of the Contractor

	
56

 

  

  

  

 

	  	
5.5

	
Conversion Clause

	
61

	  	  	  	  
	
ARTICLE 6

	
ENROLLEE SERVICES

	
63

	  	  	  	  
	  	
6.1

	
General Provisions

	
63

	  	  	  	  
	  	
6.2

	
ASES Approval of All Written Materials

	
64

	  	  	  	  
	  	
6.3

	
Requirements for Written Materials

	
64

	  	  	  	  
	  	
6.4

	
Enrollee Handbook Requirements

	
65

	  	  	  	  
	  	
6.5

	
Enrollee Rights and Responsibilities

	
70

	  	  	  	  
	  	
6.6

	
Provider Directory

	
71

	  	  	  	  
	  	
6.7

	
Enrollee Identification (ID) Card

	
72

	  	  	  	  
	  	
6.8

	
Tele MI Salud(Toll Free Telephone Service)

	
74

	  	  	  	  
	  	
6.9

	
Internet Presence / Web Site

	
79

	  	  	  	  
	  	
6.10

	
Cultural Competency

	
80

	  	  	  	  
	  	
6.11

	
Interpreter Services

	
80

	  	  	  	  
	  	
6.12

	
Enrollment Outreach for the Homeless Population

	
81

	  	  	  	  
	  	
6.13

	
Special Enrollee Information Requirements for Dual Eligible Beneficiaries

	
81

	  	  	  	  
	  	
6.14

	
Marketing

	
81

	  	  	  	  
	
ARTICLE 7

	
COVERED SERVICES AND BENEFITS

	
84

	  	  	  	  
	  	
7.1

	
Requirement to Make Available Covered Services

	
84

	  	  	  	  
	  	
7.2

	
Medical Necessity

	
85

	  	  	  	  
	  	
7.3

	
Experimental or Cosmetic Procedures

	
85

	  	  	  	  
	  	
7.4

	
Covered Services and Administrative Services

	
85

	  	  	  	  
	  	
7.5

	
Basic Coverage

	
86

	  	  	  	  
	  	
7.6

	
Dental Services

	
115

	  	  	  	  
	  	
7.7

	
Special Coverage

	
116

	  	  	  	  
	  	
7.8

	
Case and Disease Management

	
122

	  	  	  	  
	  	
7.9

	
Early and Periodic Screening, Diagnosis and Treatment Requirements (“EPSDT”)

	
125

 

  

  

  

 

	  	
7.10

	
Advance Directives

	
130

	  	  	  	  
	  	
7.11

	
Enrollee Cost-Sharing

	
130

	  	  	  	  
	  	
7.12

	
Dual Eligible Beneficiaries

	
131

	  	  	  	  
	  	
7.13

	
Moral or Religious Objections

	
132

	  	  	  	  
	
ARTICLE 8

	
INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES

	
133

	  	  	  	  
	  	
8.1

	
General Provisions

	
133

	  	  	  	  
	  	
8.2

	
Co-Location of Staff

	
133

	  	  	  	  
	  	
8.3

	
Referrals

	
134

	  	  	  	  
	  	
8.4

	
Information Sharing

	
135

	  	  	  	  
	  	
8.5

	
Staff Education

	
135

	  	  	  	  
	  	
8.6

	
Cooperation With Puerto Rico and Federal Government Agencies

	
135

	  	  	  	  
	  	
8.7

	
Contractor and MBHO Coverage of Hospitalization Services

	
135

	  	  	  	  
	  	
8.8

	
Integration Plan

	
136

	  	  	  	  
	
ARTICLE 9

	
PROVIDER NETWORK

	
136

	  	  	  	  
	  	
9.1

	
General Provisions

	
136

	  	  	  	  
	  	
9.2

	
Network Criteria

	
137

	  	  	  	  
	  	
9.3

	
Provider Qualifications

	
138

	  	  	  	  
	  	
9.4

	
Provider Credentialing

	
140

	  	  	  	  
	  	
9.5

	
Provider Ratios

	
143

	  	  	  	  
	  	
9.6

	
Network Providers

	
145

	  	  	  	  
	  	
9.7

	
Out-of-Network Providers

	
148

	  	  	  	  
	  	
9.8

	
Minimum Requirements for Access to Providers

	
148

	  	  	  	  
	  	
9.9

	
Referrals

	
149

	  	  	  	  
	  	
9.10

	
Timeliness of Prior Authorization

	
150

	  	  	  	  
	  	
9.11

	
Behavioral Health Services

	
150

	  	  	  	  
	  	
9.12

	
Hours of Service

	
151

	  	  	  	  
	  	
9.13

	
Prohibited Actions

	
151

 

  

  

  

 

	  	
Any denial, unreasonable delay, or rationing of Medically Necessary Services to Enrollees is expressly prohibited. The Contractor shall monitor compliance with this prohibition by Network Providers related to their provision of Covered Services to Enrollees

	
151

	  	  	  	  
	  	
9.14

	
Access to Services for Enrollees with Special Health Needs

	
151

	  	  	  	  
	  	
9.15

	
Preferential Turns

	
152

	  	  	  	  
	  	
9.16

	
Contracting with Government Facilities

	
152

	  	  	  	  
	  	
9.17

	
Contracting with Other Providers

	
152

	  	  	  	  
	  	
9.18

	
PMG Additions or Mergers

	
152

	  	  	  	  
	  	
9.19

	
Extended Schedule of PMGs

	
153

	  	  	  	  
	  	
9.20

	
Direct Relationship

	
153

	  	  	  	  
	  	
9.21

	
Additional PPN Standards

	
154

	  	  	  	  
	  	
9.22

	
Contractor Documentation of Adequate Capacity and Services

	
154

	  	  	  	  
	
ARTICLE 10

	
PROVIDER CONTRACTING

	
155

	  	  	  	  
	  	
10.1

	
General Provisions

	
155

	  	  	  	  
	  	
10.2

	
Provider Training

	
156

	  	  	  	  
	  	
10.3

	
Required Provisions in Provider Contracts

	
158

	  	  	  	  
	  	
10.4

	
Termination of Provider Contracts

	
164

	  	  	  	  
	  	
10.5

	
Provider Payment

	
166

	  	  	  	  
	  	
10.6

	
Acceptable Risk Arrangements

	
170

	  	  	  	  
	  	
10.7

	
Physician Incentive Plan

	
170

	  	  	  	  
	  	
10.8

	
Required Information Regarding Providers

	
172

	  	  	  	  
	
ARTICLE 11

	
UTILIZATION MANAGEMENT

	
174

	  	  	  	  
	  	
11.1

	
Utilization Management Policies and Procedures

	
174

	  	  	  	  
	  	
11.2

	
Utilization Management Guidance to Enrollees

	
175

	  	  	  	  
	  	
11.3

	
Prior Authorization and Referral Policies

	
175

	  	  	  	  
	  	
11.4

	
Use of Technology to Promote Utilization Management

	
178

	  	  	  	  
	  	
11.5

	
Court-Ordered Evaluations and Services

	
178

	  	  	  	  
	  	
11.6

	
Second Opinions

	
178

 

  

  

  

 

	  	
11.7

	
Utilization Reporting Program

	
178

	  	  	  	  
	
ARTICLE 12

	
QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM

	
180

	  	  	  	  
	  	
12.1

	
General Provisions

	
180

	  	  	  	  
	  	
12.2

	
Quality Assessment Performance Improvement (QAPI) Program

	
180

	  	  	  	  
	  	
12.3

	
Performance Improvement Projects

	
182

	  	  	  	  
	  	
12.4

	
ER Quality Initiative Program

	
183

	  	  	  	  
	  	
12.5

	
Quality Incentive Program

	
185

	  	  	  	  
	
ARTICLE 13

	
FRAUD, WASTE AND ABUSE

	
191

	  	  	  	  
	
ARTICLE 14

	
GRIEVANCE SYSTEM

	
197

	  	  	  	  
	
ARTICLE 15

	
ADMINISTRATION AND MANAGEMENT

	
211

	  	  	  	  
	
ARTICLE 16

	
PROVIDER PAYMENT MANAGEMENT

	
214

	  	  	  	  
	
ARTICLE 17

	
INFORMATION MANAGEMENT AND SYSTEMS

	
226

	  	  	  	  
	
ARTICLE 18

	
REPORTING

	
239

	  	  	  	  
	
ARTICLE 19

	
ENFORCEMENT – INTERMEDIATE SANCTIONS

	
248

	  	  	  	  
	
ARTICLE 20

	
ENFORCEMENT - LIQUIDATED DAMAGES AND OTHER REMEDIES

	
256

	  	  	  	  
	
ARTICLE 21

	
TERM OF CONTRACT

	
265

	  	  	  	  
	
ARTICLE 22

	
PAYMENT FOR SERVICES

	
265

	  	  	  	  
	
ARTICLE 23

	
FINANCIAL MANAGEMENT

	
272

	  	  	  	  
	  	
23.1

	
General Provisions

	
272

	  	  	  	  
	  	
23.2

	
Solvency and Financial Requirements

	
274

	  	  	  	  
	  	
23.3

	
Reinsurance and Stop Loss

	
274

	  	  	  	  
	  	
23.4

	
Third Party Liability and Cost Avoidance

	
274

	  	  	  	  
	  	
23.5

	
MI Salud as Secondary Payer to Medicare

	
280

	  	  	  	  
	  	
23.6

	
[Intentionally left blank]

	
281

	  	  	  	  
	  	
23.7

	
Reporting Requirements

	
281

 

  

  

  

 

	
ARTICLE 24

	
PAYMENT OF TAXES

	
284

	  	  	  	  
	
ARTICLE 25

	
RELATIONSHIP OF PARTIES

	
285

	  	  	  	  
	
ARTICLE 26

	
INSPECTION OF WORK

	
285

	  	  	  	  
	
ARTICLE 27

	
GOVERNMENT PROPERTY

	
285

	  	  	  	  
	
ARTICLE 28

	
OWNERSHIP AND USE OF DATA AND SOFTWARE

	
286

	  	  	  	  
	  	
28.1

	
Ownership and Use of Data

	
286

	  	  	  	  
	  	
28.2

	
Responsibility for Information Technology Investments

	
287

	  	  	  	  
	
ARTICLE 29

	
CRIMINAL BACKGROUND CHECKS

	
287

	  	  	  	  
	
ARTICLE 30

	
SUBCONTRACTS

	
288

	  	  	  	  
	  	
30.1

	
Use of Subcontractors

	
288

	  	  	  	  
	  	
30.2

	
Cost or Pricing by Subcontractors

	
290

	  	  	  	  
	
ARTICLE 31

	
REQUIREMENT OF INSURANCE LICENSE

	
290

	  	  	  	  
	
ARTICLE 32

	
CERTIFICATIONS

	
290

	  	  	  	  
	
ARTICLE 33

	
RECORDS REQUIREMENTS

	
292

	  	  	  	  
	  	
33.1

	
General Provisions

	
292

	  	  	  	  
	  	
33.2

	
Records Retention and Audit Requirements

	
293

	  	  	  	  
	  	
33.3

	
Medical Record Requests

	
294

	  	  	  	  
	
ARTICLE 34

	
CONFIDENTIALITY

	
295

	  	  	  	  
	  	
34.1

	
General Confidentiality Requirements

	
295

	  	  	  	  
	  	
34.2

	
HIPAA Compliance

	
296

	  	  	  	  
	  	
34.3

	
Data Breach

	
296

	  	  	  	  
	
ARTICLE 35

	
TERMINATION OF CONTRACT

	
298

	  	  	  	  
	  	
35.1

	
Termination by ASES

	
298

	  	  	  	  
	  	
35.2

	
Termination by the Contractor

	
299

	  	  	  	  
	  	
35.3

	
General Procedures

	
300

	  	  	  	  
	  	
35.4

	
Termination Procedures

	
301

 

  

  

  

 

	  	
35.5

	
Except as provided in this Article 35, a notification from a Party that it intends to terminate this Contract shall not release the other Party from its obligations under this Contract

	
305

	  	  	  	  
	
ARTICLE 36

	
PHASE IN, PHASE-OUT AND COOPERATION WITH OTHER CONTRACTORS

	
305

	  	  	  	  
	  	
36.1

	
[Intentionally left blank]

	
305

	  	  	  	  
	  	
36.5

	
Phase Out Transition Period

	
306

	  	  	  	  
	  	
36.6

	
Phase-In Transition Reports and Meetings

	
311

	  	  	  	  
	  	
36.7

	
ASES Obligations

	
313

	  	  	  	  
	  	
36.8

	
Contractor Objections to Payment

	
313

	  	  	  	  
	  	
36.9

	
Runoff Period

	
313

	  	  	  	  
	
ARTICLE 37

	
INSURANCE

	
314

	  	  	  	  
	
ARTICLE 38

	
COMPLIANCE WITH ALL LAWS

	
316

	  	  	  	  
	  	
38.1

	
Nondiscrimination

	
316

	  	
38.2

	
Compliance with All Laws

	
316

	  	  	  	  
	
Article 39

	
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

	
317

	  	  	  	  
	
Article 40

	
Choice of Law or Venue

	
318

	  	  	  	  
	
Article 41

	
THIRD-PARTY Beneficiaries

	
318

	  	  	  	  
	
Article 42

	
Survivability

	  
	
Article 43

	
Prohibited Affiliations with Individuals Debarred and Suspended 

	
319

	  	  	  	  
	
Article 44

	
Waiver

	
319

	  	  	  	  
	
Article 45

	
Force Majeure

	
319

	  	  	  	  
	
Article 46

	
Binding

	
319

	  	  	  	  
	
Article 47

	
Time is of the Essence

	
320

	  	  	  	  
	
Article 48

	
Authority

	
320

 

  

  

  

 

	
ARTICLE 49

	
ETHICS IN PUBLIC CONTRACTING

	
320

	  	  	  	  
	
ARTICLE 50

	
SECTION TITLES NOT CONTROLLING

	
321

	  	  	  	  
	
ARTICLE 51

	
INFORMAL DISPUTE RESOLUTION PROCEDURES

	  
	  	  	  	  
	
ARTICLE 52

	
HOLD HARMLESS

	
321

	  	  	  	  
	
ARTICLE 53

	
COOPERATION WITH AUDITS

	
322

	  	  	  	  
	
ARTICLE 54

	
OWNERSHIP AND FINANCIAL DISCLOSURE

	
322

	  	  	  	  
	
ARTICLE 55

	
AMENDMENT IN WRITING

	
322

	  	  	  	  
	
ARTICLE 56

	
CONTRACT ASSIGNMENT

	
322

	  	  	  	  
	
ARTICLE 57

	
SEVERABILITY

	
323

	  	  	  	  
	
ARTICLE 58

	
ENTIRE AGREEMENT

	
323

	  	  	  	  
	
ARTICLE 59

	
NOTICES

	
323

	  	  	  	  
	
ARTICLE 60

	
OFFICE OF THE COMPTROLLER

	
324

	  	  	  	  
	
ARTICLE 61

	
PHASE OUT AND PHASE IN OF ADDITIONAL SERVICE REGIONS

	
324

 

  

  

  

 

THIS AMENDED AND RESTATED CONTRACT is made and entered into as of July 1, 2013 (the “Effective Date”) by and between the Puerto Rico Health Insurance Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter referred to as “ASES” or “the Administration”), a public corporation in the Commonwealth of Puerto Rico, with employer identification number 66-050-0678; and TRIPLE-S SALUD, INC. (“the Contractor”), an insurance company duly organized and authorized to do business under the laws of the Commonwealth of Puerto Rico, with employer identification number 66-0555677.

WHEREAS, pursuant to Title XIX of the federal Social Security Act, codified as 42 USC 1396 et seq. (“the Social Security Act”), and Act No. 72 of September 7, 1993 of the Laws of the Commonwealth, as amended, (“Act 72”), a comprehensive program of medical assistance for needy persons exists in the Commonwealth;

WHEREAS, under Act 72 and other sources of law of the Commonwealth of Puerto Rico designated in Attachment 1 ASES is responsible for health care policy, purchasing, planning, and regulation of health insurance plans, and pursuant to these statutory provisions, ASES has established a managed care program under the medical assistance program, known as “MI Salud,” or “the MI Salud Program”;

WHEREAS, the Puerto Rico Health Department (“the Health Department”) is the single State agency designated to administer medical assistance in Puerto Rico under Title XIX of the Social Security Act of 1935, as amended, and is charged with ensuring the appropriate delivery of health care services under Medicaid and the Children’s Health Insurance Program (“CHIP”) in Puerto Rico, and ASES manages these programs pursuant to a 1993 interagency collaborative agreement;

WHEREAS, MI Salud serves a mixed population including not only the Medicaid and CHIP populations, but also other eligible individuals as established under Act 72;

WHEREAS, ASES seeks to comply with the public policy objective of the Commonwealth of Puerto Rico (the “Commonwealth” or “Puerto Rico”) of creating MI Salud, an integrated system of physical and behavioral health services, with an emphasis on preventative services and access to quality care;

WHEREAS, in connection with the implementation of this public policy ASES caused a Request for Proposals for Physical Health Services to be issued on May 3, 2010, subsequently amended on June 17, 2010, (as amended, “the RFP”);

WHEREAS, ASES accepted the proposal submitted under the RFP by MCS Health Management Options, Inc. (“MCS”) to provide Physical Health Services in the Service Regions;

WHEREAS, on October 14, 2010, ASES and MCS executed a contract for the Provision of Physical Health Services under the MI Salud Program in six service regions (hereinafter referred to as the “Original Contract”).  These service regions were the WEST, NORTH, METRO NORTH, SAN JUAN, NORTHEAST, and VIRTUAL Regions;

 

  

Page 8 of 327

  

 

WHEREAS, on June 9, 2011, ASES and MCS executed a restated contract (the Original Contract, as amended and restated is hereinafter referred to as the “Restated Contract”);

WHEREAS, the Restated Contract granted MCS a Limited Right of Non-Renewal and a Limited Right of Termination, in the event that MCS and ASES failed to agree on the Per Member Per Month Payment rates for the succeeding Fiscal Year, to be exercised on a specified period of time before the last day of the then current year under the Restated Contract;

WHEREAS, MCS and ASES were unable to agree on new Per Member Per Month Payment rates for each Service Region to be applicable for the Fiscal Year commencing on July 1, 2011 and therefore, MCS provided notice of non-renewal, which notice of non-renewal constituted notice of termination under the Restated Contract;

WHEREAS, MCS did not rescinded its notice of termination for which reason MCS and ASES agreed to proceed with the transition of the Service Regions to a new physical health services provider or providers to be designated by ASES for the MI Salud Program, as provided in the Restated Contract;

WHEREAS, in connection with the transition to a new physical health service provider or providers, ASES requested from all the participants in the RFP procurement process proposals for the provision of Physical Health Services in the Service Regions;

WHEREAS, the Contractor agreed to submit to ASES a proposal to administer the provision of  physical health services in the Service Regions previously serviced by MCS as a third party administrator for a fee;

WHEREAS, after considering the different proposals submitted by the other proponents under the RFP, ASES selected the Contractor to administer the provision of physical health services in the Service Regions previously administered by MCS;

WHEREAS, a Contract was executed on October 17, 2011 between ASES and the Contractor, which expired on June 30, 2013.

WHEREAS, ASES and Humana Health Plans of Puerto Rico, Inc., (“Humana”) entered into a Restated Contract dated as of June13, 2011 (the “Humana Contract”) for the provision of Covered Services in the Southwest, Southeast and East Regions (collectively the “Humana Regions”).  ASES and Humana were unable to agree on the Per Member Per Month fee for each of the Humana Regions for Fiscal Year 2013-2014, and therefore, ASES elected not to renew the Humana Contract, which terminated under the terms thereof on June 30, 2013 (the “Humana Termination Date”).

 

  

Page 9 of 327

  

 

WHEREAS, the Contractor has agreed to administer and arrange for the provision of  physical health services by Network Providers in all Nine Service Regions of MISalud as a third party administrator under the terms and conditions specified in this Contract.

NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, ASES and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

	
ARTICLE 1

	
GENERAL PROVISIONS

 

The Commonwealth implemented certain reforms to its government health program, which serves Medicaid and CHIP recipients, as well as foster care children, certain individuals and families eligible based on income, and certain Government employees, pensioners, and veterans.  The reforms produced an integrated model of physical and behavioral health services, with an emphasis on prevention and on facilitating prompt access to needed primary and specialty services.  The Parties acknowledge that the Contractor shall not be financially responsible or otherwise at risk for the provision of Covered Services and Benefits to Enrollees in the MI Salud Program.

 

	
1.1

	
The Contractor shall assist the Commonwealth by arranging for and administering the delivery of certain services under MI Salud through the described tasks, obligations, and responsibilities specified in, and subject to the terms of, this Contract.

 

	
  

	
1.1.1

	
All references in this document to the defined term “Contract” shall be deemed to mean this Contract, and the contractual relationship between the Parties shall now be governed and controlled by this Contract.

 

	
  

	
1.1.2

	
All references herein to the Contractor’s compliance with federal or Puerto Rico laws, regulations or rules, including but not limited to 42 CFR Part 438, shall apply to the Contractor and/or Contractor’s provision of Administrative Services only to the extent any such laws, regulations or rules apply to a Prepaid Inpatient Health Plan when such an entity is arranging for the provision of medical services or inpatient hospital or institutional services or providing administrative services.  For the avoidance of doubt, the Parties agree that the Contractor is not providing medical services under this Contract and shall not be regulated as such.  The foregoing notwithstanding, this will not be considered a limitation on the Contractor’s ability to render the Administrative Services.

 

	
  

	
1.1.3

	
The Contractor shall ensure all deliverables, official communications and Reports delivered to ASES are submitted in English.  Documentation delivered in Spanish may be accepted by the Administration in its reasonable discretion.  At the request of ASES, the Contractor shall translate to English at its cost any deliverable, communication and Report not delivered in English.

 

  

Page 10 of 327

  

 

	
1.2

	
Background

 

	
  

	
1.2.1

	
Effective October 1, 2010, the government health program previously referred to as La Reforma has been known as MI Salud.  MI Salud continues the services offered under La Reforma, but also embodies new policy objectives.

 

	
  

	
1.2.2

	
MI Salud has the following objectives:

 

	
  

	
1.2.2.1

	
To transform Puerto Rico’s health system through an integrated vision of physical and behavioral health.

 

	
  

	
1.2.2.2

	
To encourage the Contractor and other selected health plans to work together with Managed Behavioral Health Organizations (“MBHOs”) in each of nine service regions of Puerto Rico to provide integrated physical and behavioral health services.

 

	
  

	
1.2.2.3

	
To establish Primary Medical Groups (“PMGs”), which shall enter agreements with the Contractor, and shall act as the monitors for medical care.  PMGs shall provide, manage, and direct health services, including coordination with behavioral health personnel and specialist services, in a timely manner.

 

	
  

	
1.2.2.4

	
To develop within each of the nine service regions a Preferred Provider Network (“PPN”), which shall be composed of physician specialists, laboratories, radiology facilities, hospitals, and Ancillary Service Providers that shall render Covered Services to persons enrolled in MI Salud (“Enrollees”).

 

	
  

	
1.2.2.5

	
To facilitate access to quality primary care and specialty services within the PPN by providing all services without the requirement of a referral, and not requiring cost-sharing for services within the PPN.

 

	
  

	
1.2.2.6

	
To ensure that, other than through appropriate utilization control measures, services to Enrollees in MI Salud are not refused, restricted, or reduced, including by reason of pre-existing conditions or waiting periods.

 

	
  

	
1.2.2.7

	
To support the Puerto Rico Health Department and the Puerto Rico Mental Health and Against Addiction Services Administration (Administración de Servicios de Salud Mental y Contra la Adicción, hereinafter “ASSMCA”) in health education efforts focusing on lifestyles, HIV/AIDS prevention, the prevention of drug and substance abuse, and maternal and child health.

 

  

Page 11 of 327

  

 

	
1.3

	
Groups Eligible for Services Under MI Salud

 

	
  

	
1.3.1

	
The following groups served under MI Salud are hereinafter referred to collectively as “Eligible Persons.”

 

	
  

	
1.3.1.1

	
Medicaid.  These groups shall be referred to hereinafter as “Medicaid Eligible Persons.”  All Medicaid eligibility categories, including the following, are eligible to enroll in MI Salud:

 

	
  

	
1.3.1.1.1

	
Categorically needy, as defined in 42 CFR Part 436, refers to families and children; aged, blind, or disabled individuals; and pregnant women, who are eligible for Medicaid.  These groups are mandatory eligibility groups who, generally, are receiving or deemed to be receiving cash assistance.

 

	
  

	
1.3.1.1.2

	
Families and children refers to eligible members of families with children who are financially eligible under AFDC (Aid to Families with Dependent Children) or medically needy rules and who are deprived of parental support or care as defined under the AFDC program (see 45 CFR 233.90, 233.100).  In addition, this group includes individuals under age 21 who are not deprived of parental support or care but are financially eligible under AFDC rules or medically needy rules.

 

	
  

	
1.3.1.1.3

	
Medically needy refers to families, children, aged, blind or disabled individuals, and pregnant women who are not listed as categorically needy but who may be eligible for Medicaid because their income and resources are within limits set by the Commonwealth under its Medicaid Plan (including persons whose income and resources fall within these limits after their incurred expenses for medical or remedial care are deducted).

 

	
  

	
1.3.1.1.4

	
Dual eligible beneficiaries refers to persons eligible for both Medicaid and Medicare (either Part A only, or Parts A and B).

 

	
  

	
1.3.1.1.5

	
Foster care children in the custody of the Family and Children Administration (Administración de Familias y Niños, hereinafter “ADFAN”), provided that they otherwise meet Medicaid eligibility criteria; and

 

  

Page 12 of 327

  

 

	
  

	
1.3.1.1.6

	
Survivors of domestic violence referred by the Office of the Women’s Advocate (Oficina de la Procuradora de las Mujeres), provided that they otherwise meet Medicaid eligibility criteria.

 

	
  

	
1.3.1.1.7

	
Former foster care children who, beginning January 1, 2014 are under twenty six (26) years of age, and, as of their eighteenth (18) birthday, they were (1) in foster care and (2) enrolled in Medicaid or a Medicaid waiver program.

 

	
  

	
1.3.1.2

	
Children’s Health Insurance Program (CHIP). This group, comprised of children whose family income does not exceed two hundred percent (200%) of the Puerto Rico poverty level, will be referred to hereinafter as “CHIP Eligible Persons.”  The CHIP population may include foster care children in the custody of ADFAN, provided that they otherwise meet CHIP eligibility criteria.

 

	
  

	
1.3.1.3

	
Other Groups (Non-Medicaid/CHIP).  The following groups, which receive services under MI Salud without any federal participation, will be referred to hereinafter as “Other Eligible Persons.”

 

	
  

	
1.3.1.3.1

	
The “Commonwealth Population,” comprised of the following groups:

 

	
  

	
1.3.1.3.1.1

	
Certain persons whose family income does not exceed two hundred percent (200%) of the Puerto Rico poverty level, who are between twenty-one (21) and sixty-four (64) years of age, and who do not qualify for either Medicaid or CHIP;

 

	
  

	
1.3.1.3.1.2

	
Police officers of the Commonwealth, and their Dependents;

 

	
  

	
1.3.1.3.1.3

	
Surviving Spouses of deceased police officers;

 

	
  

	
1.3.1.3.1.4

	
Survivors of domestic violence referred by the Office of the Women’s Advocate;

 

	
  

	
1.3.1.3.1.5

	
Veterans; and

 

  

Page 13 of 327

  

 

	
  

	
1.3.1.3.1.6

	
Any other group of Eligible Persons that may be added during the Term of this Contract as a result of a change in laws or regulations.

 

	
  

	
1.3.1.3.2

	
Government Employees and Pensioners, whose eligibility for MI Salud is not based on income.

 

	
  

	
1.3.1.4

	
Throughout the term of this Contract, ASES may amend the definition of the eligibility groups to be consistent with any amendments made to the Medicaid State plan.

 

	
1.4

	
Service Regions

 

	
  

	
1.4.1

	
The Contractor shall perform Administrative Services under this Contract in the Service Regions.

 

	
  

	
1.4.2

	
For the delivery of services under MI Salud, ASES has divided Puerto Rico into nine regions: eight geographical service regions and one “Virtual Region.”  See Attachment 2 for a map of the geographical service regions.

 

	
  

	
1.4.3

	
The “Virtual Region” encompasses services provided throughout Puerto Rico to two groups of Enrollees: children who are under the custody of ADFAN; and certain survivors of domestic violence referred by the Office of the Women’s Advocate, who enroll in the MI Salud program.

 

	
1.5

	
Delegation of Authority

 

Federal law and Puerto Rico law limit the capacity of ASES to delegate decisions to the Contractor.  All decisions relating to public policy and to the administration of the Medicaid, CHIP, and the Puerto Rico government health assistance program included in MI Salud rest with the Puerto Rico Medicaid Program and ASES.

 

	
1.6

	
Availability of Funds

 

This Contract is subject to the availability of funds on the part of ASES, which in turn is subject to the transfer of federal, Puerto Rico, and municipal funds.  If available funds are insufficient to meet its contractual obligations, ASES reserves the right to terminate this Contract, pursuant to Sections 35.1.1.3 and 35.2.1.3 of this Contract.

 

	
ARTICLE 2

	
DEFINITIONS

 

Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

 

  

Page 14 of 327

  

 

Act 72: The law of the Commonwealth, adopted on September 7, 1993, and subsequently amended, which created the Puerto Rico Health Insurance Administration (ASES) and empowered ASES to administer certain government health programs.

Abandoned Call: A call initiated to a Call Center that is ended by the caller before any conversation occurs or before a caller is permitted access to a caller-selected option.

Abuse: Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the MI Salud Program, or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for Health Care. It also includes Enrollee practices that result in unnecessary cost to the Medicaid program.

Access: Adequate availability of Benefits to fulfill the needs of Enrollees.

Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part, of payment for a service (including in circumstances in which an Enrollee is forced to pay for a service; the failure to provide services in a timely manner (within the timeframes established by this Contract or otherwise established by ASES); or the failure of the Contractor to act within the timeframes provided in 42 CFR 438.408(b).

ADFAN: Families and Children Administration (Administración de Familias y Niños), which is responsible for foster care children in the custody of the Commonwealth.

Administrative Fee:  The monthly amount that ASES will pay to the Contractor for performing the Administrative Services which shall be determined by multiplying the number of Enrollees by the Per Member Per Month Administrative Fee.  This payment is made, without any deduction or Withhold unless otherwise specified in this Contract, regardless of whether Enrollees receive Covered Services or Benefits during the period covered by the payment.

Administrative Services: The Contractual obligations of the Contractor to perform administrative services with respect to the provision of Covered Services as set forth in this Contract, including Case Management, Disease Management, Utilization Management, Credentialing Network Providers, Network management, quality improvement, Marketing, Enrollment, Enrollee services, Claims administration, Information Systems, financial management and reporting, and other administrative services to be performed by the Contractor as specified in this Contract or as may be mutually agreed by the Parties in writing by amending this Contract.

Administrative Law Hearing: The appeal process administered by the Commonwealth and as required by federal law, available to Enrollees and Providers after they exhaust the applicable grievance system and complaint process with the Contractor

 

  

Page 15 of 327

  

 

Administrative Referral: A Referral of an Enrollee by the Contractor to a Provider or facility located outside the PPN, when the Enrollee’s PCP or other PMG physician does not provide a Referral in the required time period.

Advance Directive: A written instruction, such as a living will or durable power of attorney for Health Care, as defined in 42 CFR 489.100, and as recognized under Puerto Rico law under Act 160 of November 17, 2001, as amended, relating to the provision of health care when the individual is incapacitated.

Agent: An entity that contracts with ASES to perform administrative services, including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment activities; and Information Systems and technical support.

Ancillary Services: Professional services, including laboratory, radiology, physical therapy, and respiratory therapy, which are provided in conjunction with other medical or hospital care.

Appeal:  An Enrollee request for a review of an Action.

ASES: Administración de Seguros de Salud de Puerto Rico (the Puerto Rico Health Insurance Administration), the entity in the Commonwealth responsible for oversight and administration of the MI Salud Program, or its Agent.

ASES Information: All proprietary data and/ or information generated from all data requested, received, created, provided, managed and stored by the Contractor, -in hard copy, digital image or electronic format - from ASES and/or Enrollees (as defined in Art. 2, Definitions) necessary or arising out of this Contract, except for the Contractor Proprietary Information.

ASSMCA: Administración de Servicios de Salud Mental y Contra la Addicción (the Puerto Rico Mental Health and Against Addiction Services Administration), the government agency responsible for the planning and establishment of mental health and substance abuse policies and procedures and for the coordination, development, and monitoring of all behavioral health services rendered to Enrollees in MI Salud.

Authorized Representative:  A person authorized by an Enrollee in writing to make health-related decisions on behalf of an Enrollee, including, but not limited to, Enrollment and Disenrollment decisions, filing Complaints, Grievances, and Appeals, and choice of a PCP or PMG.

Authorized Signatory:  An individual designated by the Contractor who is either the Contractor’s Chief Executive Officer, the Contractor’s Chief Financial Officer, or an individual who has delegated authority to sign for, and who reports directly to, the Contractor’s Chief Executive Officer or Chief Financial Officer.

 

  

Page 16 of 327

  

 

Automatic Assignment (or Auto-Assignment):  The assignment of an Enrollee to a Primary Medical Group and a Primary Care Physician by the Contractor, normally at the time that ASES or the Contractor Auto-Enrolls the person in the MI Salud Program.

Auto-Enrollment: The Enrollment of an individual who is certified eligible for Medicaid or CHIP and the Commonwealth Population, in a MI Salud Plan by the Contractor without any action by the individual, as provided in Articles 4 and 5 of this Contract.

Basic Coverage: The MI Salud Covered Services listed in Section 7.5 of this Contract, which are available to all Enrollees.

Benefits: The services set forth in this Contract, including Basic Coverage, Dental Services and Special Coverage for which the Contractor has agreed to provide Administrative Services.

Blocked Call: A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up beyond a defined threshold.

Business Days:  Traditional workdays, including Monday, Tuesday, Wednesday, Thursday, and Friday.  Puerto Rico holidays are excluded.

Calendar Days:  All seven days of the week.

Call Center: A telephone service facility equipped to handle a large number of inbound and outbound calls.

Capitation: A method of risk sharing reimbursement contained in a written agreement through which a Provider agrees to provide specified health care services to Enrollees for a fixed amount per month.

Case Management: An Administrative Service comprised of a set of Enrollee-centered steps to ensure that an Enrollee with intensive needs, including catastrophic or high-risk conditions, receives needed services in a supportive, effective, efficient, timely, and cost-effective manner.

Centers for Medicare and Medicaid Services: The agency within the U.S. Department of Health and Human Services with responsibility for the Medicare, Medicaid and the Children’s Health Insurance Programs.

Center for the Collection of Municipal Revenues: The municipal tax collection agency of the Commonwealth.

Central Access Units: Clinics that serve as points of entry for Enrollees seeking to access Behavioral Health Services, which are staffed by an interdisciplinary team responsible for referring Enrollees to the required level of treatment, and for tracking and monitoring quality in the delivery of Behavioral Health Services.

 

  

Page 17 of 327

  

 

Certification: As provided in Section 4.3.3 of this Contract, a decision by the Puerto Rico Medicaid Program that a person is eligible for services under the MI Salud Program because the person is Medicaid Eligible, CHIP Eligible, or a member of the Commonwealth Population. Some public employees and pensioners may enroll in MI Salud without first receiving a Certification.

Children’s Health Insurance Program (“CHIP”): The Commonwealth’s Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

CHIP Eligible Person: A child eligible to enroll in the MI Salud Program because he or she is eligible for CHIP.

Chronic Condition: An ongoing physical, behavioral, or cognitive disorder, with duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive devices, etc.) and service use or need beyond that which is normally considered routine.

Claim:  Whether submitted manually or electronically, a bill for Covered Services, a line item of Covered Services, or all Covered Services for one Enrollee within a bill.

Claims Payment:  The amount that ASES pays the Contractor for Claims submitted by Providers for Covered Services provided to Enrollees under this Contract.

Claims Payment Report:  The report required to be submitted each fifteenth (15th) and (30th) day of each calendar month by the Contractor with detailed claims information and check request numbers consistent with Article 16.

Clean Claim: A Claim received by the Contractor for adjudication, which can be processed without obtaining additional information from the Provider of the service or from a Third Party, as provided in Section 23.4.5.1 of this Contract.  It includes a claim with errors originating in the Contractor’s claims system.  It does not include a claim from a Provider who is under investigation for Fraud, Waste or Abuse, or a claim under review for Medical Necessity.

Cold-Call Marketing:  Any unsolicited personal contact by the Contractor with an Eligible Person, for the purposes of marketing.

Commonwealth Population: A group eligible for participation in MI Salud as Other Eligible Persons, with no federal participation in the cost of their coverage, which is comprised of low-income persons and other groups listed in Section 1.3.1.3.1 of this Contract.

  

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Complaint: The procedure for addressing Enrollee complaints, defined as expressions of dissatisfaction about any matter other than an Action that are resolved at the point of contact rather than through filing a formal grievance.

Comprehensive Care Centers (“CCuSaI”): Integrated care centers focused on prevention, offering additional services in the areas of health promotion, healthy lifestyles, and preventing chronic diseases.

Contract:  This written agreement between ASES and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

Contract Term: The duration of time that this Contract is in effect (including any Transition Period), as defined in Article 21 of this Contract.

Contractor: Triple-S Salud, Inc., a corporation licensed as an insurer by the Puerto Rico Insurance Commissioner’s Office (“PRICO”), which contracts hereunder with ASES for the provision of Administrative Functions.

Contractor Proprietary Information:  As defined in Section 28.1.2 of this Contract.

Conversion Clause: The provision in Section 5.5 of this Contract giving the Enrollee the right to apply for a direct pay insurance policy from the Contractor upon the Effective Date of Disenrollment from the Plan.

Co-Payment: A cost-sharing requirement which is a fixed monetary amount paid by the Enrollee to a Provider for certain Covered Services as specified by ASES.

Corrective Action Plan:  The detailed written plan required by ASES from the Contractor to correct or resolve a deficiency which may include a remedy as provided in Article 19 and Article 20 of this Contract.

Cost Avoidance: A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance, and other sources of Third Party Liability, have been exhausted.

Countersignature: An authorization provided by the Enrollee’s PCP, or another Provider within the Enrollee’s PMG, for a prescription written by another Provider to be dispensed.

Covered Services:  Those Medically Necessary physical health care services (listed in Article 7 of this Contract) provided to Enrollees by Providers, the payment or indemnification of which is covered under this Contract.

Credentialing:  The Contractor’s determination as to the qualifications of a specific Provider to render specific health care services.

  

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Credible Allegation of Fraud:  Refers to any allegation that has been verified by a State, the Commonwealth or ASES, as the case may be, and that has indicia of reliability that comes from any source.

Cultural Competency:  A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among and between groups and the sensitivity to know how these differences influence relationships with Enrollees.  This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Enrollee needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.

Cultural Competency Plan:  Shall have the meaning ascribed to such term in Section 6.10.1 of this Contract.

Daily Basis: Each Business Day.

Data: A series of meaningful electrical signals that may be manipulated, assigned;

Data Set: Demographic, health or other information elements suitable for specific use.

Deductible: In the context of Medicare, the dollar amount of covered services that must be incurred before Medicare will pay for all or part of the remaining covered services.

Dental Services: The dental services provided under MI Salud, listed in Section 7.6 of this Contract.

Dependent: A person who is enrolled in MI Salud as the spouse or child of the principal Enrollee.

Deliverable:  A document, manual or report submitted to ASES by the Contractor to fulfill requirements of this Contract.

Disaster Recovery and Business Continuity Plan: A documented Plan (process) to restore vital and critical information/health care technology system in the event of business interruption from human, technical or natural causes; focuses mainly on technology systems, encompassing critical hardware, operating and application software, and tertiary elements required to support the operating environment; must support the process requirement to restore vital business data inside the defined business requirement, including an emergency mode operation plan still necessary.

Disease Management: An Administrative Service comprised of a set of Enrollee-centered steps to provide coordinated care to Enrollees suffering from diseases listed in Section 7.8.3 of this Contract.

  

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Disenrollment: The termination of a person’s Enrollment in the MI Salud Plan.

Dual Eligible Beneficiary: An Enrollee eligible for both Medicaid and Medicare.

Durable Medical Equipment:  Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a Health Care Professional to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program:  A Medicaid-mandated program that covers screening and diagnostic services to determine physical and mental deficiencies in Enrollees less than twenty-one (21) years of age, and health care, prevention, treatment, and other measures to correct or ameliorate any deficiencies and chronic conditions discovered.

Effective Date of the Contract: The first day of the Term of this Contract, which shall be the date upon which the Contract is fully executed as specified on the signature page of this Contract, but in no event later than the Implementation Date.

Effective Date of Disenrollment: The date, as defined in Section 4.5.3 of this Contract, on which an Enrollee ceases to be covered under the MI Salud Plan.

Effective Date of Enrollment: The date, as defined in Section 4.4.1 of this Contract, on which an Eligible Person becomes an Enrollee and acquires coverage under the MI Salud Plan.

Electronic Health Record (EHR) System: An electronic record of health-related information on an individual that is created, gathered, managed and consulted by authorized health care clinicians and staff and certified by ONC-Authorized Testing and Certification Bodies (ONC-ATCBs).

Eligible Person: A person eligible to enroll in the MI Salud Program, as provided in Section 1.3.1 of this Contract, by virtue of being Medicaid Eligible, CHIP Eligible, or an Other Eligible Person.

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

 

  

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Emergency Services: Covered Services (as described in Section 7.5.9 of this Contract) furnished by a qualified Provider in an emergency room that are needed to evaluate or stabilize an Emergency Medical Condition as defined above.

Encounter:  A distinct set of services provided to an Enrollee in a face-to-face setting on the dates that the services were delivered, regardless of whether the Provider is paid on a Fee-for-Service or Capitated basis.  Encounters with more than one Health Care Professional, and multiple Encounters with the same Health Care Professional, that take place on the same day in the same location will constitute a single Encounter, except when the Enrollee, after the first Encounter, suffers an illness or injury requiring an additional diagnosis or treatment.

Encounter Data:  (i) All data captured during the course of a single Encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment associated with the Enrollee receiving services during the Encounter; (ii) The identification of the Enrollee receiving and the Provider(s) delivering the health care services during the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

Enrollee: A person who is currently enrolled in the Plan, as provided in this Contract, and who, by virtue of relevant federal and Puerto Rico laws and regulations, is an Eligible Person listed in Section 1.3.1 of this Contract.

Enrollment: The process by which an Eligible Person becomes a member of the MI Salud Plan.

EPSDT Checkups:  Shall have the meaning ascribed to such term in Section 7.9.3.1 of this Contract.

EPSDT Eligible Children:  Shall have the meaning ascribed to such term in Section 7.9.1 of this Contract.

EPSDT Plan:  Shall have the meaning ascribed to such term in Section 7.9.1.1 of this Contract.

External Quality Review Organization (“EQRO”):  An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs analysis and evaluation on the quality, timeliness, and access to Covered Services and Benefits to Enrollees with respect to which the Contractor provides Administrative Services under this Contract.

Federally Qualified Health Center (“FQHC”):  An entity that provides outpatient health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.

Federally Qualified Health Center (“FQHC”) Services:  Services furnished to an individual as an outpatient of an FQHC.

 

  

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Fee-for-Service:  A method of reimbursement based on payment for specific Covered Services rendered to an Enrollee.

Final Report:  Shall have the meaning ascribed to such term in Section 35.4.4 of this Contract.

Fiscal Year: The period from July 1 of one calendar year through June 30 of the following calendar year.

Fraud:  An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person, and it includes any act that constitutes Fraud under applicable federal or Puerto Rico law.

General Network: The group of Providers under contract with the Contractor that are not members of the Contractor’s Preferred Provider Networks.

Grievance: An expression of dissatisfaction about any matter other than an Action.

Grievance System:  The overall system that includes Complaints, Grievances, and Appeals at the Contractor level, as well as access to the Administrative Law Hearing process.

Health Care Acquired Conditions: A medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in Section 1886(d)(4)(D)(iv) of the Social Security Act.

Health Care Professional:  A physician or other health care professional, including but not limited to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians.

Health Certificate: Certificate issued by a physician after an examination that includes Venereal Disease Research Laboratory (“VRDL”) and tuberculosis (“TB”) tests if the individual suffers from a contagious disease that could incapacitate him or her or prevent him or her from doing his or her job, and does not represent a danger to public health.

Health Information Exchange: is the secure and effective electronic transmission (push–pull) of patient health information between healthcare providers, across organizations within a region, community or hospital system, within a jurisdiction and/or between jurisdictions.

  

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Health Information Organization: is an organization that oversees and governs services related to the exchange of health-related information among organizations (cover entities) according to nationally recognized standards, as defined in The National Alliance for Health Information Technology Report to the Office of the National Coordinator for Health Information Technology.

Health Information Technology for Economic and Clinical Health (HITECH) Act : Public Law 111-5 (2009), including all related rules, regulations and procedures thereunder.

Health Insurance Portability and Accountability Act (“HIPAA”):  A law enacted in 1996 by the Congress of the United States, including all related rules, regulations and procedures thereunder.

 

Healthy Child Care: The battery of screenings (listed in Section 7.5.3.1 of this Contract) provided to children under age two (2) who are Medicaid- or CHIP Eligible as part of Puerto Rico’s Early and Periodic Screening, Diagnostic and Treatment Program.

HEDIS: The Healthcare Effectiveness Data and Information Set, a set of performance measures for managed care developed by the National Committee for Quality Assurance (“NCQA”).

Immediately or Immediate: Within twenty-four (24) hours, unless otherwise provided in this Contract.

Implementation Date of the Contract: The date on which the Contractor shall first be entitled to compensation for providing Administrative Services and arranging for the provision of Covered Services and Benefits under this Contract, which is July 1, 2013.

Incurred-But-Not-Reported (IBNR):  Estimate of unpaid Claims liability, including received but unpaid Claims.

Indian: Indian means an individual, defined at title 25 of the U.S.C. sections 1603(c), 1603(f), 1603(f) or who has been determined eligible, as an Indian, pursuant to 42 C.F.R. 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian health care providers (HIS, an Indian Tribe, Tribal Organization, or Urban Indian Organization-I/T/U) or through referral under Contract Health Services.

Information: Data to which meaning is assigned, according to context and assumed conventions; Meaningful fractal data for decision support purposes.

Information Service: The component of Tele MI Salud, a Call Center operated by the Contractor (described in Section 6.8 of this Contract), intended to assist Enrollees with routine inquiries which shall be fully staffed between the hours of 7:00 a.m. and, 7:00 p.m., Monday through Friday, excluding Puerto Rico holidays.

 

  

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Information System(s): A combination of computing and communications hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e. structured data (which may include digitized audio and video) and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction.

 

Insolvent: Unable to meet or discharge financial liabilities.

Integration Model: The service delivery model under the MI Salud Program, providing physical and behavioral health services in close coordination, to ensure optimum detection, prevention, and treatment of physical and behavioral health conditions.

MA-10: Form issued by the Puerto Rico Medicaid Program, entitled “Notice of Action Taken,” containing the Certification decision (whether a person was determined eligible or ineligible for Medicaid, CHIP, or the Commonwealth Population).

Managed Behavioral Health Organization (“MBHO”): An entity that contracts with ASES for the provision of the behavioral health component of the MI Salud Program.

Managed Care Organization (“MCO”): An entity that is organized for the purpose of providing health care and is licensed as an insurer by the Puerto Rico Insurance Commisioner’s Office, which contracts with ASES for the provision of Covered Services and Benefits, except for Behavioral Health Services, in designated Service Regions, under the MI Salud Program. For the avoidance of doubt, the Parties agree that Contractor is not an MCO for purposes of this Contract.

Marketing:  Any communication from the Contractor to any Eligible Person regarding the MI Salud Program that can reasonably be interpreted as intended to influence the individual to enroll in the MI Salud Plan, or not to enroll in another plan, or to disenroll from another plan.

Marketing Materials: Materials that are produced in any medium, by or on behalf of the Contractor, that can reasonably be interpreted as intended to market to individuals the MI Salud Program.

Master Formulary:  The list of pharmaceutical products set forth on Attachment 5 to this Contract.

Medicaid:  The joint federal/state program of medical assistance established by Title XIX of the Social Security Act.

Medicaid Eligible Person:  An individual eligible to receive services under Medicaid, who is eligible, on this basis, to enroll in the MI Salud Program.

Medicaid Management Information System (MMIS):  Computerized system used for the processing, collecting, analysis and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

  

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Medical Advice Service: The twenty-four (24) hour emergency medical advice toll-free phone line operated by the Contractor through its Tele MI Salud service, described in Section 6.8 of this Contract.

Medical Record:  The complete, comprehensive record of an Enrollee including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Enrollee’s Network Primary Care Physician or Provider, that documents all health care services received by the Enrollee, including inpatient, outpatient, ancillary, and emergency care, prepared in accordance with all applicable federal and Puerto Rico rules and regulations, and signed by the Provider rendering the services.

Medical Necessity or Medically Necessary: Shall have the meaning ascribed to such terms in Section 7.2 of this Contract.

Medicare: The federal program of medical assistance for persons over age 65 and certain disabled persons under Title XVIII of the Social Security Act.

Medicare Part A: The part of the Medicare program that covers inpatient hospital stays and skilled nursing facility, home health, and hospice care.

Medicare Part B: The part of the Medicare program that covers physician, outpatient, home health, and preventive services.

Medicare Part C: The part of the Medicare program that permits Medicare recipients to select coverage among various private insurance plans.

Medicare Platino: A program administered by ASES for Dual Eligible Beneficiaries, in which managed care organizations or other insurers under contract with ASES function as Part C plans to provide services covered by Medicare, and also to provide a “wraparound” benefit of Covered Services and Benefits under MI Salud.

MI Salud (or “the MI Salud Program”): The government health services program (formerly referred to as “La Reforma”) offered by the Commonwealth, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical and behavioral health services.

MI Salud Plan or Plan: The physical health component of the MI Salud Program offered to Eligible Persons in the Service Regions covered by this Contract, and with respect to which the Contractor shall provide Administrative Services under this Contract.

MI Salud Policies and Procedures:  Shall have the meaning ascribed to such term in Section 4.7.3 of this Contract.

  

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National Provider Identifier: The unique identifying number system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System.

Negative Redetermination Decision: A decision by the Puerto Rico Medicaid Program that a person is no longer eligible for services under the MI Salud Program (because the person no longer meets the eligibility standards for Medicaid, CHIP, or Puerto Rico’s government health assistance program).

Network: The entire group of Providers under contract with the Contractor, including those that are members of the General Network and those that are members of the PPN.

Network Provider: A Provider that has a contract with the Contractor under the MI Salud Program.  This term includes Providers in the General Network and Providers in the PPN.

Non-Emergency Medical Transportation (“NEMT”): Transportation for a non-emergency service.

Notice of Action: The notice described in Section 14.4.3 of this Contract, in which the Contractor notifies both the Enrollee and the Provider of an Action.

Notice of Disposition: The notice in which the Contractor explains in writing to the Enrollee and the Provider of the results and date of resolution of a Complaint, Grievance, or Appeal.

Office of the Patient Advocate: An office of the Commonwealth created by Law 11 of April 11, 2001, which is tasked with protecting the patient rights and protections contained in the Patient’s Bill of Rights Act.

Office of the Women’s Advocate: An office of the Commonwealth which is tasked, among other responsibilities, with protecting victims of domestic violence.

Other Eligible Person: A person eligible to enroll in the MI Salud Program under Section 1.3.1.3 of this Contract, who is not Medicaid- or CHIP Eligible; this group is comprised of the Commonwealth Population and certain public employees and pensioners.

Out-of-Network Provider: A Provider that does not have a contract with the Contractor under MI Salud; i.e., the Provider is not in either the General Network or the PPN.

Patient Protection and Affordable Care Act (PPACA): Public Law 111-148 (2010) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 (2010), including all related rules, regulations and procedures thereunder.

Patient’s Bill of Rights Act: Law 194 of August 25, 2000, as amended, a law of the Commonwealth relating to patient rights and protection.

  

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Per Member Per Month Administrative Fee: The monthly amount that ASES will pay to the Contractor per member per month (PMPM) in accordance with Attachment 11 of this Contract, in consideration of the Administrative Services.

Pharmacy Benefit Manager (PBM):  An entity under contract with ASES under the MI Salud Program, responsible for the administration of pharmacy Claims processing, formulary management, drug utilization review, pharmacy network management, and Enrollee information services relating to Pharmacy Services.

Pharmacy Program Administrator (PPA): An entity, under contract with ASES, responsible for implementing and offering support to ASES and the contracted PBMs in the negotiation of rebates and development of the Maximum Allowable Cost (“MAC”) List.

Physician Incentive Plan:  Any compensation arrangement between the Contractor and a physician or physician group that is intended to advance Utilization Management.

Plan:  See definition of the MI Salud Plan.

Post-Stabilization Services: Covered Services, relating to an Emergency Medical Condition, that are provided after an Enrollee is stabilized, in order to maintain the stabilized condition, or to improve or resolve the Enrollee’s condition.

Potential Enrollee:  A person who has been Certified by the Puerto Rico Medicaid Program as eligible to enroll in MI Salud (whether on the basis of Medicaid eligibility, CHIP eligibility, or eligibility as a member of the Commonwealth Population), but whose auto-assignment process has not been completed.

PR Prompt Payment Law: collectively, Chapter 30 of the Puerto Rico Insurance Code and Rule Number 73 promulgated thereunder by the Puerto Rico Insurance Commissioner’s Office.

Preferential Turns: The policy of requiring Network Providers to give priority in treating Enrollees from the island municipalities of Vieques and Culebra, so that they may be seen by a Provider within a reasonable time after arriving in the Provider’s office.  This priority treatment is necessary because of the remote locations of these municipalities, and the greater travel time required for their residents to seek medical attention.

Preferred Drug List (“PDL”): A published subset of pharmaceutical products used for the treatment of physical and behavioral health conditions developed by the PPA from the Master Formulary after clinical and financial review.

Preferred Provider Network: A group of Network Providers that MI Salud Enrollees may access without any requirement of a Referral or Prior Authorization; provides services to MI Salud Enrollees without imposing any Co-Payments; and meets the Network requirements described in Article 9 of this Contract.

 

  

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Prepaid Inpatient Health Plan (“PIHP”):  An entity that: (a) provides medical services to Enrollees under a contract with ASES with prepaid Capitation or other payment arrangements that do not use State plan payment plans; (b) provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital or institutional services for its Enrollees; and (c) does not have a comprehensive risk contract.

Preventive Services: Health care services provided by a physician or other Health Care Professional within the scope of his or her practice under Puerto Rico law to prevent disease, disability, or other health conditions; and to promote physical and mental health and efficiency.

Primary Care: All health care services, including periodic examinations, preventive health care services and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of Referrals to specialty Providers described in this Contract and for maintaining continuity of patient care.

Primary Care Physician (“PCP”): A licensed medical doctor (MD) who is a Provider and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for providing all required Primary Care to Enrollees.   The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.

Primary Medical Group (“PMG”): A grouping of associated Primary Care Physicians and other Providers for the delivery of services to MI Salud Enrollees using a coordinated care model.  PMGs may be organized as Provider care organizations, or as another group of Providers who have contractually agreed to offer a coordinated care model to MI Salud Enrollees under the terms of this Contract.

Prior Authorization:  Authorization granted by the Contractor in advance of the rendering of a Covered Service, which, in some instances, is made a condition for receiving the Covered Service.

Provider:  Any physician, hospital, facility, or other Health Care Professional who is licensed or otherwise authorized to provide health care services in the jurisdiction in which they are furnished.

Provider Contract:  Any written contract between the Contractor and a Provider setting forth the terms and conditions under which the Provider will provide Covered Services to Enrollees under this Contract.

Psychiatric Emergency: A psychiatric condition manifesting itself in acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or in causing serious impairments of bodily functions, or serious dysfunction of any bodily organ or part.  A Psychiatric Emergency shall not be defined on the basis of lists of diagnoses or symptoms.

  

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Puerto Rico Health Department (“Health Department”): The Single State Agency charged with administration of the Medicaid Program of the Commonwealth, which (through the Puerto Rico Medicaid Program) is responsible for Medicaid and CHIP eligibility determinations.

Puerto Rico Insurance Commissioner’s Office (“PRICO”): The Puerto Rico Government agency responsible for regulating, monitoring, and licensing insurance business.

Puerto Rico Medicaid Program: The subdivision of the Puerto Rico Health Department that conducts eligibility determinations for Medicaid, CHIP, and the Commonwealth Population.

Quality Assessment and Performance Improvement Program (QAPI): A set of programs aiming to increase the likelihood of desired health outcomes of Enrollees through the provision of health services that are consistent with current professional knowledge; the QAPI Program includes incentives to comply with HEDIS standards, to provide adequate preventive service, and to reduce the unnecessary use of Emergency Services.

Quality Incentive Program: Shall have the meaning ascribed to such term in Article 12 of the Contract.

Reasonable Efforts: means the taking of those steps in the power of the relevant Party that are capable of producing the desired result, being steps which a reasonable person desiring to achieve such result would take; provided that, subject to the relevant Party’s other express obligations under this Agreement, the relevant Party shall not be required to expend any funds other than those funds (A) necessary to meet the reasonable costs reasonably incidental or ancillary to the steps to be taken by the relevant Party and (B) the expenditure of which is not the obligation of the other Party hereunder.

Recertification: A determination by the Puerto Rico Medicaid Program that a person previously enrolled in MI Salud subsequently received a Negative Redetermination Decision, is again eligible for services under the MI Salud Program.

Redetermination: The periodic redetermination of eligibility for Medicaid, CHIP, or the Commonwealth Population, conducted by the Puerto Rico Medicaid Program.

Referral:  A request by a PCP or other Provider in the PMG for an Enrollee to be evaluated and/or treated by a different Provider, usually a specialist.

  

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Reinsurance:  An agreement whereby ASES transfers risk or liability for losses, in whole or in part, sustained under this Contract.  A reinsurance agreement may also exist at the Provider level through a stop-loss arrangement as provided in Section 23.3 of this Contract.

Remedy: ASES’s means to enforce the terms of the Contract through liquidated damages and other sanctions.

Reports:  Shall have the meaning ascribed to such term in Section 18.2 of this Contract.

Retention Fund: Shall have the meaning ascribed to such term in Section 12.5.2 of this Contract..

Runoff Period: A period not to exceed ten (10) consecutive months, commencing on the Calendar Day immediately following the Termination Date.

Rural Health Clinic (“RHC”): A clinic that is located in an area that has a health-care Provider shortage.  An RHC provides primary health care and related diagnostic services and may provide optometric, podiatry, chiropractic and mental health services.  An RHC employs, contracts or obtains volunteer services from Providers to provide services.

Service Authorization Request: An Enrollee’s request for the provision of a Covered Service.

Service Region: A geographic area comprised of those municipalities where the Contractor is responsible for providing services under the MI Salud Program which for purposes of this Contract shall include all nine service regions of the MI Salud Program.

Span of Control: Information systems and telecommunications capabilities that the Contractor operates or for which it is otherwise legally responsible according to the terms and conditions of this Contract.  The Contractor’s Span of Control also includes Systems and telecommunications capabilities outsourced by the Contractor.

Special Coverage: A component of Covered Services, described in Section 7.7 of this Contract, which are more extensive than the Basic Coverage services, and for which Enrollees are eligible only by “registering”; registration for Special Coverage is based on intensive medical needs occasioned by serious illness.

Subcontract: Any written contract between the Contractor and a third party, including a Provider, to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor(s): A third party to a written contract with the Contractor to perform a specified part of the Contractor’s obligations under this Contract.

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

 

  

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Telecommunication Device for the Deaf (“TDD”):  Special telephone devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.

Tele MI Salud: The Enrollee support Call Center that the Contractor shall operate as described in Section 6.8 of this Contract, containing two components: the Information Service and the Medical Advice Service.

Tele MI Salud Outreach Program:  Shall have the meaning ascribed to such term in Section 6.8.12 of this Contract.

Terminal Condition: A condition caused by injury, illness, or disease, from which, to a reasonable degree of certainty, will lead to the patient’s death in a period of, at most, six (6) months.

Termination Date of Contract or Termination Date: The final date upon which the Contractor is required to provide Administrative Services hereunder including any services rendered during the Transition Period, but excluding the Runoff Period, as described in Articles 34 and 35 of this Contract.

Third Party:  Any person, institution, corporation, insurance company, public, private or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an Enrollee.

Third Party Liability: Legal responsibility of any Third Party to pay for health care services.

Transition Report:  Any Report that is not otherwise required to be prepared by the Contractor during the Contract Term, except upon ASES’s reasonable request during the Transition Period regarding the Contractor’s operations with respect to the MI Salud Program under this Contract during the Transition Period or the Runoff Period.

Urgency:  Shall have the meaning ascribed to such term in the Patient’s Bill of Rights Act.

Utilization:  The rate patterns of service usage or types of service occurring within a specified time.

Utilization Management (“UM”):  A service performed by the Contractor which seeks to ensure that Covered Services provided to Enrollees are in accordance with, and appropriate under, the standards and requirements established by this Contract, or a similar program developed, established or administered by ASES.

Virtual Region: The Service Region for the MI Salud Program that is comprised of children who are in the custody of ADFAN, as well as certain survivors of domestic violence referred by the Office of the Women’s Advocate, who enroll in the MI Salud Program.  The Virtual Region encompasses services for these Enrollees throughout Puerto Rico.

  

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Week: The traditional seven-day week, Sunday through Saturday.

Withhold:  A percentage of payments or set dollar amounts that ASES deducts from its payment to the Contractor, or that the Contractor deducts from its payment to a Network Provider, depending on specific predetermined factors.

	
  

	
ARTICLE 3

	
ACRONYMS

 

The acronyms included in this Contract stand for the following terms.

 

	
ACH -

	
Automated Clearinghouse

	  	  
	
ADFAN -

	
Puerto Rico Administración de Familias y Niños, or Families and Children Administration

	  	  
	
AICPA -

	
American Institute of Certified Public Accountants

	  	  
	
ARRA -

	
American Recovery and Reinvestment Act of 2009

	  	  
	
ASES -

	
Administración de Seguros de Salud, or Puerto Rico Health Insurance Administration

	  	  
	
ASSMCA -

	
The Mental Health and Against Addiction Services Administration or Administración de Servicios de Salud Mental y Contra la Addicción

	  	  
	
ASUME -

	
Minor Children Support Administration or Administración para el Sustento de Menores

	  	  
	
BC-DR -

	
Business Continuity and Disaster Recovery

	  	  
	
CCuSAI -

	
Comprehensive Health Center

	  	  
	
CFR -

	
Code of Federal Regulations

	  	  
	
CHIP -

	
Children’s Health Insurance Program

	  	  
	
CLIA -

	
Clinical Laboratory Improvement Amendment

	  	  
	
CMS -

	
Centers for Medicare & Medicaid Services

	  	  
	
DME -

	
Durable Medical Equipment

	  	  
	
DRG

	
Diagnostic Related Groups

  

Page 33 of 327

  

 

	
ECM -

	
Electronic Claims Management

	  	  
	
EDI -

	
Electronic Data Interchange

	  	  
	
EFT -

	
Electronic Funds Transfer

	  	  
	
EHR -

	
Electronic Health Record

	  	  
	
EIN -

	
Employer Identification Number

	  	  
	
EMTALA -

	
Emergency Medical Treatment and Labor Act

	  	  
	
EPSDT -

	
Early and Periodic Screening, Diagnostic, and Treatment

	  	  
	
EQR -

	
External Quality Review

	  	  
	
EQRO -

	
External Quality Review Organization

	  	  
	
ER -

	
Emergency Room

	  	  
	
FQHC -

	
Federally Qualified Health Center

	  	  
	
PMG -

	
Primary Medical Group

	  	  
	
HEDIS -

	
The Healthcare Effectiveness Data and Information Set

	  	  
	
HHS -

	
U.S. Department of Health & Human Services

	  	  
	
HIE -

	
Health Information Exchange

	  	  
	
HIPAA -

	
Health Insurance Portability and Accountability Act of 1996

	  	  
	
IBNR -

	
Incurred-But-Not-Reported

	  	  
	
MAC -

	
Maximum Allowable Cost

	  	  
	
MBHO -

	
Managed Behavioral Health Organization

	  	  
	
MMIS -

	
Medicaid Management Information System

	  	  
	
NDC

	
National Drug Code

	  	  
	
NEMT -

	
Non-Emergency Medical Transportation

	  	  
	
NPI -

	
National Provider Identifier

  

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OIG -

	
Office of the Inspector General of the U.S. Department of Health and Human Services

	  	  
	
PBM -

	
Pharmacy Benefits Manager

	  	  
	
PCP -

	
Primary Care Physician

	  	  
	
PDL -

	
Preferred Drug List

	  	  
	
PIHP -

	
Prepaid Inpatient Health Plan

	  	  
	
PIP -

	
Performance Improvement Projects

	  	  
	
PMG -

	
Primary Medical Group

	  	  
	
PPA -

	
Pharmacy Program Administrator

	  	  
	
PPN -

	
Preferred Provider Network

	  	  
	
QAPI -

	
Quality Assessment Performance Improvement Program

	  	  
	
RFP -

	
Request for Proposals

	  	  
	
RHC -

	
Rural Health Center

	  	  
	
SAS -

	
Statements on Auditing Standards

	  	  
	
SSN -

	
Social Security Number

	  	  
	
TDD -

	
Telecommunication Device for the Deaf

	  	  
	
TPL -

	
Third-Party Liability

	  	  
	
UCF -

	
Uniform Central Formulary

	  	  
	
UM -

	
Utilization Management

 

	
ARTICLE 4

	
ASES RESPONSIBILITIES

 

	
4.1

	
General Provision

 

ASES will be responsible for administering the MI Salud government health plan.  ASES will administer contracts, monitor the Contractor’s performance, and provide oversight of all aspects of the Contractor’s operations.  Specifically, ASES will perform the activities as specified in Article 4.

 

  

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4.2

	
Legal Compliance

 

ASES will comply with, and will monitor the Contractor’s compliance with, all federal and Puerto Rico laws, rules, regulations, statutes, policies or procedures that may govern the Contract, including but not limited to those listed in Attachment 1, to the extent applicable.

 

	
4.3

	
Eligibility

 

	
  

	
4.3.1

	
The Commonwealth has sole authority to determine eligibility for MI Salud, as provided in federal law and Puerto Rico’s State Plan, with respect to the Medicaid and CHIP eligibility groups listed in Sections 1. 3.1.1-1.3.1.2 of this Contract; and, with respect to the Other Eligible Persons listed in Section 1.3.1.3 of this Contract, as provided in Article VI, Section 5 of Act 72 and other Puerto Rico law and Regulation 7758 – Regulation Number 138 of the Puerto Rico Health Department.

 

	
  

	
4.3.2

	
The Puerto Rico Medicaid Program will determine eligibility for the eligibility categories listed in Sections 1.3.1.1, 1.3.1.2, and 1.3.1.3.1 above (Medicaid - and CHIP Eligible Persons and the Commonwealth Population).

 

	
  

	
4.3.3

	
The Medicaid Program determination that a person is eligible for MI Salud is contained on Form MA-10, titled “Notification of Action Taken on Request and/or Re-Evaluation,” and shall be referred to hereinafter as “Certification.”  A person who has received a Certification shall be referred to hereinafter as a “Potential Enrollee.”  If the Potential Enrollee has not received the Enrollee Id Card, he or she shall have access to the Covered Services for up to thirty (30) Calendar Days with the MA-10.

 

	
  

	
4.3.4

	
Effective Date of Eligibility.  ASES shall observe the following rules with respect to the Effective Date of Eligibility for services under MI Salud.

 

	
  

	
4.3.4.1

	
Effective Date of Eligibility for Medicaid - and CHIP Eligible Persons and Commonwealth Population.  Medicaid - and CHIP Eligible Persons and members of the Commonwealth Population (see Sections 1.3.1.1, 1.3.1.2, 1.3.1.3.1 of this Contract) shall be eligible to enroll in MI Salud as of the eligibility effective date specified on the MA-10.

 

	
  

	
4.3.4.2

	
Effective Date of Eligibility for Public Employees and Pensioners.  Public employees and pensioners (see Section 1.3.1.3.2 of this Contract) shall be eligible to enroll in MI Salud according to policies determined by the Commonwealth.  The Puerto Rico Medicaid Program does not play a role in determining their eligibility.

 

  

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4.3.4.3

	
Certification Date is the date when the person visits the Medicaid Program Office and eligibility is determined.  As of that date the Potential Enrollee may access the Covered Services.

 

	
  

	
4.3.4.4

	
Effective Date is the date which is up to ninety (90) Calendar Days before the Certification Date during which services can be retroactively covered for Medicaid and CHIP populations.

 

	
  

	
4.3.5

	
Termination of Eligibility

 

	
  

	
4.3.5.1

	
An Enrollee who is determined ineligible for MI Salud after a Redetermination conducted by the Puerto Rico Medicaid Program shall remain eligible for services under MI Salud until the date specified in a Negative Redetermination Decision issued by the Medicaid Program.

 

	
  

	
4.3.5.2

	
An Enrollee who is a public employee or pensioner (see Section 1.3.1.3.2 of this Contract) shall remain eligible until disenrolled from MI Salud.

 

	
  

	
4.3.6

	
ASES Notice to Contractor

 

	
  

	
4.3.6.1

	
ASES shall notify the Contractor of Certifications and Negative Redetermination Decisions referenced in Sections 4.3.3 and 4.3.5 of this Contract.

 

	
  

	
4.3.6.2

	
ASES will receive a file with Certification and Negative Redetermination Decision data from the Puerto Rico Medicaid Program on a daily basis, and shall notify the Contractor of a Certification or Negative Redetermination Decision within one (1) Business Day of receiving notice of it via said file.  ASES shall forward these data to the Contractor in an electronic format agreed to between the Parties (the “Daily Update / Carrier Eligibility File Format”).

 

	
4.4

	
Enrollment Process

 

	
  

	
4.4.1

	
Effective Date of Enrollment

 

	
  

	
4.4.1.1

	
General Provision.  Except as provided below, Enrollment will be effective (hereinafter referred to as the “Effective Date of Enrollment”) as of the eligibility certification entered in the Medicaid system. The effective date in the Medicaid system is the day the application process is complete.

 

	
  

	
4.4.1.2

	
Enrollment of Persons who Access Medical Services Before Completing the Enrollment Process. When an Eligible Person who is a Medicaid or CHIP Eligible Person (see Sections 1.3.1.1 and 1.3.1.2) receives Medical Services before the date indicated in Section 4.4.1.1 above, such person shall be deemed covered by the Contractor or by the MBHO according to the effective date as per section 4.3.4.4.

 

  

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4.4.1.3

	
Effective Date of Re-Enrollment for Enrollees Who Lose Eligibility. If an Enrollee who is a Medicaid- or CHIP Eligible Person or member of the Commonwealth Population loses eligibility for MI Salud for not more than two (2) months, Enrollment in the MI Salud Plan shall be reinstated.  Upon notification from ASES of the Recertification, the Contractor shall Auto-Enroll the person, with Enrollment effective as of the new Effective Date of Eligibility.

 

	
  

	
4.4.1.4

	
Effective Date of Enrollment for Newborns

 

	
  

	
4.4.1.4.1

	
A newborn shall be Auto-Enrolled, with an Effective Date of Enrollment of the date of his or her birth, provided that the Contractor meets the notification requirements in Section 5.2.5 of this Contract.

 

	
  

	
4.4.1.4.2

	
ASES shall require the Contractor to provide notification to Medicaid when it learns about any Enrollee that a Network Provider encounters who is an expectant mother, per Section 5.2.5 of this Contract.

 

	
  

	
4.4.1.4.3

	
ASES shall require the Contractor to Auto-Enroll the newborn as provided in Section 5.2.5 of this Contract.

 

	
  

	
4.4.1.5

	
Re-Enrollment Policy and Effective Date of Re-Enrollment for Mothers Who are Minor Dependents.  In the event that a female Enrollee who is included in a family group for coverage under MI Salud as a Dependent child becomes pregnant, the Enrollee shall be referred to the Puerto Rico Medicaid Program.  She will be considered to be a new family and will become the head of household of the new family.  The Effective Date of Enrollment of the new family will be the date of the first diagnosis of the pregnancy, and the Enrollee shall be Auto-Enrolled, effective as of this date.  The mother shall be Auto-Assigned to the PMG and PCP to which she was assigned before the Re-Enrollment.

 

  

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4.4.2

	
Term of Enrollment.  The Term of Enrollment shall be a period of twelve (12) consecutive months for all MI Salud Enrollees, except that in cases in which the Puerto Rico Medicaid Program has designated an eligibility redetermination period shorter than twelve months for an Enrollee who is a Medicaid or CHIP Eligible Person or a member of the Commonwealth Population, that same period shall also be considered the Enrollee’s Term of Enrollment.  Such a shortened eligibility redetermination period may apply, in the discretion of the Puerto Rico Medicaid Program, when an Enrollee is pregnant, is homeless, or anticipates a change in status (such as receipt of unemployment benefits) or in family composition.  Notwithstanding this Section, Section 4.5 of this Contract controls the Effective Date of Disenrollment.

 

	
  

	
4.4.3

	
The Contractor shall have policies and procedures in place to comply with Auto-Enrollment for the MI Salud Medicaid, CHIP and Commonwealth Population. MI Salud

 

	
  

	
4.4.3.1

	
The Contractor shall Auto-Enroll each Enrollee in the MI Salud Plan covering the Service Region where the Enrollee lives or, for an Enrollee who is a foster child in the custody of ADFAN or a survivor of domestic violence referred by the Women’s Advocate, in the MI Salud Plan covering the Virtual Region.

 

	
  

	
4.4.3.2

	
Puerto Rico Medicaid Program will ensure that each Enrollee receives an MA-10 and welcome letter upon certification. The welcome letter shall explain to the Enrollee how to use the MA-10 until the membership card is received, to obtain services immediately.

 

	
  

	
4.4.3.3

	
The Auto-Enrollment process will include Auto-Assignment of a PMG and PCP.  A new Enrollee who is a dependent of a current MI Salud Enrollee shall be automatically assigned to the same PMG as his or her parent or spouse who is a current MI Salud Enrollee.

 

	
  

	
4.4.3.4

	
The Contractor shall notify the Enrollee in writing of the right to request a change in assigned PMG and/or PCP for up to ninety (90) days after the Auto-Assignment, without cause.

 

	
  

	
4.4.3.5

	
The Contractor’s notice to the Enrollee and to ASES of the Enrollment shall be carried out as provided in Sections 5.2.3 through 5.2.9 of this Contract.

 

	
  

	
4.4.3.6

	
The Effective Date of Enrollment for those Auto-Enrolled will be governed by the rules stated in Section 4.4.1 of this Contract.  The Contractor’s notice of Auto-Enrollment, required by Section 5.2.4 of this Contract, shall serve as the notice of Enrollment referenced in Section 4.4.1.1 of this Contract.

 

  

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4.4.4

	
Except as otherwise provided in this Section 4.4 of this Contract, and notwithstanding the Term of Enrollment provided in Section 4.4.2 of this Contract, Enrollees shall remain enrolled in the MI Salud Plan until the occurrence of an event listed in Section 4.5 of this Contract (Disenrollment Responsibilities of ASES).

 

	
4.5

	
Disenrollment Responsibilities of ASES

 

	
  

	
4.5.1

	
Disenrollment occurs only when ASES or the Medicaid Program determines that an Enrollee is no longer eligible for MI Salud; or when Disenrollment is requested by the Contractor or Enrollee, and approved by ASES, as provided in Section 5.4.3-5.4.4 of this Contract.

 

	
  

	
4.5.2

	
Disenrollment will be effected by ASES, and ASES will issue notification to the Contractor.  Such notice shall be delivered via file transfer to the Contractor on a daily basis simultaneously with information on Enrollees within five (5) Calendar Days of making a final determination on Disenrollment.  ASES’s notice to the Contractor concerning Disenrollment will be conveyed by ASES simultaneously with information on Enrollees (see Section 4.3.6.1 of this Contract).

 

	
  

	
4.5.3

	
Disenrollment shall occur according to the following timeframes (the “Effective Date of Disenrollment”).  Upon the Effective Date of Disenrollment, the Conversion Clause in Section 5.5 of this Contract shall be triggered.

 

	
  

	
4.5.3.1

	
Except as otherwise provided in this Section 4.5, Disenrollment will take effect as of the Disenrollment date specified in ASES’s notice to the Contractor that an Enrollee is no longer eligible.  If ASES notifies the Contractor of Disenrollment on or before the last working day of the month in which eligibility ends, the Disenrollment will be effective on the first day of the following month.

 

	
  

	
4.5.3.2

	
When Disenrollment is effected at the Contractor’s or the Enrollee’s request, as provided in Sections 4.5.4, 4.5.5, and 5.4 of this Contract, Disenrollment shall take effect no later than the first day of the second month following the month that the Contractor or Enrollee requested the Disenrollment.  If ASES fails to make a decision on the Contractor’s or Enrollee’s request before this date, the Disenrollment will be deemed granted.  If the Enrollee requests reconsideration of a Disenrollment through the Contractor’s Grievance System, as provided in Article 14, the Grievance process shall be completed in time to permit the Disenrollment (if approved) to take effect in accordance with this timeframe.

 

  

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4.5.3.3

	
If what would otherwise be the Effective Date of Disenrollment under this subsection 4.5.3 falls:

 

	
  

	
4.5.3.3.1

	
When the Enrollee is an inpatient at a hospital, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the Enrollee is discharged from the hospital, or the last day of the month following the month in which Disenrollment would otherwise be effective, whichever occurs earlier;

 

	
  

	
4.5.3.3.2

	
During a month in which the Enrollee is in the second or third trimester of pregnancy, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the date of delivery; or

 

	
  

	
4.5.3.3.3

	
During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the following month.

 

	
  

	
4.5.3.4

	
For the public employees and pensioners who are Other Eligible Persons referred to in Section 1.3.1.3.2, Disenrollment shall occur according to the timeframes set for in Circular Letter 10-10-06, issued on October 6, 2011 (Attachment 13 to this Contract), by ASESt or in the Rules and Regulations to be issued by ASES, which will be timely notified to Contractor.

 

	
  

	
4.5.4

	
ASES will initiate Disenrollment at the request of the Contractor only under the circumstances set forth in Section 5.4.4 of this Contract.  ASES will approve a Disenrollment request by the Contractor, in ASES’s discretion, only if ASES determines:

 

	
  

	
4.5.4.1

	
That it is impossible for the Contractor to continue to provide services to the Enrollee without endangering the Enrollee or other MI Salud Enrollees; and

 

	
  

	
4.5.4.2

	
That an action short of Disenrollment, such as transferring the Enrollee to a different PCP or PMG, will not resolve the problem.

 

	
  

	
4.5.5

	
ASES will initiate Disenrollment at the request of an Enrollee only under the circumstances set forth in Section 5.4.3 of this Contract. ASES may approve or disapprove the request based on the reasons specified in the Enrollee’s request, or upon any relevant information provided to ASES by the Contractor about the Disenrollment request.

 

  

Page 41 of 327

  

 

	
  

	
4.5.6

	
Upon the Effective Date of Disenrollment, the Conversion Clause in Section 5.5 of this Contract shall apply.

 

	
  

	
4.5.7

	
ASES shall ensure, through the obligations of the Contractor under this Contract that Enrollees receive the notices contained in Section 5.2.6 (Re-Enrollment Procedures).  While these notices shall be issued by the Contractor, per Section 5.4.2 of this Contract, ASES shall provide the Contractor with the information on Certification and Negative Redetermination Decision (see Section 4.3.6.1 of this Contract) needed for the Contractor to carry out this responsibility. 

 

	
4.6

	
Enrollee Services and Marketing

 

	
  

	
4.6.1

	
ASES will provide to the Contractor a document entitled MI Salud Universal Beneficiary Guidelines (Attachment 3 to this Contract) for the purpose of providing uniform information in the Contractor’s Enrollee Handbook for MI Salud, as required by 42 CFR 438.10, and according to the requirements set forth in Section 6.4 of this Contract.

 

	
  

	
4.6.2

	
ASES shall have sole authority to review and approve all informational and Marketing Materials disseminated to Enrollees of the MI Salud Plan, including, but not limited to, the following:

 

	
  

	
4.6.2.1

	
ASES shall have sole authority to review and approve the Enrollee Handbook before it is printed and distributed, and will review and approve any amendment to the Enrollee Handbook before it is printed and distributed.  The Handbook, and any subsequent substantive changes to it, shall be final only upon ASES’s written confirmation of approval, as required in Sections 6.2.2 and 6.4.5 of this Contract.

 

	
  

	
4.6.2.2

	
ASES shall have sole authority to review and approve the format and content of the Enrollee ID Card that the Contractor intends to issue in accordance with CMS requirements and the guidelines set forth in Section 6.7 of this Contract.

 

	
4.7

	
Covered Services

 

	
  

	
4.7.1

	
Given the objective of MI Salud to promote an integrated approach to physical and behavioral health, and to improve Access to quality primary and specialty care services, ASES shall utilize all mechanisms set forth in this Contract (including, but not limited to, the Quality Improvement and Reporting provisions set forth in Articles 12 and 18) to ensure that the Contractor performs the services and tasks assigned to advance the program goals of MI Salud.

 

  

Page 42 of 327

  

 

	
  

	
4.7.2

	
[Intentionally left blank].

 

	
  

	
4.7.3

	
ASES shall provide to the Contractor before the Implementation Date of this Contract, and on an ongoing basis, updated information on the operational policies, procedures, and regulations of MI Salud that affect the scope of the Administrative Services to be provided by the Contractor and Covered Services under this Contract or otherwise affect this Contract (collectively, the “MI Salud Policies and Procedures”).  Accordingly, the Contractor will be included in any mailing list for the purpose of providing such information, and in any advisory committee or general meetings convened by ASES, the Pharmacy Benefits Manager, or any other organization whose objectives are to instruct MI Salud contractors on modifications to policies or benefits coverage.

 

	
4.8

	
Provider Network

 

	
  

	
4.8.1

	
ASES will provide the Contractor with timely updates to Puerto Rico’s list of excluded Providers, and also, if applicable, any such list issued by CMS or the U.S. Department of Health and Human Services, as well as any additional information that will affect who may be included in the Contractor’s Provider Network.  ASES will provide the Puerto Rico Provider Credentialing policies to the Contractor prior to the Implementation Date of this Contract.  The Puerto Rico Provider Credentialing policies shall be considered to be part of the MI Salud Policies and Procedures.

 

	
4.9

	
Quality Monitoring

 

	
  

	
4.9.1

	
ASES, in strict compliance with applicable provisions of 42 CFR 438.204 and other federal and Puerto Rico regulations, shall evaluate the delivery of health care by the Contractor’s Provider Network.  Such quality monitoring shall include monitoring of all the Contractor’s Quality Improvement programs described in Article 12 of this Contract.  ASES shall monitor the following items, among others:

 

	
  

	
4.9.1.1

	
The availability of Covered Services;

 

	
  

	
4.9.1.2

	
The adequacy of the Contractor’s Provider Network;

 

	
  

	
4.9.1.3

	
The Contractor’s coordination and continuity of care for Enrollees;

 

	
  

	
4.9.1.4

	
The coverage and authorization of Covered Services and Benefits;

 

	
  

	
4.9.1.5

	
The Contractor’s policies and procedures for selection and retention of Providers;

 

  

Page 43 of 327

  

 

	
  

	
4.9.1.6

	
The Contractor’s compliance with Enrollee information requirements in accordance with 42 CFR 438.10;

 

	
  

	
4.9.1.7

	
The Contractor’s compliance with Puerto Rico and federal privacy laws and regulations relative to confidentiality of Enrollee information;

 

	
  

	
4.9.1.8

	
The Contractor’s compliance with Enrollment and Disenrollment requirements and limitations;

 

	
  

	
4.9.1.9

	
The Contractor’s Grievance System;

 

	
  

	
4.9.1.10

	
The Contractor’s oversight of all Subcontractor relationships and delegations;

 

	
  

	
4.9.1.11

	
The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and, upon request, to Enrollees, and Providers’ application of the Guidelines;

 

	
  

	
4.9.1.12

	
The Contractor’s quality assessment and performance improvement program; and

 

	
  

	
4.9.1.13

	
The Contractor’s Information Systems to ensure it supports initial and ongoing review of Puerto Rico’s quality strategy.

 

	
4.10

	
Coordination with Contractor’s Key Staff

 

	
  

	
4.10.1

	
ASES will make diligent, good-faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of MI Salud operations.

 

	
  

	
4.10.2

	
Specifically, ASES will designate individuals within ASES who will serve as liaisons to the corresponding individuals on the Contractor’s staff, including:

 

	
  

	
4.10.2.1

	
A program integrity staff member;

 

	
  

	
4.10.2.2

	
A quality oversight staff member;

 

	
  

	
4.10.2.3

	
A Grievance System staff member; and

 

	
  

	
4.10.2.4

	
An information systems coordinator.

 

	
4.11

	
Information Systems and Reporting

 

	
  

	
4.11.1

	
ASES reserves the right to modify, expand, or delete the requirements contained in Articles 17 and 18 of this Contract with respect to the Data that the Contractor is required to submit to ASES, or to issue new requirements, in consultation with Contractor, as required by federal o Puerto Rico regulations or based in any public health policy change or ASES strategy.  If the change in requirements imposes material additional costs or expenses on the Contractor, or otherwise reduces such costs and expenses materially, the Parties shall negotiate and implement an adjustment in the Administrative Fee prior to any change in the Data requirements set forth in Articles 17 and 18 of this Contract.  Unless otherwise mutually agreed upon by the Parties, the Contractor shall have not less than thirty (30) Calendar Days and no more than ninety (90) Calendar Days from the day on which ASES issues notice of a required modification, addition, or deletion, to comply with the modification, addition, or deletion.   Any payment made by ASES that is based on Data submitted by the Contractor is contingent upon the Contractor’s compliance with the certification requirements contained in 42 CFR 438.606.

 

  

Page 44 of 327

  

 

	
  

	
4.11.2

	
ASES will make available a secure FTP server, accessible via the Internet, for receipt of electronic files and reports from the Contractor.  The Contractor shall provide a similar system for ASES to transmit files and reports deliverable by ASES to the Contractor.  When such systems are not operational, ASES and the Contractor shall agree mutually on alternate methods for the exchange of files.

 

	
  

	
4.11.3

	
ASES will deliver data to the Contractor, according to the layouts defined by ASES,  with the following information, according to the following timeframes:

 

	
  

	
4.11.3.1

	
On a Daily basis: Certifications and Negative Redetermination Decisions; Enrollment rejections and errors;

 

	
  

	
4.11.3.2

	
On a Daily and Monthly Basis: Enrollment data (including Certification and Negative Redetermination Decision);

 

	
  

	
4.11.3.3

	
On a Monthly Basis: Error return files and processing summary reports for monthly files submitted by the Contractor.

 

	
  

	
4.11.4

	
In an effort to improve the efficiency and quality of services to Enrollees and to help prevent Fraud, Waste and Abuse in the MI Salud Program, ASES shall require that all PCPs and PPN physician specialists maintain Enrollees’ Medical Records through a certified EHR system.  Any such certified EHR system, whether maintained as a complete or component system, must be ONC-ATCBs certified and shall meet the specifications set forth in Attachment 15. The PCPs and PPN physician specialists shall have a certified EHR system in place on or before December 31, 2013 or such later date as set forth in his/her Provider Contract.  Upon request, the Contractor shall assist the PCPs and PPN physician specialists in the acquisition and installation of such an appropriate EHR system at the Contractor’s expense. The Contractor shall also provide each such Provider with information on (i) the benefits of the EHR system and (ii) the costs of maintaining the EHR system.  MI Salud

 

  

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4.12

	
Readiness Review

 

	
  

	
4.12.1

	
ASES will conduct a readiness review of Contractor’s operations related to this Contract that will include, at a minimum, one (1) on-site review to provide assurances that the Contractor is able and prepared to perform all Administrative Services.

 

	
  

	
4.12.2

	
ASES’s review will document the status of the Contractor’s compliance with the MI Salud Program standards set forth in this Contract.  A multidisciplinary team appointed by ASES will conduct the readiness review.  The scope of the readiness review will include, but not be limited to, review and/or verification of:

 

	
  

	
4.12.2.1

	
Provider Network composition and Access;

 

	
  

	
4.12.2.2

	
Staff;

 

	
  

	
4.12.2.3

	
Marketing materials;

 

	
  

	
4.12.2.4

	
Content of Provider contracts;

 

	
  

	
4.12.2.5

	
EPSDT Plan;

 

	
  

	
4.12.2.6

	
Enrollee services capability;

 

	
  

	
4.12.2.7

	
Comprehensiveness of quality and Utilization Management strategies;

 

	
  

	
4.12.2.8

	
Policies and procedures for the Grievance System;

 

	
  

	
4.12.2.9

	
Financial solvency;

 

	
  

	
4.12.2.10

	
Contractor litigation history, current litigation, audits and other government investigations both in Puerto Rico and in other jurisdictions;

 

	
  

	
4.12.2.11

	
Information Systems performance and interfacing capabilities; and

 

	
  

	
4.12.2.12

	
All other matters ASES may deem reasonable in order to determine the Contractor’s compliance with the requirements of this Contract.

 

  

Page 46 of 327

  

 

	
  

	
4.12.3

	
The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.

 

	
  

	
4.12.4

	
Eligible Persons may not be enrolled in the MI Salud Program until ASES has determined that the Contractor is capable of meeting these standards.  The Contractor’s failure to pass the readiness review may result in the application of a Corrective Action Plan for any areas where the Contractor fails to pass the readiness review.

 

	
  

	
4.12.5

	
ASES will provide the Contractor with a summary of findings from the readiness review, as well as areas requiring remedial action.

 

	
ARTICLE 5

	
CONTRACTOR RESPONSIBILITIES

 

	
5.1

	
General Provisions

 

	
  

	
5.1.1

	
The Contractor shall complete the following actions, tasks, obligations, and responsibilities:

 

	
  

	
5.1.2

	
The Contractor must maintain the staff, organizational, and administrative capacity and capabilities necessary to carry out all the duties and responsibilities under this Contract.

 

	
  

	
5.1.3

	
The Contractor shall notify ASES within five (5) Business Days of  a change in the following:

 

	
  

	
5.1.3.1

	
Its business address, telephone number, facsimile number, and e-mail address;

 

	
  

	
5.1.3.2

	
Its corporate status;

 

	
  

	
5.1.3.3

	
Its solvency (as a result of a non-operational event);

 

	
  

	
5.1.3.4

	
Its corporate officers or executive employees involved in providing the Administrative Services contemplated in this Contract;

 

	
  

	
5.1.3.5

	
Its federal employee identification number or federal tax identification number; or

 

	
  

	
5.1.3.6

	
Its owner’s business address, telephone number, facsimile number, and e-mail address.

 

	
  

	
5.1.4

	
The Contractor shall provide to ASES, a report of the amount of the Administrative Fee that the Contractor incurred to perform the different administrative services under this Contract, including but not limited to: Case Management, Disease Management, Utilization Management, Credentialing Network providers, Network management, Quality improvement, Marketing, Enrollment, Enrollee services, Claims administration, Information Systems, financial management and reporting.  The report shall be submitted to ASES for every six (6) month period of the Contract on or before thirty (30) days after each six (6) month period.

 

  

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5.2

	
Enrollment Responsibilities of the Contractor

 

	
  

	
5.2.1

	
General Provisions

 

	
  

	
5.2.1.1

	
The Contractor shall coordinate with ASES as necessary for all Enrollment and Disenrollment functions.

 

	
  

	
5.2.1.2

	
The Contractor shall enroll in the Plan all certified Eligible Persons within the Service Regions upon receipt of notice from ASES that the individual is eligible, as provided in this Contract.

 

	
  

	
5.2.1.2.1

	
The Contractor shall provide assistance in the transition of Enrollees who are eligible according to Section 1.3.1.1.7 to the Region of residence from the Virtual Region upon notification of the change in eligibility category, and shall ensure continuity of care for authorized services.

 

	
  

	
5.2.1.3

	
The Contractor shall recognize Enrollees as enrolled as provided in, and effective according to the timeframes specified in Section 4.4 of this Contract.

 

	
  

	
5.2.1.4

	
The Contractor shall accept all certified Eligible Persons into the Plan without restrictions.  The Contractor shall not discriminate against individuals on the basis of religion, gender, race, color, national origin, or sexual preference, and will not use any policy or practice that has the effect of discriminating on the basis of religion, gender, race, color, or national origin or on the basis of health, health status, pre-existing condition, or need for health care services.

 

	
  

	
5.2.1.5

	
The Eligible Person will be immediately enrolled in the Contractor’s system.  The Contractor shall send the ID Card and other Enrollment documents within the timeframes established in sections 5.2.4.1 and 5.2.4.2.

 

	
  

	
5.2.2

	
General Enrollment Procedures for Certified Eligible Persons

 

	
  

	
5.2.2.1

	
The Contractor shall maintain adequate capacity in the Service Regions, to ensure prompt and voluntary Enrollment of all Enrollees, on a daily basis and in the order in which they apply.

 

  

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5.2.2.2

	
The Contractor shall provide Enrollees with specific information allowing for prompt, voluntary, and reliable Enrollment.

 

	
  

	
5.2.2.3

	
The Contractor shall use its Reasonable Efforts to maintain the functionality and reliability of all systems necessary for Enrollment and Disenrollment as provided in Article 17 of this Contract.

 

	
  

	
5.2.3

	
Enrollment Procedures with Respect to Potential Enrollees

 

	
  

	
5.2.3.1

	
Upon receipt from ASES of Certification Data, as provided in Section 4.3.6.1, the Contractor shall comply with the process of Auto-Enrollment and shall issue to the Enrollee a notice informing the Enrollee of the PMG and PCP he/she is assigned to and his/her rights to change, without cause, the PMG or PCP during a ninety (90) Calendar Days period from the effective date of the enrollment by calling or visiting the Contractor’s office.  The Contractor shall also inform the Enrollee of his/her rights to disenroll for cause as provided in Section 5.4.3.

 

	
  

	
5.2.3.2

	
Any Potential Enrollee may initiate the manual Enrollment process prior to the assigned Auto-Enrollment date by contacting the Contractor directly after the Potential Enrollee has been certified by Medicaid. If the Potential Enrollee visits the Contractor’s office to Enroll, the Contractor shall request that the Potential Enrollee select a PMG and PCP.  During the visit, the Contractor shall issue to the new Enrollee an Enrollee ID Card, a notice of Enrollment, an Enrollee Handbook, and a Provider Directory; or, such notice, ID Card, Handbook, and Provider Directory may be sent to the Enrollee via surface mail within the timeframes established in sections 5.2.4.1 and 5.2.4.2.

 

	
  

	
5.2.3.3

	
Once the Enrollee calls or visits the Contractor’s office to exercise the right of changing the assigned PMG, PCP, or both, the Contractor shall issue to the Enrollee a new Enrollee Id Card and, upon request, a notice of Enrollment change.  These may be sent to the Enrollee via surface mail within the timeframes in section 5.2.4.2.

 

  

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5.2.4

	
Procedures with Respect to Auto-Enrollment of Enrollees Other Than Newborns

 

	
  

	
5.2.4.1

	
Upon receipt from ASES of Certification of persons listed in Section 4.4.1.3 of this Contract (Enrollees who lose and regain eligibility within two months) and 4.4.1.5 of this Contract (mothers who are minor dependents and re-apply for MI Salud), the Contractor shall send the person, via surface mail, a notice that he or she has been Auto-Enrolled; that he or she shall be Auto-Assigned to the same PMG or PCP that he or she had during his or her previous Term of Enrollment; that he or she shall have ninety (90) Calendar Days from the Effective Date of Enrollment to disenroll from the Plan or the MBHO or to change PMG without cause; and that he or she has the right to disenroll for cause, as provided in Section 5.4.3.2 of this Contract.  The notice of Enrollment will clearly state the Effective Date of Enrollment.  Such notice shall be issued within five (5) Business Days of receipt of this information from ASES.

 

	
  

	
5.2.4.2

	
With the notice of Auto-Enrollment, the Contractor shall deliver the Enrollee ID Card, Enrollee Handbook, and Provider Directory; or, if it is impracticable to send these items in the same mailing, they shall be sent to the Enrollee via surface mail within two (2) Business Days of the date of mailing of the notice of Auto-Enrollment.

 

	
  

	
5.2.5

	
Procedures for Auto-Enrollment of Newborns

 

	
  

	
5.2.5.1

	
The Contractor shall notify Medicaid of any Enrollees who are expectant mothers, promptly upon its being informed about the diagnosis of the pregnancy by a Network Provider.

 

	
  

	
5.2.5.2

	
The Contractor shall promptly, upon learning that an Enrollee is an expectant mother, mail a newborn Enrollment packet to the expectant mother (1) instructing her to register the newborn with the Puerto Rico Medicaid Program within ninety (90) Calendar Days of the newborn’s birth by providing the newborn’s birth certificate; (2) notifying her that the newborn will be Auto-Enrolled in the MI Salud Plan; (3) informing her that unless she visits the Contractor’s office to select a PMG and PCP, the child will be Auto-Assigned to the mother’s PMG and to a PCP who is a pediatrician; and (4) informing her that she will have ninety (90) days after the child’s birth to disenroll the child from the Plan or the MBHO or to change the child’s PMG and PCP, without cause.

 

	
  

	
5.2.5.3

	
The Contractor shall provide assistance to any expectant mother who contacts the Contractor wishing to make a PCP and PMG selection for her newborn, per Section 5.3 of this Contract, and record that selection.

 

	
  

	
5.2.5.4

	
If the mother has not made a PCP and PMG selection at the time of the child’s birth, the Contractor shall, within five (5) Business Days of becoming aware of the birth, Auto-Assign the newborn to a PCP who is a pediatrician and to the mother’s PMG.

 

  

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5.2.5.5

	
Within seventy-two (72) hours of becoming aware of the birth of a child to an Enrollee, the Contractor shall submit a newborn notification to the Puerto Rico Medicaid Program, using a standard form to be provided by ASES.

 

	
  

	
5.2.5.6

	
If the mother has made a PCP and PMG selection on behalf of the newborn, per Section 5.3.1.3, this information shall be included in the notification to the Puerto Rico Medicaid Program.

 

	
  

	
5.2.5.7

	
The Contractor shall participate in any meeting, working group, or other mechanism requested by ASES in order to ensure coordination among the Contractor, ASES, and the Puerto Rico Medicaid Program in order to implement newborn Auto-Enrollment.

 

	
  

	
5.2.6

	
Re-Enrollment Procedures

 

	
  

	
5.2.6.1

	
The Contractor shall inform Enrollees who are Medicaid- and CHIP Eligible Persons and members of the Commonwealth Population of an impending Redetermination.  Such notice shall be provided ninety (90) Calendar Days, sixty (60) Calendar Days, and thirty (30) Calendar Days before the scheduled date of the Redetermination.  The notice shall inform the Enrollee that, if he or she is Recertified, his or her term of Enrollment in the Plan will automatically renew; but that, effective as of the date of Recertification, he or she will have a ninety- (90) day period in which he or she may disenroll from the Plan or from the MBHO without cause or to change his or her PMG selection without cause.  The notice shall advise Enrollees that Disenrollment will terminate the Enrollee’s access to health services under the MI Salud Plan.

 

	
  

	
5.2.6.2

	
The Contractor shall provide Enrollees with sixty (60) Calendar Days written notice before the start of each Term of Enrollment, as specified in Section 5.4.3.1 of this Contract, of the right to disenroll or to change PMG or PCP during the first ninety (90) Calendar Days of the new Term of Enrollment.  The notice shall specify that the right of Disenrollment applies separately to the Contractor and to the MBHO.

 

	
  

	
5.2.6.3

	
Upon written request of ASES, the Contractor shall provide a report for a specific period of time containing documentation that the Contractor has furnished the notices required in this subsection 5.2.6 of this Contract.

 

  

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5.2.6.4

	
The form letters used for the notices in Sections 5.2.6.1and 5.2.6.2 of this Contract fall within the requirement in Section 6.2.1 of this Contract that the Contractor seek advance written approval from ASES of certain documents

 

	
  

	
5.2.7

	
Specific Contractor Responsibilities Regarding Dual Eligible Beneficiaries. At the time of Enrollment, the Contractor shall provide Enrollees who are Medicaid-eligible and are also eligible for Medicare Part A or Part A and Part B (“Dual Eligible Beneficiaries”) with the information about their Covered Services and Co-Payments that is listed in Section 6.13 of this Contract.  In determining whether an Enrollee is a Dual Eligible Beneficiary, the Contractor must, in compliance with the ASES Normative Letter issued June 28, 2010, review the MA-10 to determine whether the Enrollee is Medicaid-Eligible (see Section 1.3.1 of this Contract).  Members of the Commonwealth Population (see Section 1.3.1.3.1 of this Contract) who are Medicare-eligible shall not be considered Dual Eligible Beneficiaries.

 

	
  

	
5.2.8

	
Enrollment Database

 

	
  

	
5.2.8.1

	
The Contractor shall maintain an Enrollment database that includes all Enrollees in its knowledge, and contains, for each Enrollee, the information specified in the carrier billing file/carrier eligibility file format agreed to by the Parties.

 

	
  

	
5.2.8.2

	
The Contractor shall notify Medicaid within one (1) Business Day when the Enrollment Database is updated to reflect a change in the place of residence of an Enrollee.

 

	
  

	
5.2.8.3

	
The Contractor shall secure any authorization required from Enrollees under the laws of Puerto Rico in order to allow the U.S. Department of Health and Human Services, and ASES and its Agents to review Enrollee medical records, in order to evaluate and determine quality, appropriateness, timeliness and cost of services performed under this Contract; provided that such authorization shall be limited by the Contractor’s obligation to observe the confidentiality of Enrollee patient information, as provided in Article 34.

 

	
  

	
5.2.9

	
Notification to Contractor of New Enrollees and of Completed Disenrollments

 

	
  

	
5.2.9.1

	
ASES shall notify Contractor, the MBHO, and the Pharmacy Benefits Manager (“PBM”) of new Enrollees and of completed Disenrollments on a routine daily basis. Such notification will be made through electronic transmissions.

 

  

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5.2.9.2

	
The notification will include all new Enrollees as of the Business Day before the notification is issued, and will be sent no later than the following Business Day after the Enrollment process has been completed (as signified by issuance of the Enrollee ID Card, either in person or by surface mail) or the Disenrollment process has been complete (as signified by the issuance of a Disenrollment notice).

 

	
  

	
5.2.9.3

	
In the event that the Contractor must update information previously submitted to ASES about a new Enrollment, or that the Contractor must add a new Enrollee who was previously omitted from the daily report, such update must occur the next Business Day after the information is updated or a new Enrollee is added.  ASES reserves the authority not to accept any new additions or corrections to Enrollment data after sixty (60) Calendar Days past the Effective Date of Enrollment stated in the Contractor’s notification to ASES.

 

	
  

	
5.2.10

	
Collaboration with MBHO and the PBM. Within the limits set by federal and Puerto Rico law, the Contractor shall provide to the MBHO and the PBM any information relating to new Enrollees that will assist the MBHO and the PBM, in its operations.

 

	
  

	
5.2.11

	
At any time, during the term of this Contract, ASES may redefine the Enrollment process in order to make it simpler and more efficient. Contractor commits to applying the required changes in their systems and operational processes to support these modifications provided, however that ASES will timely notify Contractor of any such changes in the process in order to ensure adequate implementaiton.

 

	
5.3

	
Selection and Change of a Primary Medical Group (“PMG”) and Primary Care Physician (“PCP”)

 

	
  

	
5.3.1

	
Selection of a PMG and PCP

 

	
  

	
5.3.1.1

	
The Contractor shall, at the time of Auto-Enrollment as described in Sections 4.4.3.3, 5.2.3 and 5.2.4 of this Contract, Auto-Assign the Enrollee to a PCP and PMG, bearing in mind the Enrollee’s needs as described in Section 5.3.1.2 of this Contract. At the time the Enrollee chooses to change his/her PMG, PCP, or both, the Contractor shall provide the necessary assistance.  The Contractor shall also permit the Enrollee to freely choose one Primary Care Physician(s) (PCP) and one PMG, provided however that in the case of women seeking Ob-gyn care, such Enrollee shall be allowed to choose two PCP’s, one of which shall be an Ob-gyn specialist.

 

  

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5.3.1.2

	
When Auto-Assigning the Enrollee to a PCP, the Contractor shall choose a physician other than, or in addition to, a general practice physician as their PCP, as follows:

 

	
  

	
5.3.1.2.1

	
Women Enrollees will be recommended to choose an obstetrician / gynecologist as a PCP.

 

	
  

	
5.3.1.2.2

	
Enrollees under twenty one (21) years of age will be recommended to choose a pediatrician as a PCP.

 

	
  

	
5.3.1.2.3

	
Enrollees with chronic health conditions including heart failure, kidney failure, or diabetes will be recommended to choose an internist as a PCP.

 

	
  

	
5.3.1.3

	
Per Section 5.2.5 of this Contract, following the Contractor’s notice to an expectant mother of her child’s upcoming Auto-Enrollment in the MI Salud Plan, the Contractor shall record any notice it receives from the mother concerning the selection of a PCP or PMG for the child.  The Contractor shall ensure that such selections take effect as of the date of the child’s birth.

 

	
  

	
5.3.1.4

	
In order to comply with the PMG capitation payment process, if Enrollee changes PMG during the first five days of the month, the change will be effective in the next subsequent month. If Enrollee changes PMG after the fifth day of the month, the change will be effective in the second subsequent month of the change.  Enrollee can still receive services until the change is effective through the original PMG assigned by the Contractor at the Auto-Enrollment process.

 

	
  

	
5.3.1.5

	
[Deleted. Intentionally left blank]MI Salud

 

	
  

	
5.3.2

	
Change of PMG or PCP

 

	
  

	
5.3.2.1

	
The Contractor shall permit Enrollees to change their PMG or PCP at any time for cause.  The following shall constitute cause for change of PMG.

 

	
  

	
5.3.2.1.1

	
The Enrollee’s religious or moral convictions conflict with the services offered by Providers in the PMG;

 

	
  

	
5.3.2.1.2

	
The Enrollee needs related services to be provided concurrently; not all services are available within the Preferred Provider Network associated with a PMG; and the Enrollee’s PCP or any other Provider has determined that receiving the services separately could expose the Enrollee to an unnecessary risk; or

 

  

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5.3.2.1.3

	
Other reasons, including poor quality of care, inaccessibility to Covered Services, inaccessibility to Providers with the experience to take care of the health care needs of the Enrollee.

 

	
  

	
5.3.2.2

	
The Contractor shall permit Enrollees to change their PMG or PCP for any reason, within certain timeframes:

 

	
  

	
5.3.2.2.1

	
During the ninety (90) Calendar days following the Effective Date of Enrollment;

 

	
  

	
5.3.2.2.2

	
At least every twelve (12) months, following the ninety (90) Calendar days after the Effective Date of Enrollment;

 

	
  

	
5.3.2.2.3

	
At any time, during time periods in which the Contractor is subject to intermediate sanctions, as defined in 42 CFR 438.702(a)(3).

 

	
  

	
5.3.2.2.4

	
If a request to change PMGs is submitted to the Contractor on or before the fifth day of a month, the change will become effective on the first day of the following month.  If a change is filed after the fifth day of the month, the change will be effective on the first day of the second succeeding month.

 

	
  

	
5.3.2.3

	
A Contractor may change an Enrollee’s PMG at the request of the PCP or other Provider within that PMG, in limited situations, as follows:

 

	
  

	
5.3.2.3.1

	
The Enrollee’s continued participation in the PMG seriously impairs the PMG’s ability to furnish services to either this particular Enrollee or other Enrollees;

 

	
  

	
5.3.2.3.2

	
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness; or

 

	
  

	
5.3.2.3.3

	
The Enrollee’s use of services constitutes Fraud, Waste or Abuse (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services).

 

  

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5.4

	
Disenrollment Responsibilities of the Contractor

 

	
  

	
5.4.1

	
Disenrollment occurs only (1) when ASES determines that an Enrollee is no longer eligible for MI Salud; or (2) for any of the reasons listed in this Section 5.4 of this Contract.

 

	
  

	
5.4.2

	
Notice to Enrollee of Disenrollment

 

	
  

	
5.4.2.1

	
Disenrollment decisions are the responsibility of ASES; however, notice to Enrollees of Disenrollment shall be issued by the Contractor.  The Contractor shall issue such notice in person or via surface mail to the Enrollee within five (5) Business Days of its receipt of a final Disenrollment decision from ASES, as provided in Sections 5.4.3 and 5.4.4 of this Contract.

 

	
  

	
5.4.2.2

	
Each notice of Disenrollment shall include information concerning:

 

	
  

	
5.4.2.2.1

	
the Effective Date of Disenrollment;

 

	
  

	
5.4.2.2.2

	
the reason for the Disenrollment;

 

	
  

	
5.4.2.2.3

	
the Enrollee’s appeal rights, including the availability of the Grievance System and of ASES’s Administrative Law Hearing process, as provided by Act 72 of September 7, 1993;

 

	
  

	
5.4.2.2.4

	
the right to re-enroll in MI Salud upon receiving a Recertification from the Puerto Rico Medicaid Program, if applicable; and

 

	
  

	
5.4.2.2.5

	
the Enrollee’s right, under the Conversion Clause in Section 5.5 of this Contract, to apply for a direct payment policy from the Contractor.

 

	
  

	
5.4.2.3

	
The Contractor shall be responsible for processing any Disenrollment from the MBHO that is distinct from a Disenrollment from the MI Salud Plan. If an Enrollee requests Disenrollment from the MBHO, as provided in 42 CFR 438.56(c), or if the MBHO wishes to request the Disenrollment of an Enrollee, as provided in 42 CFR 438.56(b), the MBHO shall convey the request to the Contractor, which shall forward the request to ASES, within ten (10) Business Days of receipt of the request, with a recommendation of the action to be taken (except that Disenrollments without cause from the MBHO, during specific timeframes established at 42 CFR 438.56(c)(2), shall be granted without any recommendation from the MI Salud Plan).

 

  

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5.4.3

	
Disenrollment at Enrollee Request

 

	
  

	
5.4.3.1

	
ASES shall make the final decision on Enrollee requests for Disenrollment.  An Enrollee wishing to request Disenrollment must submit an oral or written request to ASES or to the Contractor. If the request is made to the Contractor, the Contractor shall forward the request to ASES, within ten (10) Business Days of receipt of the request, with a recommendation of the action to be taken.

	
  

	
5.4.3.2

	
An Enrollee may request Disenrollment from the Plan without cause during the ninety (90) Calendar Days following the Effective Date of Enrollment with the Plan or the date that the Contractor sends the Enrollee notice of the Enrollment, whichever is later.  An Enrollee may request Disenrollment without cause every twelve (12) months thereafter.  In addition, an Enrollee may request Disenrollment without cause in the event that ASES notifies the Enrollee that Puerto Rico has imposed or intends to impose on the Contractor that sanction pursuant to the applicable  intermediate sanctions set forth in 42 CFR 438.702(a)(3).

 

	
  

	
5.4.3.3

	
An Enrollee may request Disenrollment from the MI Salud Plan for cause at any time.  The following constitute cause for Disenrollment by the Enrollee:

 

	
  

	
5.4.3.3.1

	
The Enrollee moves to a Service Region not administered by the Contractor, or outside of Puerto Rico;

 

	
  

	
5.4.3.3.2

	
The Enrollee needs related services to be performed at the same time, and not all related services are available within the General Network.  The Enrollee’s PCP or another Provider in the Preferred Provider Network have determined that receiving service separately would subject the Enrollee to unnecessary risk; and

 

	
  

	
5.4.3.3.3

	
Other acceptable reasons for Disenrollment at Enrollee request, per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care, lack of Access to Covered Services, or lack of Providers experienced in dealing with the Enrollee’s health care needs.  ASES shall determine whether the reason constitutes cause.

 

  

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5.4.3.4

	
If the Contractor fails to refer a Disenrollment request within the timeframe specified in Section 5.4.3.1 of this Contract, or if ASES fails to make a Disenrollment determination so that the Enrollee may be disenrolled by the first day of the second month following the month when the Disenrollment request was made, per Section 4.5.3 of this Contract, the Disenrollment shall be deemed approved at that time.

 

	
  

	
5.4.3.5

	
If the Enrollee’s request for Disenrollment under this Section is denied, the Contractor shall provide the Enrollee with a notice of the decision.  The notice shall include the grounds for the denial and shall inform the Enrollee of his or her right to use the Grievance System as provided in Article 14, and to have access to an Administrative Law Hearing.

 

	
  

	
5.4.4

	
Disenrollment Initiated by the Contractor

 

	
  

	
5.4.4.1

	
The Contractor shall complete all paperwork required by ASES for the Disenrollment of Enrollees it is seeking to disenroll.

 

	
  

	
5.4.4.2

	
ASES reserves authority to make all Disenrollment decisions; nonetheless, the Contractor shall issue the notice of Disenrollment to the Enrollee (see Section 5.4.2 of this Contract).

 

	
  

	
5.4.4.3

	
The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee’s consent. The Contractor shall notify ASES upon identification of an Enrollee who it knows or believes meets the criteria for Disenrollment.

 

	
  

	
5.4.4.4

	
When requesting Disenrollment of an Enrollee for reasons described in Section 5.4.4.7 of this Contract, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and care coordination to resolve any difficulty leading to the request.  The Contractor shall also provide evidence of having given at least one (1) written warning to the Enrollee, certified return receipt requested, regarding implications of his or her actions.

 

	
  

	
5.4.4.5

	
If the Enrollee has demonstrated abusive or threatening behavior as defined by ASES, only one (1) Contractor intervention, and a subsequent written attempt to resolve the difficulty, are required.

 

	
  

	
5.4.4.6

	
The Contractor shall submit Disenrollment requests to ASES, and the Contractor shall honor all Disenrollment determinations made by ASES.  ASES’s decision on the matter shall be final, conclusive and not subject to appeal by the Contractor.

 

  

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5.4.4.7

	
The following are acceptable reasons for the Contractor to request Disenrollment:

 

	
  

	
5.4.4.7.1

	
The Enrollee’s continued Enrollment in the MI Salud Plan seriously impairs the ability to furnish services to either this particular Enrollee or other Enrollees;

 

	
  

	
5.4.4.7.2

	
The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness;

 

	
  

	
5.4.4.7.3

	
The Enrollee’s use of services constitutes Fraud, Waste or Abuse (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services);

 

	
  

	
5.4.4.7.4

	
The Enrollee has moved out of Puerto Rico or out of the Contractor’s  Service Regions;

 

	
  

	
5.4.4.7.5

	
The Enrollee is placed in a long-term care nursing facility or intermediate care facility for the mentally retarded;

 

	
  

	
5.4.4.7.6

	
The Enrollee’s Medicaid or CHIP eligibility category changes to a category ineligible for MI Salud; or

 

	
  

	
5.4.4.7.7

	
The Enrollee has died or has been incarcerated, thereby making him or her ineligible for Medicaid or CHIP or otherwise ineligible for MI Salud.

 

	
  

	
5.4.4.8

	
The Contractor may not request Disenrollment for any discriminatory reason, including but not limited to the following:

 

	
  

	
5.4.4.8.1

	
Adverse changes in an Enrollee’s health status;

 

	
  

	
5.4.4.8.2

	
Missed appointments;

 

	
  

	
5.4.4.8.3

	
Utilization of medical services;

 

	
  

	
5.4.4.8.4

	
Diminished mental capacity;

 

	
  

	
5.4.4.8.5

	
Pre-existing medical condition;

 

  

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5.4.4.8.6

	
The Enrollee’s attempt to exercise his or her rights under the Grievance System; or

 

	
  

	
5.4.4.8.7

	
Uncooperative or disruptive behavior resulting from the Enrollee’s special needs (except when his or her continued enrollment in the MI Salud Plan seriously impairs the entity’s ability to furnish services to either such Enrollee or other Enrollees).

 

	
  

	
5.4.4.9

	
The request of one PMG to have an Enrollee assigned to a different PMG, per Section 5.3.2.3 of this Contract, shall not be sufficient cause for the Contractor to request that the Enrollee be disenrolled from the Plan.  Rather, the Contractor shall, if possible, assign the Enrollee to a different and available PMG within the Plan.

 

	
  

	
5.4.4.10

	
In the event that the Contractor seeks Disenrollment of an Enrollee, the Contractor must notify the Enrollee of the availability of the Grievance System and of ASES’s Administrative Law Hearing process, as provided by Act 72 of September 7, 1993, as amended.

 

	
  

	
5.4.4.11

	
The Contractor shall maintain policies and procedures to comply with the Puerto Rico Patient’s Bill of Rights Act and with the Medicaid Regulations at 42 CFR 438.100, to ensure that Enrollee’s exercise of Grievance rights does not adversely affect the services provided to the Enrollee by the Contractor or by ASES.

 

	
  

	
5.4.5

	
Use of the Contractor’s Grievance System. ASES may at its option require that the Enrollee seek redress through the Contractor’s Grievance System before ASES makes a determination on the Enrollee’s request for Disenrollment.  The Contractor shall within two (2) Business Days inform ASES of the outcome of the grievance process.  ASES may take this information into account in making a determination on the request for Disenrollment.  The Grievance process must be completed in time to permit the Disenrollment (if approved) to be effective in accordance with the timeframe specified in Section 4.5.3 of this Contract; if the process is not completed by that time, then the Disenrollment will be deemed approved by ASES.

 

	
  

	
5.4.6

	
Disenrollment during Termination Hearing Process. If ASES notifies the Contractor of its intention to terminate the Contract as provided in Article 35, ASES may allow Enrollees to disenroll immediately without cause.  In the event of such termination, ASES must provide Enrollees with the notice required by 42 CFR 438.10, listing their options for receiving services following the Termination Date of the Contract.

 

  

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5.5

	
Conversion Clause

 

	
  

	
5.5.1

	
If during the term of this Contract, an Enrollee is disenrolled from the MI Salud Plan, the Enrollee shall have the right to subscribe to a direct payment policy from the Contractor pursuant to the Contractor’s standard policies and procedures.  The Contractor’s obligation to provide such a policy is limited as provided in this Section 5.5.  The direct payment policy shall be issued by the Contractor without imposing pre-existing condition bars or waiting periods.  The Enrollee must request the subscription to a direct payment policy in writing, and submit the first premium to the Contractor, on or before thirty-one (31) Calendar Days after the Effective Date of Disenrollment, bearing in mind that:

 

	
  

	
5.5.1.1

	
Enrollment in the direct payment policy shall be at the option of the former Enrollee.

 

	
  

	
5.5.1.2

	
The premium for the direct payment policy will be in accordance with the Contractor’s rate then in effect, applicable to the form and benefits of the direct payment policy, in accordance with the risk category applicable to the former Enrollee, and the age reached on the Effective Date of Disenrollment from the direct payment policy.

 

	
  

	
5.5.1.3

	
The direct payment policy shall also provide for coverage to any Dependent of the former Enrollee, if such Dependent was considered an Eligible Person for MI Salud as of the Effective Date of Disenrollment. At the option by the Contractor, separate direct payment policies may be issued to cover family members who were formerly MI Salud Enrollees, rather than enrolling such family members in one policy.

 

	
  

	
5.5.2

	
If the Enrollee requests a direct payment policy in the timeframe provided in this Section, the policy will be effective upon the Effective Date of Disenrollment from MI Salud.

 

	
  

	
5.5.3

	
The Contractor will not be obligated to issue a direct payment policy covering a person who has the right to receive similar services provided by any insurance coverage or under the Medicare Program, if such benefits, jointly provided with the direct payment policy, result in an excess of coverage (over insurance), according to the standards of the Contractor.

 

	
  

	
5.5.4

	
[Intentionally left blank].

 

	
  

	
5.5.5

	
Subject to the conditions and limitations in this Section, a conversion to a direct payment policy shall be granted only:

 

  

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5.5.5.1

	
To Enrollees who are Disenrolled because they receive a Negative Redetermination Decision from the Puerto Rico Medicaid Program; and

 

	
  

	
5.5.5.2

	
To Enrollees who are Disenrolled because they are no longer Eligible Persons as defined in Section 1.3.1 of this Contract, regardless of whether their family members who are MI Salud Enrollees remain eligible and continue to be enrolled.

 

	
  

	
5.5.6

	
If a former Enrollee under this Contract receives health services that are covered services under the direct payment policy described in this Section, and such services are rendered during the period when the former Enrollee is already eligible to receive the direct payment policy pursuant to this Section but before the policy is in effect, the benefits which he or she would have a right to collect under such direct payment policy will be paid as a claim under the direct payment policy, so long as the former Enrollee has requested the direct payment policy as of the date such services are rendered and has paid the first premium.

 

	
  

	
5.5.7

	
If any Enrollee under this Contract subsequently acquires the right to obtain a direct payment policy, as provided in this Section 5.5 and is not notified of the existence of this right at least fifteen (15) Calendar Days prior to the expiration of the period in which the Enrollee may request the subscription to a direct payment policy and pay its corresponding first premium, as provided in Section 5.5.1, such Enrollee will be granted an additional period during which time the Enrollee may request to be subscribed to a direct payment policy.  This additional period does not imply the continuation of the Enrollee’s Enrollment under this Contract. The additional period specified in this Section 5.5.7 will expire fifteen (15) Calendar Days after the Enrollee is notified, but in no case will it be extended beyond sixty (60) Calendar Days after the Disenrollment or event of termination specified in sections 5.5.5 and 5.5.8 of this Contract, respectively.  The notification of the additional period specified herein shall be made in writing and handed to the Enrollee or mailed to the last known address of the Enrollee. If the Enrollee is granted an additional period, as provided herein, and if during such additional period the Enrollee submits the written request and makes the first premium payment, the effective date of the direct payment policy will be the termination of the health insurance coverage under this Contract.

 

	
  

	
5.5.8

	
Subject to the other conditions stated in this Section 5.5, Enrollees will have the right to conversion, up to the following dates:

 

	
  

	
5.5.8.1

	
The Enrollee’s Effective Date of Disenrollment;

 

	
  

	
5.5.8.2

	
The Termination Date of this Contract; or

 

  

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5.5.8.3

	
The date of amendment of this Contract, if such an amendment eliminates the Enrollee’s eligibility.

 

	
ARTICLE 6

	
ENROLLEE SERVICES

 

	
6.1

	
General Provisions

 

	
  

	
6.1.1

	
The Contractor shall ensure that Enrollees are aware of their rights and responsibilities; how to obtain care; what to do in an emergency or urgent medical situation; how to request a Grievance, Appeal, or Administrative Law Hearing; and how to report suspected Fraud, Waste and Abuse.

 

	
  

	
6.1.2

	
The Contractor’s informational materials must convey to Enrollees the important changes in the delivery of Covered Services reflected in the introduction of the MI Salud Program, including the integration of physical and behavioral health services and the concepts of Primary Medical Groups and Preferred Provider Networks.

 

	
  

	
6.1.3

	
The information conveyed in the Contractor’s written materials shall conform with ASES’s Universal Beneficiary Guidelines, included as Attachment 3 to this Contract.

 

	
  

	
6.1.4

	
The Contractor shall convey information to Enrollees via written materials and via telephone, internet, and face-to-face communications and shall allow Enrollees to submit questions and to receive responses from the Contractor.

 

	
  

	
6.1.5

	
In developing informational materials on MI Salud, the Contractor shall remain cognizant that MI Salud includes a mixed population of Enrollees.  In advising an individual Enrollee about Enrollment, the scope of services, and cost-sharing, Contractor shall provide information applicable to that Enrollee’s eligibility category.  The Contractor shall ensure that the informational materials disseminated to all MI Salud Enrollees accurately identify differences among the categories of Eligible Persons.

 

	
  

	
6.1.6

	
The Contractor shall provide Enrollees with at least thirty (30) Calendar Days written notice of any significant change in policies concerning Enrollees’ Disenrollment rights (see Section 5.4.3 of this Contract), right to change PMGs or PCPs (see Section 5.3 of this Contract), or any significant change to any of the items listed in Enrollee Rights and Responsibilities (Section 6.5 of this Contract), regardless of whether ASES or the Contractor caused the change to take place.  This Section 6.1.6 shall not be construed as giving the Contractor the right to change its policies and procedures related to its services under this Contract without prior written approval from ASES.

 

  

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6.2

	
ASES Approval of All Written Materials

 

	
  

	
6.2.1

	
Except as otherwise provided below, written materials described in this Article 6 must be submitted to ASES for review at least thirty (30) Calendar days before their printing and distribution, as required by Act 194 of August 2000.  This requirement applies to:

 

	
  

	
6.2.1.1

	
The materials described in this Article 6 distributed to all Enrollees, including the Enrollee Handbook;

 

	
  

	
6.2.1.2

	
Policy letters, coverage policy statements, or other communications about Covered Services under MI Salud distributed to Enrollees; and

 

	
  

	
6.2.1.3

	
Standard letters and notifications, such as the notice of Enrollment required in Section 5.2.3.2 of this Contract, the notice of Redetermination required in Section 5.2.6.1 of this Contract, and the notice of Disenrollment required in Section 5.4.2 of this Contract.

 

	
  

	
6.2.2

	
The Contractor shall provide ASES with advance notice of any changes made to written materials that will be distributed to all Enrollees.  Notice shall be provided to ASES at least thirty (30) Calendar Days before the effective date of the change.  Within five (5) Business Days of receipt of the materials, ASES will respond to the Contractor’s submission with either an approval of the materials, recommended modifications, or a notification that more review time is required.  If the Contractor receives no response from ASES within ten (10) Business Days of ASES’s receipt of the materials, the materials shall be deemed approved.  Except as otherwise provided in this Section, the Contractor may distribute the revised written materials only upon written approval of the changes from ASES.

 

	
6.3

	
Requirements for Written Materials

 

	
  

	
6.3.1

	
The Contractor shall make all written materials available in alternative formats and in a manner that takes into consideration the Enrollee’s special needs, including Enrollees who are visually impaired or have limited reading proficiency.  The Contractor shall notify all Enrollees that information is available in alternative formats, and shall instruct them how to access those formats.

 

	
  

	
6.3.2

	
Except as provided in Section 6.4 of this Contract (Enrollee Handbook), the Contractor shall make all written information available in Spanish, with a language block in English, explaining (1) that the Enrollee may access an English translation of the information if needed; and (2) that the Contractor will provide oral interpretation services into any language other than Spanish or English, if needed.  Such translation or interpretation shall be provided by the Contractor at no cost to the Enrollee. The language block shall comply with 42 CFR 438.10(c)(2).

 

  

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6.3.3

	
If oral interpretation services are required in order to explain the Benefits covered under MI Salud to an Enrollee or Potential Enrollee who does not speak either English or Spanish, the Contractor must, at its own cost, make such services available in a third language, in compliance with 42 CFR 438.10(c)(4).

 

	
  

	
6.3.4

	
All written materials shall be worded such that they are understandable to a person who reads at the fourth (4th) grade level.

 

	
  

	
6.3.5

	
Within ninety (90) Calendar Days of a notification from ASES that ASES has identified a prevalent language other than Spanish or English (with “prevalent language” defined as a language that is the primary language of more than five percent (5%) of the population of Puerto Rico), all vital Contractor documents shall be translated into and made available in such language.

 

	
6.4

	
Enrollee Handbook Requirements

 

	
  

	
6.4.1

	
The Contractor shall produce at its sole cost, and shall mail to all new Enrollees, an Enrollee Handbook including information on both physical and behavioral health services offered under MI Salud.  The Contractor shall collect from the MBHO the information on behavioral health services needed to compile the Enrollee Handbook.  The Contractor shall distribute the Handbook either simultaneously with the notice of Enrollment referenced in Section 5.2.3.2 of this Contract or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.

 

	
  

	
6.4.2

	
The Contractor shall :

 

	
  

	
6.4.2.1

	
As required by 42 CFR 438.10(i), on the later of August 1 or thirty (30) Calendar Days after its approval by ASES, mail to all Enrollees a Handbook supplement that includes information on the following:

 

	
  

	
6.4.2.1.1

	
The Contractor’s service area;

 

	
  

	
6.4.2.1.2

	
Benefits covered under MI Salud in the Service Regions;

 

	
  

	
6.4.2.1.3

	
Any cost-sharing imposed by ASES; and

 

	
  

	
6.4.2.1.4

	
To the extent available, quality and performance indicators, including Enrollee satisfaction.

 

  

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6.4.3

	
The Contractor shall use the Universal Beneficiary Guide, provided by ASES and included as Attachment 3 to this Contract, as a model for its Handbook; however, the Contractor shall ensure that its Handbook meets all the requirements listed in this Section 6.4.

 

	
  

	
6.4.4

	
Pursuant to the requirements set forth in 42 CFR 438.10, the Enrollee Handbook shall include, at a minimum, the following:

 

	
  

	
6.4.4.1

	
A table of contents;

 

	
  

	
6.4.4.2

	
An explanation of the purpose of the Enrollee ID Card and a warning that transfer of the card to another person constitutes Fraud;

 

	
  

	
6.4.4.3

	
Information about the role of the PCP and how to choose a PCP;

 

	
  

	
6.4.4.4

	
Information about the PMG, how to choose a PMG, and which Benefits may be accessed through the PMG;

 

	
  

	
6.4.4.5

	
Information about the Preferred Provider Network associated with the Enrollee’s PMG, and the benefits of seeking services within the PPN;

 

	
  

	
6.4.4.6

	
Information about the circumstances under which Enrollees may change to a different PMG;

 

	
  

	
6.4.4.7

	
Information about what to do when family size changes, including the responsibility of new mothers who are Medicaid Eligible to register their newborn with the Puerto Rico Medicaid Program and to apply for Enrollment of the newborn;

 

	
  

	
6.4.4.8

	
Appointment procedures;

 

	
  

	
6.4.4.9

	
Information on Benefits and Covered Services, including how the scope of Benefits and Covered Services differs between Medicaid- and CHIP Eligible Persons and Other Eligible Persons;

 

	
  

	
6.4.4.10

	
An explanation of the integration of physical and behavioral health services under MI Salud, and the availability of behavioral health Providers within the PPN;

 

	
  

	
6.4.4.11

	
Information on how to access local resources for Non-Emergency Medical Transportation (NEMT);

 

	
  

	
6.4.4.12

	
An explanation of any service limitations or exclusions from coverage;

 

  

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6.4.4.13

	
Information on where and how Enrollees may access benefits not available from or not covered by the MI Salud Plan;

 

	
  

	
6.4.4.14

	
The Medical Necessity definition used in determining whether services will be covered (see Section 7.2 of this Contract);

 

	
  

	
6.4.4.15

	
A description of all pre-certification, Prior Authorization or other requirements for treatments and services;

 

	
  

	
6.4.4.16

	
The policy on Referrals for specialty care and for other Covered Services not furnished by the Enrollee’s PCP;

 

	
  

	
6.4.4.17

	
Information on how to obtain services when the Enrollee is outside the Contractor’s Service Regions;

 

	
  

	
6.4.4.18

	
Information on how to obtain after-hours coverage;

 

	
  

	
6.4.4.19

	
An explanation of cost-sharing, including

 

	
  

	
6.4.4.19.1

	
the differences in cost-sharing responsibilities between Medicaid- and CHIP Eligible Persons and Other Eligible Persons, and

 

	
  

	
6.4.4.19.2

	
the cost-sharing responsibilities of Dual Eligible Beneficiaries, as well as the other information for Dual Eligible Beneficiaries listed in Section 6.13 of this Contract;

 

	
  

	
6.4.4.20

	
The geographic boundaries of the Service Regions;

 

	
  

	
6.4.4.21

	
Notice of all appropriate mailing addresses and telephone numbers to be utilized by Enrollees seeking information or authorization, including the Contractor’s toll-free telephone line and Web site address;

 

	
  

	
6.4.4.22

	
A description of Utilization Management policies and procedures used by the Contractor;

 

	
  

	
6.4.4.23

	
A description of Enrollee rights and responsibilities as described in Section 6.5 of this Contract;

 

	
  

	
6.4.4.24

	
The policies and procedures for Disenrollment, including when Disenrollment may be requested without Enrollee consent by the Contractor and information about Enrollee’s right to request Disenrollment, and including notice of the fact that the Enrollee will lose access to services under MI Salud if he or she chooses to disenroll;

 

  

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6.4.4.25

	
Information on Advance Directives, including the right of Enrollees to file directly with ASES or with the Puerto Rico Office of the Patient Advocate, complaints concerning Advance Directive requirements listed in Section 7.10 of this Contract;

 

	
  

	
6.4.4.26

	
A statement that additional information, including the Provider guidelines and information on the structure and operation of the MI Salud Plan and the Physician Incentive Plan, shall be made available to Enrollees upon request;

 

	
  

	
6.4.4.27

	
Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:

 

	
  

	
6.4.4.27.1

	
What constitutes an Emergency Medical Condition;

 

	
  

	
6.4.4.27.2

	
The fact that Prior Authorization is not required for Emergency  Services;

 

	
  

	
6.4.4.27.3

	
Notice that

 

	
  

	
6.4.4.27.3.1

	
For Medicaid and CHIP Eligible Persons,

 

	
  

	
6.4.4.27.3.1.1

	
No Co-Payments shall be charged for the treatment of an Emergency Medical Condition;

 

	
  

	
6.4.4.27.3.1.2

	
No Co-Payments shall be charged for children  twenty-one years of age  and under except those who are under the public employee’s coverage;

 

	
  

	
6.4.4.27.3.1.3

	
No Co-Payments will be charged for Indians; and

 

	
  

	
6.4.4.27.3.1.4

	
Co-Payments apply to emergency room services outside the Enrollee’s PPN to treat a condition that does not meet the definition of Emergency Medical Condition set forth in this Contract, but by using the Tele MI Salud service (see Section 6.8 of this Contract), the Enrollee may avoid a Co-Payment for such services; and

 

	
  

	
6.4.4.27.3.2

	
For Other Eligible Persons, Co-Payments apply to Emergency Services outside the Enrollee’s PPN, but the Enrollee may avoid a Co-Payment by using the Tele MI Salud service (see Section 6.8 of this Contract).

 

  

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6.4.4.27.4

	
The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;

 

	
  

	
6.4.4.27.5

	
The scope of Post-Stabilization Services offered under the Plan;

 

	
  

	
6.4.4.27.6

	
The locations of emergency rooms and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and

 

	
  

	
6.4.4.27.7

	
The fact that an Enrollee has a right to use any hospital or other setting for Emergency Services;

 

	
  

	
6.4.4.28

	
An explanation of the Redetermination process, including

 

	
  

	
6.4.4.28.1

	
Disenrollment as a consequence of a Negative Redetermination Decision, and

 

	
  

	
6.4.4.28.2

	
The Re-Enrollment period that follows a new Certification; and

 

	
  

	
6.4.4.29

	
Information on the Contractor’s Grievance Systems policies and procedures, as described in Article 14 of this Contract.  This description must include the following:

 

	
  

	
6.4.4.29.1

	
The right to file a Grievance and Appeal with the Contractor;

 

	
  

	
6.4.4.29.2

	
The requirements and timeframes for filing a Grievance or Appeal with the Contractor;

 

	
  

	
6.4.4.29.3

	
The availability of assistance in filing a Grievance or Appeal with the Contractor;

 

	
  

	
6.4.4.29.4

	
The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal with the Contractor by phone;

 

	
  

	
6.4.4.29.5

	
The right to an Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;

 

  

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6.4.4.29.6

	
Notice that if the Enrollee files an Appeal or a request for an Administrative Law Hearing and requests continuation of services, the Enrollee may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee;

 

	
  

	
6.4.4.29.7

	
Any Appeal rights that Puerto Rico chooses to make available to Providers to challenge the failure of the Contractor to cover a service;

 

	
  

	
6.4.4.29.8

	
Instructions on how an Enrollee can report suspected Fraud on the part of a Provider, and protections that are available for whistleblowers; and

 

	
  

	
6.4.4.29.9

	
Information on the family planning services provided by the Puerto Rico Health Department.

 

	
  

	
6.4.5

	
The Enrollee Handbook shall be submitted to ASES for review and prior written approval.  Submission of the Handbook by the Contractor shall be in accordance with the timeframes specified in Attachment 12 to this Contract (Initial Deliverable Due Dates).

 

	
  

	
6.4.6

	
The Contractor shall be responsible for producing the Enrollee Handbook in both English and Spanish.

 

	
6.5

	
Enrollee Rights and Responsibilities

 

The Contractor shall have written policies and procedures regarding the rights of Enrollees and shall comply with any applicable federal and Puerto Rico laws and regulations that pertain to Enrollee rights, including those set forth in 42 CFR 438.100 and in the Puerto Rico Patient’s Bill of Rights Act 194 of August 25, 2000; the Puerto Rico Mental Health Law of October 2, 2000, as amended and implemented; and Law 11 of April 11, 2001, creating the Office of the Patient Advocate.  These rights shall be included in the Enrollee Handbook.  At a minimum, the policies and procedures shall specify the Enrollee’s right to:

 

	
  

	
6.5.1

	
Receive information pursuant to 42 CFR 438.10;

 

	
  

	
6.5.2

	
Be treated with respect and with due consideration for the Enrollee’s dignity and privacy;

 

	
  

	
6.5.3

	
Have all records and medical and personal information remain confidential, except to the extent it may be or must be disclosed by law.

 

  

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6.5.4

	
Receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee’s condition and ability to understand;

 

	
  

	
6.5.5

	
Participate in decisions regarding his or her health care, including the right to refuse treatment;

 

	
  

	
6.5.6

	
Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in 42 CFR 482.13(e) and other federal regulations on the use of restraints and seclusion;

 

	
  

	
6.5.7

	
Request and receive a copy of his or her Medical Records pursuant to 45 CFR Parts 160 and 164, subparts A and E, in hard copy or electronic format, and request to amend or correct the record, as specified in 45 CFR 164.524 and 164.526, respectively;

 

	
  

	
6.5.8

	
Be furnished health care services in accordance with 42 CFR 438.206 through 438.210;

 

	
  

	
6.5.9

	
Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the Enrollee is treated;

 

	
  

	
6.5.10

	
Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Enrollee for which ASES does not pay the Contractor; not be held liable for Covered Services provided to the Enrollee for which ASES or the MI Salud Plan does not pay the Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of amount the Enrollee would owe if the Provider provided the services directly; and

 

	
  

	
6.5.11

	
Only be responsible for cost-sharing in accordance with 42 CFR 447.50 through 42 CFR 447.59.

 

	
6.6

	
Provider Directory

 

	
  

	
6.6.1

	
The Contractor shall produce and shall mail to all new Enrollees a Provider Directory that includes information on both physical and behavioral health service Providers under MI Salud.  The Contractor shall collect from the MBHO the information on behavioral health Providers needed in order to compile the Provider Directory.  The Contractor shall distribute the Provider Directory by delivering it at the time of Certification in person, or, if this is impractical, by sending it via surface mail, within five (5) Calendar Days of sending the notice of Enrollment referenced in Section 5.2.3.2 of this Contract.

 

  

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6.6.2

	
The Contractor shall produce and distribute annual updates of the Provider Directory to all Enrollees.

 

	
  

	
6.6.3

	
The Contractor shall make the Provider Directory available on its Web site.

 

	
  

	
6.6.4

	
The Provider Directory shall include names, locations, office hours, and telephone numbers of current Network Providers.  This includes, at a minimum, information, sorted by Service Region, on PCPs, specialists, dentists, FQHCs and RHCs, behavioral health and substance abuse Providers affiliated with the MBHO in each Service Region, and hospitals. The Provider Directory shall also identify providers that are not accepting new patients.

 

	
  

	
6.6.5

	
The Provider Directory shall group Providers according to the PMG Preferred Provider Network with which they are affiliated.

 

	
  

	
6.6.6

	
The Contractor shall submit the Provider Directory to ASES for review and prior approval in the timeframe specified in Attachment 12 to this Contract.

 

	
  

	
6.6.7

	
The Contractor shall update and amend the Provider Directory on its Web site within five (5) Business Days of any changes.

 

	
  

	
6.6.8

	
On a monthly basis, the Contractor shall submit to ASES any changes and edits to the Provider Directory, including any changes supplied to the Contractor by the MBHO.  Such changes shall be submitted electronically in the format specified by ASES.

 

	
6.7

	
Enrollee Identification (ID) Card

 

	
  

	
6.7.1

	
The Contractor shall furnish to all new Enrollees an Enrollee ID Card.  The Id card shall be made of durable plastic material and will be sent to the Enrollee via surface mail within two (2) Calendar Days of sending the Auto-Enrollment notification with the assignment of the PMG and the PCP

 

	
  

	
6.7.2

	
The Enrollee ID Card must, at a minimum, include the following information:

 

	
  

	
6.7.2.1

	
The “MI Salud” logo;

 

	
  

	
6.7.2.2

	
The Enrollee’s name;

 

	
  

	
6.7.2.3

	
A designation of the Enrollee as a Medicaid Eligible, CHIP Eligible, or Other Eligible Person;

 

  

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6.7.2.4

	
The Enrollee’s Medicaid identification number, or CHIP identification number;

 

	
  

	
6.7.2.5

	
The Enrollee’s Plan group number;

 

	
  

	
6.7.2.6

	
If the Enrollee is eligible for MI Salud as a Dependent, the Enrollee’s relationship to the principal Enrollee;

 

	
  

	
6.7.2.7

	
The Effective Date of Enrollment in MI Salud;

 

	
  

	
6.7.2.8

	
The master patient index;

 

	
  

	
6.7.2.9

	
The applicable Co-Payment levels for various services outside the Enrollee’s PPN, and for children of public employees enrolled in MI Salud classified as coverage 400, and the assurance that no Co-Payment will be charged for the treatment of an Emergency Medical Condition for a Medicaid Eligible Person and for CHIP children twenty-one (21) years of age or under, no Co-Payments will be charged under any circumstances.

 

	
  

	
6.7.2.10

	
The PCP’s name and the PMG’s number;

 

	
  

	
6.7.2.11

	
The name and telephone number(s) of the Contractor;

 

	
  

	
6.7.2.12

	
The twenty-four (24) hour, seven (7) day a week toll-free Tele MI Salud Medical Advice Service phone number;

 

	
  

	
6.7.2.13

	
A notice that the Enrollee ID Card may under no circumstances be used by a person other than the identified Enrollee; and

 

	
  

	
6.7.2.14

	
Instructions for emergencies.

 

	
  

	
6.7.3

	
The Contractor shall reissue the Enrollee ID Card in the following situations and timeframes:

 

	
  

	
6.7.3.1

	
within ten (10) Calendar Days of notice if an Enrollee reports a lost, stolen or damaged ID Card and requests a replacement;

 

	
  

	
6.7.3.2

	
within ten (10) Calendar Days of notice if an Enrollee reports a name change;

 

	
  

	
6.7.3.3

	
within twenty (20) Calendar Days of the effective date of a change of PMG or change or addition of PCP, as provided in Section 5.3.2 of this Contract.

 

	
  

	
6.7.4

	
[Deleted.  Intentionally left blank]

 

  

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6.7.5

	
The Contractor shall submit a front and back sample Enrollee ID Card to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to Enrollee ID Card must be previously approved in writing by ASES.

 

	
  

	
6.7.6

	
The Contractor must require an Enrollee to surrender his or her ID Card in each of the following events:

 

	
  

	
6.7.6.1

	
the Enrollee is disenrolled;

 

	
  

	
6.7.6.2

	
the Enrollee requests a change to his or her PCP or PMG, and is therefore issued a new Enrollee ID Card; or

 

	
  

	
6.7.6.3

	
the Enrollee requests a new ID Card because his or her existing card is damaged.

 

	
  

	
6.7.7

	
In the event ASES requires that the Contractor issue new Enrollee ID Cards to all or part of the Enrollee population as a result of a change in the Enrollees’ MBHO or  PBM at any time during the Contract Term, ASES shall cover all costs related to the production and delivery of such cards.

 

	
6.8

	
Tele MI Salud(Toll Free Telephone Service)

 

	
  

	
6.8.1

	
The Contractor shall operate a toll-free telephone number, “Tele MI Salud,” equipped with caller identification and automatic call distribution equipment capable of handling the expected volume of calls. Tele MI SaludMI Salud shall have two components:

 

	
  

	
6.8.1.1

	
Subject to any applicable privacy laws and regulations, an Information Service to respond to questions, concerns, inquiries, and complaints regarding MI Salud from the Enrollee or the Enrollee’s family or the Enrollee’s representative, or the Provider, and its employees or in representation of an Enrollee; and MI Salud

 

	
  

	
6.8.1.2

	
A Medical Advice Service to advise Enrollees about how to resolve medical or behavioral health concerns.

 

	
  

	
6.8.2

	
The Contractor shall establish, operate, monitor and support an automated call distribution system for Tele MI Salud that supports, at a minimum:

 

	
  

	
6.8.2.1

	
Capacity to handle the call volume;

 

	
  

	
6.8.2.2

	
A daily analysis of the quantity, length, and types of calls received;

 

  

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6.8.2.3

	
A daily analysis of the amount of time it takes to answer the call, Blocked Calls, and Abandoned Calls;

 

	
  

	
6.8.2.4

	
The ability to measure average waiting time; and

 

	
  

	
6.8.2.5

	
The ability to monitor calls from a location by a third party, including ASES.

 

	
  

	
6.8.3

	
Hours of Operation. Each service shall be made available as follows:

 

	
  

	
6.8.3.1

	
The Information Service shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m., Monday through Friday, excluding Puerto Rico holidays.  The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. Puerto Rico time Monday through Friday and at all hours on weekends and holidays.  This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages.  The Contractor shall ensure that the voice mailbox has the required capacity to receive all messages.  A Contractor’s representative shall reply to one hundred percent (100%) of messages by the next Business Day.

 

	
  

	
6.8.3.2

	
The Medical Advice Service shall be fully staffed and available to Enrollees twenty-four (24) hours per day, seven (7) days per week.

 

	
  

	
6.8.4

	
Staffing

 

	
  

	
6.8.4.1

	
The Contractor shall be responsible for the required staffing of Tele MI Salud with individuals who are able to communicate effectively with MI Salud Enrollees.

 

	
  

	
6.8.4.2

	
The Contractor shall make key staff responsible for operating Tele MI Salud available to meet with ASES staff on a regular basis, as requested by ASES, to review reports and all other obligations under the Contract relating to Tele MI Salud.

 

	
  

	
6.8.4.3

	
The Contractor shall hire and train adequate staff by the Implementation Date of the Contract. The training program shall include, but is not limited to, systems, policies and procedures, and telephone scripts.

 

	
  

	
6.8.4.4

	
Subject to any applicable privacy laws and regulations, for the Information Service, the Contractor shall ensure that call center attendants have the necessary training to respond to questions, concerns, inquiries, and complaints from Enrollee, the Enrollee’s family, or the Enrollee’s representative, or the Provider, itself and its employees, or in representation of an Enrollee,  relating to this Contract, including but not limited to Covered Services, Grievances and Appeals, the Provider Network, Enrollment and Disenrollment, and issues related to the payments to Providers.

 

  

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6.8.4.5

	
For the Medical Advice Service, the Contractor shall ensure that call center attendants are registered nurses with the necessary training to advise Enrollees about appropriate steps they should take to resolve a medical or behavioral health complaint or concern.

 

	
  

	
6.8.4.6

	
The Contractor shall ensure that Tele MI Salud call center staff are trained to identify behavioral health concerns and, where appropriate, to transfer Enrollee callers to the MBHO’s Call Center for assistance.  Tele MI Salud shall be equipped with the capacity to effect a “warm transfer” to the MBHO’s Call Center for behavioral health advice.

 

	
  

	
6.8.4.7

	
The Contractor shall ensure that Tele MI Salud call center staff is trained to identify situations in which an Enrollee may need services that are offered through the Puerto Rico Health Department rather than through MI Salud, and Tele MI Salud staff shall provide the Enrollee with information on where to access these services.

 

	
  

	
6.8.4.8

	
The Contractor shall ensure that Tele MI Salud call center staff is trained to provide to Medicaid and CHIP Eligible Enrollees information on how to access any local NEMT resources, to enable an Enrollee without available transportation to receive Medically Necessary services.

 

	
  

	
6.8.4.9

	
The Contractor shall ensure that Tele MI Salud call center staff are trained to process and fulfill requests by Enrollees to receive, by surface mail, the Enrollee Handbook, the Provider Directory, or the Provider guidelines.  The Contractor shall fulfill such requests by mailing the requested document within five (5) Business Days of the request.

 

	
  

	
6.8.5

	
The Contractor may provide the Information Service and the Medical Advice Service as separate phone lines with a “warm transfer” capability, or as separate dialing options within one phone line.  “Warm transfer” refers to the process of an agent connecting a caller to a third-party contact.  Once the third-party contact has answered, the agent introduces himself to the contact and provides the caller’s necessary information.  The agent stays on the line to confirm that the third-party contact and the caller have connected before the agent disconnects.

 

  

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6.8.6

	
The Contractor shall have the capability of making out-bound calls.

 

	
  

	
6.8.7

	
Tele MI Salud shall be equipped to handle calls in Spanish and English, as well as, through a telecommunication device for the deaf (TDD), calls from Enrollees who are hearing-impaired. For callers who do not speak either English or Spanish, the Contractor shall provide interpreter services free of charge to Enrollees. The Contractor shall not permit Enrollees’ family members, especially minor children, or friends to provide oral interpreter services, unless specifically requested by the Enrollee.

 

	
  

	
6.8.8

	
The Contractor shall (i) record calls on a random basis following its standard call center protocols, and (ii) document all calls, identifying the date and time, the type of call, the reason for the call and the resolution of the call.

 

	
  

	
6.8.9

	
The Contractor shall generate a call identification number for each phone call made by an Enrollee to the Medical Advice Service.  Enrollees who use this service to seek advice on their health condition before visiting the emergency room will not be responsible for any Co-Payment otherwise imposed for emergency room visits (as provided under Section 7.11.4 of this Contract) outside the Enrollee’s PPN, provided that the Enrollee presents his or her Tele MI Salud call identification number at the emergency room.  No Co-Payment shall be imposed on a Medicaid or CHIP Eligible Enrollee for the treatment of an Emergency Medical Condition (regardless of whether the Enrollee uses the Medical Advice Service).  The Medical Advice Service does not apply to services outside of Puerto Rico.

 

	
  

	
6.8.10

	
The Contractor shall develop Tele MI Salud policies and procedures, including staffing, training, hours of operation, access and response standards, transfers/referrals, monitoring of calls via recording and other means, and compliance with other performance standards.

 

	
  

	
6.8.11

	
The Contractor shall develop Tele MI Salud Quality Criteria and Protocols.  These protocols shall, at a minimum,

 

	
  

	
6.8.11.1

	
Measure and monitor the accuracy of responses and phone etiquette in Tele MI Salud (including through recording of phone calls) and take corrective action as necessary to ensure the accuracy of responses and appropriate phone etiquette by staff;

 

	
  

	
6.8.11.2

	
Provide for quality calibration sessions between the Contractor’s staff and ASES;

 

  

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6.8.11.3

	
Require that, on a monthly basis, the Average Speed of Answer is at least eighty percent (80%) of calls answered within thirty (30) seconds;

 

	
  

	
6.8.11.4

	
Require that, on a monthly basis, the Blocked Call rate does not exceed three percent (3%) of all calls from or relating to Enrollees or Potential Enrollees; and

 

	
  

	
6.8.11.5

	
Require that, on a monthly basis, the rate of Abandoned Calls does not exceed five percent (5%) of all calls from or relating to Enrollees or Potential Enrollees.

 

These standards serve as a minimum for each Tele MI Salud service.  The Contractor may elect to establish more rigorous performance standards.  The Contractor may elect to establish different quality criteria for the Medical Advice Service than for the Information Service; provided, however, that in that event, the standards governing the Medical Advice Service must be stricter than the standards for the Information Service.

 

	
  

	
6.8.12

	
The Contractor must develop and implement a Tele MI Salud outreach program to educate Enrollees about the Tele MI Salud service and to encourage its use (the “Tele MI Salud Outreach Program”).  The Tele MI Salud Outreach Program shall include, at a minimum, the following components:

 

	
  

	
6.8.12.1

	
A section on Tele MI Salud in the Enrollee Handbook;

 

	
  

	
6.8.12.2

	
Contact information for Tele MI Salud on the Enrollee ID Card and on the Contractor’s Web site; and

 

	
  

	
6.8.12.3

	
Informational flyers on Tele MI Salud to be placed in the offices of the Contractor and the Network Providers.

 

Each document or communication included in this Tele MI Salud Outreach Program must explain that (1) by using the Medical Advice Service before visiting the emergency room, and presenting their call identification number at the emergency room, Enrollees can avoid any emergency room Co-Payments otherwise applicable under Section 7.11.4 of this Contract for services outside the PPN; and (2) no Co-Payment shall be imposed for the treatment of an Emergency Medical Condition for a Medicaid or CHIP Eligible Person.  All written materials included in the Tele MI Salud Outreach Program must be written at a fourth- (4th) grade reading level and must be available in Spanish and English.

 

	
  

	
6.8.13

	
The Contractor shall prepare scripts addressing the questions expected to arise most often for both the Information Service and the Medical Advice Service.  The Contractor shall submit these scripts to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract. It is the responsibility of the Contractor to maintain and update these scripts and to ensure that they are developed at the fourth (4th) grade reading level. The Contractor shall submit revisions to the script to ASES for approval prior to use, pursuant to Section 6.2 of this Contract.

 

  

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6.8.14

	
The Contractor shall submit the following written materials referred to in this Section 6.8 to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract and any subsequent changes to the following must be previously approved in writing by ASES, which approval shall not be unreasonably withheld, conditioned or delayed:

 

	
  

	
6.8.14.1

	
Tele MI Salud policies and procedures;

 

	
  

	
6.8.14.2

	
Tele MI Salud quality criteria and protocols;

 

	
  

	
6.8.14.3

	
Tele MI Salud Outreach Program; and

 

	
  

	
6.8.14.4

	
Training materials for Tele MI Salud call center employees.

 

	
6.9

	
Internet Presence / Web Site

 

	
  

	
6.9.1

	
The Contractor shall provide on its Web site general and up-to-date information about MI Salud and about the MI Salud Plan, including the Provider Network, customer services, Tele MI Salud, and its Grievance System.  The Enrollee Handbook and the Provider Directory shall be available on the Web site.

 

	
  

	
6.9.2

	
The Contractor shall maintain an Enrollee portal that allows Enrollees to access a searchable Provider Directory that shall be updated within five (5) Business Days to reflect any change to the Provider Network.

 

	
  

	
6.9.3

	
The Web site must have the capability for Enrollees to submit questions and comments to the Contractor and receive responses.  The Contractor shall reply to Enrollee questions within two (2) Business Days.

 

	
  

	
6.9.4

	
The Web site must comply with the marketing policies and procedures and with requirements for written materials described in Sections 6.2 and 6.3 of this Contract and must be consistent with applicable Puerto Rico and federal laws.

 

	
  

	
6.9.5

	
The Contractor shall submit Web site screenshots to ASES for review and approval of information on the website relating to the MI Salud Program according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to Contractor’s Web site relating to the MI Salud Program must be previously approved in writing by ASES, which approval shall not be unreasonably withheld, conditioned or delayed.

 

  

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6.9.6

	
The Contractor’s Web site shall provide secured online access to the Enrollee’s historical and current information.

 

	
  

	
6.9.7

	
The Contractor’s Web site shall prominently feature a link to Web site of ASES, www.asespr.org.

 

	
6.10

	
Cultural Competency

 

	
  

	
6.10.1

	
In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written cultural competency plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Enrollees (the “Cultural Competency Plan”).  The Cultural Competency Plan must describe how the Providers, individuals and systems within the Contractor’s Plan will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes, values, affirms and respects the worth of the individual Enrollees and protects and preserves the dignity of each.

 

	
  

	
6.10.2

	
The Contractor shall submit the Cultural Competency Plan to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the Cultural Competency Plan must be previously approved in writing by ASES.

 

	
  

	
6.10.3

	
The Contractor may distribute a summary of the Cultural Competency Plan, rather than the entire document, to Providers if the summary includes information on how the Provider may access the full Cultural Competency Plan on the Contractor’s Web site.  This summary shall also detail how the Provider can request a hard copy from the Contractor at no charge to the Provider.

 

	
6.11

	
Interpreter Services

 

	
  

	
6.11.1

	
The Contractor shall provide oral interpreter services to any Enrollee who speaks any language other than English or Spanish as his or her primary language, regardless of whether the Enrollee speaks a language that meets the threshold of a Prevalent Non-English Language.  The Contractor is required to notify its Enrollees of the availability of oral interpretation services and to inform them of how to access oral interpretation services.  There shall be no charge to an Enrollee for interpreter services.

 

  

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6.12

	
Enrollment Outreach for the Homeless Population

 

The Contractor shall, upon prior written notice, participate in at least four (4) public events per year held by government agencies in different locations in each Service Region, to allow homeless individuals to complete the Enrollment process pursuant to the terms of this Contract.

 

	
6.13

	
Special Enrollee Information Requirements for Dual Eligible Beneficiaries

 

The Contractor shall inform an Enrollee who is a Dual Eligible Beneficiary:

 

	
  

	
6.13.1

	
That the Dual Eligible Beneficiary is eligible for services under MI Salud with the limits stated in Section 7.12 of this Contract;

 

	
  

	
6.13.2

	
That the MI Salud Plan will cover Medicare Part B deductibles and co-insurance, but not Medicare Part A deductibles;

 

	
  

	
6.13.3

	
That the Dual Eligible Beneficiary may not be simultaneously enrolled in MI Salud and in a Medicare Platino plan, for the reason that the Platino plan already includes MI Salud Benefits; and

 

	
  

	
6.13.4

	
That as an Enrollee in the Plan, the Dual Eligible Beneficiary may access Covered Services only through the PMG, not through the Medicare provider list.

 

	
6.14

	
Marketing

 

	
  

	
6.14.1

	
Prohibited Marketing Activities.  The Contractor is prohibited from engaging in the following activities:

 

	
  

	
6.14.1.1

	
Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call Marketing activities to Enrollees or Eligible Individuals;

 

	
  

	
6.14.1.2

	
Offering any favors, inducements or gifts, promotions, or other insurance products that are designed to induce Enrollment in the MI Salud Plan;

 

	
  

	
6.14.1.3

	
Distributing plans and materials that contain statements that ASES determines are inaccurate, false, or misleading.  Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the MI Salud Plan is endorsed by the federal government or Commonwealth, or similar entity; and

 

	
  

	
6.14.1.4

	
Distributing materials that, according to ASES, mislead or falsely describe the Contractor’s Provider network, the participation or availability of Network Providers, the qualifications and skills of Network Providers (including their bilingual skills); or the hours and location of network services.

 

  

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6.14.2

	
Allowable Marketing Activities.  The Contractor shall be permitted to perform the following Marketing activities:

 

	
  

	
6.14.2.1

	
Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);

 

	
  

	
6.14.2.2

	
Make telephone calls, mailings and home visits only to Enrollees  currently enrolled in the MI Salud Plan, for the sole purpose of educating them about services offered by or available through the Contractor;

 

	
  

	
6.14.2.3

	
Distribute brochures and display posters at Provider offices that inform patients that the Provider is part of MI Salud Provider Network; and

 

	
  

	
6.14.2.4

	
Attend activities that benefit the entire community, such as health fairs or other health education and promotion activities.

 

	
  

	
6.14.3

	
If the Contractor performs an allowable activity in a Service Region, the Contractor shall conduct that activity in all other Service Regions covered by this Contract.

 

	
  

	
6.14.4

	
All Marketing Materials shall be in compliance with the information requirements in 42 CFR 438.10.

 

	
  

	
6.14.5

	
ASES Approval of Marketing Materials

 

	
  

	
6.14.5.1

	
The Contractor shall submit a detailed description of its Marketing Plan and copies of all Marketing Materials (written and oral) that it or its Subcontractors plan to distribute to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  This requirement includes, but is not limited to posters, brochures, Web sites, and any materials that contain statements regarding the benefit package and Provider network-related materials.  Neither the Contractor nor its Subcontractors shall distribute any Marketing Materials without the prior written approval from ASES pursuant to Section 6.2.

 

	
  

	
6.14.5.2

	
The Contractor shall submit any changes to previously approved marketing materials and receive the approval from ASES of the changes before distribution pursuant to Section 6.2.

 

  

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6.14.5.3

 

 

	
The Advisory Committee of the Puerto Rico Medicaid Program, which advises the Puerto Rico Medicaid Program and ASES about government health programs, will assist ASES in the evaluation and review of any marketing materials submitted by the Contractor for approval.

 

	
  

	
6.14.6

	
Provider Marketing Materials

 

	
  

	
6.14.6.1

	
The Contractor is responsible for ensuring that not only its Marketing activities, but also the marketing activities of its Subcontractors and Providers, meet the requirements of this Section 6.14.

 

	
  

	
6.14.6.2

	
The Contractor shall collect from its Providers any Marketing Materials they intend to distribute and submit these to ASES for review and approval prior to distribution.

 

	
  

	
6.14.6.3

	
The Contractor shall provide for equitable distribution of all Marketing Materials without bias toward or against any group.

 

	
  

	
6.14.7

	
The Parties acknowledge and agree that nothing herein shall require the Contractor to engage in the Marketing of the MI Salud Program to: (a) Other Eligible Persons who are public employees or pensioners as described in Section 1.4.1.3.2 of this Contract; or (b) small or medium businesses located in the Service Regions.  The Parties further agree that nothing herein is intended to limit the Contractor’s right to market its other insurance or managed care products to Other Eligible Persons who are public employees or pensioners as described in Section 1.4.1.3.2 of this Contract or any other Eligible Person.

 

	
  

	
6.14.8

	
Assistance with Network Provider EHR Systems

 

	
  

	
6.14.8.1

	
The Contractor shall assist the PCPs and PPN physician specialists, upon their request, in the acquisition and installation of such an appropriate EHR system, at its expense, consisting of the hardware, software and related materials specified in Attachment 15.  Any such EHR system, whether maintained as a complete or component system, must be ONC-ATCBs certified, and shall meet the specifications set forth in Attachment 15.

 

	
  

	
6.14.8.2

	
The Contractor shall ensure that all the PCPs and PPN physician specialists shall have an operational EHR system in place on or before December 31, 2013 or such later date as set forth in his/her Provider Contract.

 

  

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6.14.8.3

	
The Contractor shall also provide each such Provider with information on (i) the benefits of the EHR system and (ii) the costs of maintaining the EHR system.

 

	
ARTICLE 7

	
COVERED SERVICES AND BENEFITS

 

	
  7.1

	
Requirement to Make Available Covered Services

 

	
  

	
7.1.1

	
The Contractor shall, at a minimum, make available through its Network Providers Covered Services, and other Benefits set forth in this Article, as of the Effective Date of Enrollment (including the period specified in Section 4.4.1.2 of this Contract) pursuant to the program requirements of MI Salud, and the Puerto Rico Medicaid State Plan and CHIP Plan.  The Contractor may not impose any other exclusions, limitations, or restrictions, and may not arbitrarily deny or reduce the amount, duration or scope of a required service solely because of the diagnosis, type of illness, or condition.

 

	
  

	
7.1.1.1

	
In accordance with Section 2702 of the PPACA, the Contractor must have mechanisms in place to prevent payment for the following Provider preventable conditions:

 

	
  

	
7.1.1.1.1

	
All hospital acquired conditions as identified by Medicare other than deep vein thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

 

	
  

	
7.1.1.1.2

	
Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

 

	
  

	
7.1.2

	
The Contractor may not deny Covered Services based on pre-existing conditions, individual’s genetic information, or waiting periods.

 

	
  

	
7.1.3

	
The Contractor shall not be required to pay a Claim for a service that would otherwise be a Covered Service, but for the fact that the recipient of the service is not an Eligible Person.

 

	
  

	
7.1.4

	
The Contractor shall not be required to pay a Claim for a service already provided, which would be a Covered Service but for the fact that:

 

	
  

	
7.1.4.1

	
The Enrollee paid the Provider for the service (except when, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the United States; these expenses shall be reimbursed under MI Salud); or

 

  

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7.1.4.2

	
The service was provided by a person or entity that does not meet the definition of a Network Provider (with the exception of Medical Emergencies and cases where the service was Prior Authorized by the Contractor).

 

	
  

	
7.1.5

	
Notwithstanding the provisions of this Section 7.1, the Contractor shall comply with Section 9.7 of this Contract.

 

	
7.2

	
Medical Necessity

 

Based upon generally accepted medical practices in light of conditions at the time of treatment, Medically Necessary services are those that relate to the prevention, diagnosis, and treatment of health impairments, or to the ability to achieve age-appropriate growth and development and the ability to attain, maintain, or regain functional capacity, and are:

 

	
7.2.1

	
Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Enrollee’s medical condition;

 

	
  

	
7.2.2

	
Compatible with the standards of acceptable medical practice in the community;

 

	
  

	
7.2.3

	
Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;

 

	
  

	
7.2.4

	
Not provided solely for the convenience of the Enrollee or the convenience of the Provider; and

 

	
  

	
7.2.5

	
Not primarily custodial care (for example, foster care).

 

	
7.3

	
Experimental or Cosmetic Procedures

 

In no instance shall the Contractor be required to pay Claims for experimental or cosmetic procedures, except as required by the Puerto Rico Patient’s Bill of Rights Act or any other federal or Puerto Rico law or regulation.  As provided in Section 7.5.6.2 of this Contract, breast reconstruction after a mastectomy and surgical procedures that are determined to be Medically Necessary to treat morbid obesity shall not be regarded as cosmetic procedures.

 

	
7.4

	
Covered Services and Administrative Services

 

	
  

	
7.4.1

	
Benefits under MI Salud are comprised of four categories: (1) Basic Coverage, (2) Dental Services, (3) Special Coverage, and (4) Administrative Services.  The scope of items (1) – (3) is described in Section 7.5 of this Contract.

 

  

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7.5

	
Basic Coverage

 

	
  

	
7.5.1

	
Basic Coverage is available to all MI Salud Enrollees, except as provided in the table below.  Basic Coverage includes the following categories:

 

	
BASIC COVERAGE SERVICES

	
MI SALUD ELIGIBILITY

GROUPS COVERED

	
Preventive Services

	
All

	
Diagnostic Test Services

	
All

	
Outpatient Rehabilitation Services

	
All

	
Medical and Surgical Services

	
All

	
Emergency Transportation Services

	
All

	
Maternity and Pre-Natal Services

	
All

	
Emergency Services

	
All (Services outside Puerto Rico available only for Medicaid and CHIP Eligible Persons)

	
Hospitalization Services

	
All

	
Behavioral Health Services

	
All (Note: Services provided by MBHO; not covered under this Contract.)

	
Pharmacy Services

	
All (Note: Claims processing and adjudication Services provided by PBM; not covered under this Contract.)

 

	
  

	
7.5.2

	
Exclusions from Basic Coverage

 

	
  

	
7.5.2.1

	
The following services are excluded from all Basic Coverage.  In addition, exclusions specific to each category of Covered Services are noted in subsections 7.5.3 – 7.5.12 below.

 

	
  

	
7.5.2.1.1

	
Expenses for personal comfort material or services, such as, telephone, television, toiletries;

 

	
  

	
7.5.2.1.2

	
Services rendered by close family relatives (parents, children, siblings, grandparents, grandchildren, spouses);

 

	
  

	
7.5.2.1.3

	
Weight control treatment (obesity or weight gain) for aesthetic reasons, provided, however, that procedures determined Medically Necessary to address morbid obesity shall not be excluded;

 

  

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7.5.2.1.4

	
Sports medicine, music therapy, and natural medicine;

 

	
  

	
7.5.2.1.5

	
Services, diagnostic testing or treatment ordered or rendered by naturopaths, naturists, chiropractors, iridologists, or osteopaths;

 

	
  

	
7.5.2.1.6

	
Health certificates, except as provided in Section 7.6.3.2.10 of this Contract (Preventive Services);

 

	
  

	
7.5.2.1.7

	
Epidural anesthesia services;

 

	
  

	
7.5.2.1.8

	
Chronic pain treatment, if it is determined that the pain has a psychological or psychosomatic origin;

 

	
  

	
7.5.2.1.9

	
Smoking cessation treatment, except as provided in Section

	
  

	
7.5.8.3.7 of this Contract for pregnant women (smoking cessation in general is covered by the MBHO);

 

	
  

	
7.5.2.1.10

	
Educational tests or services;

 

	
  

	
7.5.2.1.11

	
Peritoneal dialysis or hemodialysis services (covered under  Special Coverage, not Basic Coverage);

 

	
  

	
7.5.2.1.12

	
Hospice care;

 

	
  

	
7.5.2.1.13

	
Services received outside the territorial limits of  Puerto Rico, except as provided in Sections 7.5.7.10 (Emergency Transportation) and 7.5.9.3 (Emergency Services) of this Contract;

 

	
  

	
7.5.2.1.14

	
Expenses incurred for the treatment of conditions resulting from services not covered under MI Salud;

 

	
  

	
7.5.2.1.15

	
Judicially ordered evaluations for legal purposes;

 

	
  

	
7.5.2.1.16

	
Psychological, psychometric and psychiatric tests and evaluations to obtain employment or insurance, or for purposes of litigation;

 

	
  

	
7.5.2.1.17

	
Travel expenses, even when ordered by the primary care physician;

 

  

Page 87 of 327

  

 

	
  

	
7.5.2.1.18

	
Eyeglasses, contact lenses and hearing aids;

 

	
  

	
7.5.2.1.19

	
Acupuncture services;

 

	
  

	
7.5.2.1.20

	
Rent or purchase of durable medical equipment, wheelchair or any other transportation method for the handicapped, either manual or electric, and any expense for the repair or alteration of said equipment, except when the patient’s life depends on this service; and

 

	
  

	
7.5.2.1.21

	
Sex change procedures.

 

	
  

	
7.5.3

	
Preventive Services

 

	
  

	
7.5.3.1

	
Healthy Child Care. The Contractor shall make available through its Network Providers the following Preventive Services under the Healthy Child Care Program, which serves Enrollees under age two:

 

	
  

	
7.5.3.1.1

	
An annual comprehensive evaluation (1) by a certified health professional, which complements other services for children and young adults provided pursuant to the periodicity scheme of the American Academy of Pediatrics; and

 

	
  

	
7.5.3.1.2

	
Other services, as needed, during the first two years of the child’s life.

 

	
  

	
7.5.3.2

	
Other Preventive Services. The following are required Preventive Services for all MI Salud Enrollees:

 

	
  

	
7.5.3.2.1

	
Vaccines (the vaccines themselves are provided and paid for by the Puerto Rico Health Department; the Contractor shall cover the administration of the vaccines);

 

	
  

	
7.5.3.2.2

	
Eye exam;

 

	
  

	
7.5.3.2.3

	
Hearing exam, including hearing screening for newborns;

 

	
  

	
7.5.3.2.4

	
Evaluation and nutritional screening;

 

	
  

	
7.5.3.2.5

	
Medically Necessary laboratory exams and diagnostic tests, appropriate to the Enrollee’s age, sex, and health condition, including, but not limited to:

 

  

Page 88 of 327

  

 

	
  

	
7.5.3.2.5.1

	
Prostate and gynecological cancer screening according to accepted medical practice, including Pap smears (for Enrollees over age 18), mammograms (for Enrollees age 40 and over), and P.S.A. tests when Medically Necessary; and

 

	
  

	
7.5.3.2.5.2

	
Sigmoidoscopy and colonoscopy for colon cancer detection in adults 50 years and over, classified in risk groups according to accepted medical practice;

 

	
  

	
7.5.3.2.6

	
Nutritional, oral and physical health education;

 

	
  

	
7.5.3.2.7

	
Reproductive health counseling and family planning (The Contractor shall make available through its Network Providers and pay Claims for the following family planning services: counseling, pregnancy testing, diagnosis and treatment of sexually transmitted diseases, infertility assessment, and oral contraceptive medications that are used for the purpose of treating menstrual dysfunction and other hormonal conditions.  Contraceptive methods prescribed for family planning purposes, however, are not covered under MI Salud, but shall be provided by the Puerto Rico Health Department);

 

	
  

	
7.5.3.2.8

	
Syringes for home medicine administration;

 

	
  

	
7.5.3.2.9

	
Annual physical exam and follow-up for diabetic patients according to the diabetic patient treatment guide and Puerto Rico Health Department protocols; and

 

	
  

	
7.5.3.2.10

	
Health Certificates covered under MI Salud; provided that Co-Payments applicable for necessary procedures and laboratory testing related to generating a Health Certificate will be the Enrollee’s responsibility.  Such certificates shall include

 

	
  

	
7.5.3.2.10.1

	
Venereal Disease Research Laboratory (VDRL) tests;

 

	
  

	
7.5.3.2.10.2

	
Tuberculosis (TB) tests; and

 

	
  

	
7.5.3.2.10.3

	
Any certification for MI Salud Enrollees related to eligibility for the Medicaid Program (provided at no charge).

 

  

Page 89 of 327

  

 

	
  

	
7.5.3.3

	
Except where Medically Necessary to treat a health condition, weight control measures are not a covered Preventive Service.

 

	
  

	
7.5.3.4

	
Wellness Plan

 

	
  

	
7.5.3.4.1

	
In order to advance the goals of strengthening preventive services and providing integrated physical, behavioral health, and dental services to all Eligible Persons, the Contractor shall develop a Wellness Plan.

 

	
  

	
7.5.3.4.2

	
The Wellness Plan shall include a strategy for coordination with government agencies of the Commonwealth integral to disease prevention efforts, including the Puerto Rico Health Department, the Department of the Family, and the Department of Education.

 

	
  

	
7.5.3.4.3

	
The Wellness Plan shall present strategies and educational campaigns for encouraging Enrollees to:

 

	
  

	
7.5.3.4.3.1

	
Seek an annual health checkup;

 

	
  

	
7.5.3.4.3.2

	
Appropriately use the services of MI Salud, including Tele MI Salud;

 

	
  

	
7.5.3.4.3.3

	
Seek women’s health screenings including mammograms, Pap smears, cervical screenings, and tests for sexually transmitted diseases;

 

	
  

	
7.5.3.4.3.4

	
Maintain a healthy body weight, through good nutrition and exercise;

 

	
  

	
7.5.3.4.3.5

	
Seek an annual dental exam; and

 

	
  

	
7.5.3.4.3.6

	
Attend to the medical and developmental needs of children and adolescents, including vaccinations.

 

	
  

	
7.5.3.4.4

	
The Contractor shall, according to the timeframe specified in Attachment 12 to this Contract, present its Wellness Plan containing the strategies and educational campaigns described above, to ASES for review and approval, which approval will not be unreasonably withheld, conditioned or delayed.  Any subsequent changes to the Wellness Plan must be previously approved in writing by ASES.

 

  

Page 90 of 327

  

 

	
  

	
7.5.4

	
Diagnostic Test Services

 

	
  

	
7.5.4.1

	
The Contractor shall make available through its Network Providers the following Diagnostic Test Services:

 

	
  

	
7.5.4.1.1

	
Diagnostic and testing services for Enrollees under age 21 required by EPSDT, as defined in section 1905(r) of the Social Security Act;

 

	
  

	
7.5.4.1.2

	
Clinical labs, including any laboratory order for disease diagnostic purposes, even if the final diagnosis is a condition or disease whose treatment is not a Covered Service;

 

	
  

	
7.5.4.1.3

	
X-Rays;

 

	
  

	
7.5.4.1.4

	
Electrocardiograms;

 

	
  

	
7.5.4.1.5

	
Radiation Therapy (Prior Authorization required);

 

	
  

	
7.5.4.1.6

	
Pathology;

 

	
  

	
7.5.4.1.7

	
Arterial gases and pulmonary function test;

 

	
  

	
7.5.4.1.8

	
Electroencephalograms; and

 

	
  

	
7.5.4.1.9

	
Diagnostic services for Enrollees who present learning disorder symptoms.

 

	
  

	
7.5.4.2

	
The following shall not be considered Diagnostic Test Services covered under MI Salud:

 

	
  

	
7.5.4.2.1

	
Polysomnography Study; and

 

	
  

	
7.5.4.2.2

	
Clinical labs processed outside of Puerto Rico.

 

	
  

	
7.5.5

	
Outpatient Rehabilitation Services

 

	
  

	
7.5.5.1

	
The Contractor shall make available through its Network Providers the following Outpatient Rehabilitation Services:

 

	
  

	
7.5.5.1.1

	
Medically Necessary outpatient rehabilitation services for Enrollees under age 21, as required by EPSDT, section 1905(r) of the Social Security Act;

 

	
  

	
7.5.5.1.2

	
Physical therapy (up to a maximum amount of fifteen sessions per Enrollee per condition per contract year.  Coverage of additional fifteen sessions per condition per contract year when ordered by a physiatrist or orthopedist with prior authorization; []  [

 

  

Page 91 of 327

  

 

	
  

	
7.5.5.1.3

	
Occupational therapy, without limitations; and

 

	
  

	
7.5.5.1.4

	
Speech therapy, without limitations.

 

	
  

	
7.5.6

	
Medical and Surgical Services

 

	
  

	
7.5.6.1

	
The Contractor shall make available through its Network Providers  the following Medical and Surgical Services:

 

	
  

	
7.5.6.1.1

	
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, as defined in section 1905(r) of the Social Security Act;

 

	
  

	
7.5.6.1.2

	
Primary care physician visits, including nursing services;

 

	
  

	
7.5.6.1.3

	
Specialist treatment;

 

	
  

	
7.5.6.1.4

	
Sub-specialist treatment;

 

	
  

	
7.5.6.1.5

	
Physician home visits when Medically Necessary;

 

	
  

	
7.5.6.1.6

	
Respiratory therapy, without limitations;

 

	
  

	
7.5.6.1.7

	
Anesthesia services (except for epidural anesthesia);

 

	
  

	
7.5.6.1.8

	
Radiology services;

 

	
  

	
7.5.6.1.9

	
Pathology services;

 

	
  

	
7.5.6.1.10

	
Surgery;

 

	
  

	
7.5.6.1.11

	
Outpatient surgery facility services;

 

	
  

	
7.5.6.1.12

	
Practical nurse services;

 

	
  

	
7.5.6.1.13

	
Voluntary sterilization of men and women of legal age and sound mind, provided that they have been previously informed about the medical procedure implications, and that there is evidence of Enrollee’s written consent;

 

	
  

	
7.5.6.1.14

	
Public health nursing services;

 

	
  

	
7.5.6.1.15

	
Prosthetics, including supply of all body extremities including therapeutic ocular prosthetics, segmental instrument tray and spine fusion in scoliosis and vertebral surgery;

 

  

Page 92 of 327

  

 

	
  

	
7.5.6.1.16

	
Ostomy equipment for outpatient level ostomized patients;

 

	
  

	
7.5.6.1.17

	
Blood and blood plasma, without limitations, including

 

	
  

	
7.5.6.1.17.1

	
authologal and irradiated blood;

 

	
  

	
7.5.6.1.17.2

	
monoclonal factor IX with a certified hematologist Referral;

 

	
  

	
7.5.6.1.17.3

	
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 

	
  

	
7.5.6.1.17.4

	
monoclonal type antihemophilic factor with a certified hematologist’s authorization; and

 

	
  

	
7.5.6.1.17.5

	
activated protrombine complex (Autoflex and Feiba) with a certified hematologist’s authorization; and

 

	
  

	
7.5.6.1.18

	
Services to patients with chronic renal disease in Levels 1 and 2 (Levels 3 to 5 are included in Special Coverage).

 

	
  

	
7.5.6.1.18.1

	
Renal disease levels 1 and 2 are defined as follows:

 

	
  

	
7.5.6.1.18.1.1

	
Level 1- GFR (Glomerular Filtration – ml/min. per 1.73m2 per corporal area surface) over 90; slight damage when protein is present in the urine.

 

	
  

	
7.5.6.1.18.1.2

	
Level 2- GFR between 60 and 89, a slight decrease in kidney function.

 

	
  

	
7.5.6.1.18.2

	
When GFR decreases to under 60 ml/min per 1.73 m2, the Enrollee must be referred to a nephrologist for proper management.  The Enrollee will be registered for Special Coverage.

 

	
  

	
7.5.6.2

	
While cosmetic procedures shall be excluded from Basic Coverage, breast reconstruction after a mastectomy and surgical procedures Medically Necessary to treat morbid obesity shall not be considered to be cosmetic procedures.

 

  

Page 93 of 327

  

 

	
  

	
7.5.6.3

	
To the extent possible, medical and surgical services, as furnished through PCPs, PMGs, and other Providers, must be made available to Enrollees twenty-four (24) hours per day, seven (7) days per week.

 

	
  

	
7.5.7

	
Emergency Transportation Services

 

	
  

	
7.5.7.1

	
The Contractor shall arrange for the provision of Emergency Transportation Services, including maritime and ground transportation, in emergency situations.

 

	
  

	
7.5.7.2

	
Emergency Transportation Services shall be available twenty-four (24) hours a day, seven (7) days per week, in each municipality in each of the Contractor’s Service Regions, and throughout Puerto Rico.

 

	
  

	
7.5.7.3

	
Emergency Transportation Services do not require Prior Authorization.

 

	
  

	
7.5.7.4

	
The Contractor shall ensure that adequate Emergency Transportation is available to transport Enrollees with Emergency Medical Conditions, or whose conditions require Emergency Transportation because of their geographical location.

 

	
  

	
7.5.7.5

	
[Intentionally left blank].

 

	
  

	
7.5.7.6

	
Aerial Emergency Transportation Services are not part of the Covered Services under this Contract. ASES will provide, at full risk, Aerial Emergency Transportation Services directly through contract with the “Cuerpo de Emergencias Médicas de Puerto Rico”.

 

	
  

	
7.5.7.7

	
The Contractor shall pay Claims for Emergency Transportation and shall adhere to Puerto Rico laws and regulations concerning Emergency Transportation, including fees. The Contractor shall negotiate fees for the Emergency Transportation Services subjecto to ASES’s approval.

 

	
  

	
7.5.7.8

	
The Contractor may not retroactively deny a Claim for Emergency Transportation Services because the Enrollee’s condition, which at the time of service appeared to be an Emergency Medical Condition under the prudent layperson standard, was ultimately determined to be non-emergency.

 

  

Page 94 of 327

  

 

	
  

	
7.5.7.9

	
In any case in which an Enrollee is transported by ambulance to a facility that is not a Network Provider, and, after being stabilized, is transported by ambulance to a facility that is a Network Provider, all Emergency Transportation Claims, provided that they are justified by the definition of Emergency Services in this Contract prudent layperson standards, shall be paid by the Contractor.

 

	
  

	
7.5.7.10

	
The Contractor shall be responsible for timely payment for Claims for Emergency Transportation Services in the United States for Enrollees who are Medicaid or CHIP Eligible Persons, if the emergency transportation is associated with an Emergency Service in the United States covered under Section 7.5.9.3.1.2 of this Contract.  If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Transportation Services provided in the United States, the Contractor shall reimburse the Enrollee for such expenses within 30 days of receipt of such expenses, and the reimbursement shall be considered a Covered Service.

 

	
  

	
7.5.7.11

	
Emergency Transportation Services will be subject to periodic reviews by applicable governmental agencies to ensure quality of services.

 

	
  

	
7.5.8

	
Maternity and Pre-Natal Services

 

	
  

	
7.5.8.1

	
The Contractor shall make available through its Network Providers the following Maternity and Pre-Natal Services:

 

	
  

	
7.5.8.1.1

	
Pregnancy testing;

 

	
  

	
7.5.8.1.2

	
Medical services during pregnancy and post-partum;

 

	
  

	
7.5.8.1.3

	
Physician and nurse obstetrical services during vaginal delivery and caesarean section, and services to address any complication that arises during delivery;

 

	
  

	
7.5.8.1.4

	
Treatment of conditions secondary to pregnancy or delivery, when medically recommended;

 

	
  

	
7.5.8.1.5

	
Hospitalization for a period of at least forty-eight (48) hours in cases of vaginal delivery, and at least ninety-six hours (96) in cases of  caesarean section;

 

	
  

	
7.5.8.1.6

	
Anesthesia, excluding epidural;

 

	
  

	
7.5.8.1.7

	
Incubator use;

 

  

Page 95 of 327

  

 

	
  

	
7.5.8.1.8

	
Fetal monitoring services, during hospitalization only;

 

	
  

	
7.5.8.1.9

	
Nursery room routine care for newborns;

 

	
  

	
7.5.8.1.10

	
Circumcision and dilatation services for newborns;

 

	
  

	
7.5.8.1.11

	
Transportation of newborns to tertiary facilities newborn when necessary;

 

	
  

	
7.5.8.1.12

	
Pediatrician assistance during delivery; and

 

	
  

	
7.5.8.1.13

	
Delivery services provided in free-standing birth centers.

 

	
  

	
7.5.8.2

	
The following are excluded from Maternity and Pre-Natal Services:

 

	
  

	
7.5.8.2.1

	
Outpatient use of fetal monitor;

 

	
  

	
7.5.8.2.2

	
Treatment services for infertility and/or related to conception by artificial means; and

 

	
  

	
7.5.8.2.3

	
Services, treatments or hospitalizations as a result of a provoked non-therapeutic abortion or its complications; the following are considered to be provoked abortions:

 

	
  

	
7.5.8.2.3.1

	
Dilatation and curettage (Code 59840);

 

	
  

	
7.5.8.2.3.2

	
Dilatation and expulsion (Code 59841);

 

	
  

	
7.5.8.2.3.3

	
Intra-amniotic injection (Codes 59850, 59851, 59852);

 

	
  

	
7.5.8.2.3.4

	
One or more vaginal suppositories (e.g., Prostaglandin) with or without cervical dilatation (e.g., Laminar), including hospital admission and visits, fetus birth and secundines (Code 59855);

 

	
  

	
7.5.8.2.3.5

	
One or more vaginal suppositories (e.g., prostaglandin) with dilatation and curettage/or evacuation (Code 59856);

 

	
  

	
7.5.8.2.3.6

	
One or more vaginal suppositories (e.g., prostaglandin) with hysterectomy (omitted medical expulsion) (Code 59857); and

 

	
  

	
7.5.8.2.3.7

	
Epidural anesthesia services.

 

  

Page 96 of 327

  

 

	
  

	
7.5.8.3

	
The Contractor shall implement a Pre-Natal and Maternal Wellness Plan, aimed at preventing complications during and after pregnancy, and advancing the objective of lowering the incidence of low birth weight and premature deliveries.

 

	
  

	
7.5.8.3.1

	
The Plan shall include, at a minimum, the following components:

 

	
  

	
7.5.8.3.2

	
A Pre-Natal Care Card, ensuring access to services;

 

	
  

	
7.5.8.3.3

	
Counseling regarding HIV testing;

 

	
  

	
7.5.8.3.4

	
Pregnancy testing;

 

	
  

	
7.5.8.3.5

	
A RhoGAM injection for all pregnant women who have a negative RH factor according to the established protocol;

 

	
  

	
7.5.8.3.6

	
Alcohol screening of pregnant women with the TWEAK instrument or CAGE Test;

 

	
  

	
7.5.8.3.7

	
Smoking cessation counseling and treatment (to be provided by the MBHO, which will collaborate with the Contractor in providing services under the Maternal and Pre-Natal Wellness Plan);

 

	
  

	
7.5.8.3.8

	
Post-partum depression screening using the Edinburgh post-natal depression scale;

 

	
  

	
7.5.8.3.9

	
Post-partum counseling and referral to the WIC program;

 

	
  

	
7.5.8.3.10

	
Dental evaluation during the second trimester of gestation; and

 

	
  

	
7.5.8.3.11

	
Educational workshops regarding prenatal care topics (importance of pre-natal medical visits and post-partum care), breast-feeding, stages of childbirth, oral and mental health, family planning, newborn care, among others.

 

	
  

	
7.5.8.3.12

	
The Contractor shall prepare Marketing Materials regarding services under the Pre-Natal and Maternal Wellness Plan, and contractually require that PCP Providers inform pregnant Enrollees either directly or through such Marketing Materials of such services.  The Contractor shall submit its Pre-Natal and Maternal Wellness Plan to ASES according to the timeframe specified in Attachment 12 to this Contract, and shall submit reports quarterly concerning the usage of services under this program.  ASES will monitor the performance of such plan on a quarterly basis. Any subsequent changes to the Pre-Natal and Maternal Wellness Plan must be previously approved in writing by ASES.

 

  

Page 97 of 327

  

 

	
  

	
7.5.8.4

	
The Contractor shall make available through its Network Providers reproductive health and family planning counseling. Such services shall be provided voluntarily and confidentially, including where the Enrollee is under age eighteen (18).  Family Planning Services will include, at a minimum, the following:

 

	
  

	
7.5.8.4.1

	
Education and counseling necessary to make informed choices and understand contraceptive methods;

 

	
  

	
7.5.8.4.2

	
Pregnancy testing;

 

	
  

	
7.5.8.4.3

	
Diagnosis and treatment of sexually transmitted diseases;

 

	
  

	
7.5.8.4.4

	
Infertility assessment;

 

	
  

	
7.5.8.4.5

	
Oral contraceptive medications, but only when prescribed for the purpose of treating menstrual dysfunction and other hormonal conditions; and

 

	
  

	
7.5.8.4.6

	
Information on the family planning services available through the Department of Health.

 

	
  

	
7.5.9

	
Emergency Services

 

	
  

	
7.5.9.1

	
The Contractor shall pay Claims for Emergency Services where necessary to treat an Emergency Medical Condition.  The Contractor shall ensure that Emergency Services are available twenty-four (24) hours a day, seven (7) days per week.  No Prior Authorization will be required for Emergency Services.

 

	
  

	
7.5.9.2

	
Emergency Services shall include the following:

 

	
  

	
7.5.9.2.1

	
Emergency room visits, including medical attention and routine and necessary services;

 

	
  

	
7.5.9.2.2

	
Trauma services;

 

  

Page 98 of 327

  

 

 

	
  

	
7.5.9.2.3

	
Operating room use;

 

	
  

	
7.5.9.2.4

	
Respiratory therapy;

 

	
  

	
7.5.9.2.5

	
Specialist and sub-specialist treatment when required by the emergency room physician;

 

	
  

	
7.5.9.2.6

	
Anesthesia;

 

	
  

	
7.5.9.2.7

	
Surgical material;

 

	
  

	
7.5.9.2.8

	
Laboratory tests and X-Rays;

 

	
  

	
7.5.9.2.9

	
Post-Stabilization Services, as provided in Section 7.5.9.5 below;

 

	
  

	
7.5.9.2.10

	
Drugs, medicine and intravenous solutions used in the emergency room; and

 

	
  

	
7.5.9.2.11

	
Blood and blood plasma, without limitations, including

 

	
  

	
7.5.9.2.11.1

	
authologal and irradiated blood;

 

	
  

	
7.5.9.2.11.2

	
monoclonal factor IX with a certified hematologist Referral;

 

	
  

	
7.5.9.2.11.3

	
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 

	
  

	
7.5.9.2.11.4

	
monoclonal type antihemophilic factor with a certified hematologist’s authorization; and

 

	
  

	
7.5.9.2.11.5

	
activated protrombine complex (Autoflex and Feiba) with a certified hematologist’s authorization.

 

	
  

	
7.5.9.3

	
Emergency Services Within and Outside Puerto Rico

 

	
  

	
7.5.9.3.1

	
The Contractor shall arrange for Emergency Services to be available:

 

	
  

	
7.5.9.3.1.1

	
For all Enrollees, throughout Puerto Rico, including outside the Contractor’s Service Regions, and notwithstanding whether the emergency room is a Network Provider; and

 

  

Page 99 of 327

  

 

	
  

	
7.5.9.3.1.2

	
For Medicaid and CHIP Eligible Persons, in Puerto Rico or in the United States, when the services are Medically Necessary and could not be anticipated, notwithstanding that emergency rooms outside of Puerto Rico are not Network Providers.  Subject to Sections 16.10.2.3 and 21.3 of this Contract, the Contractor shall be responsible for timely payment of Claims for Emergency Services rendered to Enrollees in the United States. If, in an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the United States, ASES shall reimburse the Enrollee for such expenses within thirty (30) days of receipt of such expenses, and the reimbursement shall be considered a Covered Service.

 

	
  

	
7.5.9.3.2

	
For Medicaid and CHIP Eligible Persons, in covering Emergency Services provided by Puerto Rico Providers outside the Contractor’s Network, or by Providers in the United States, the Contractor shall pay Claims for such Emergency Services to such out-of-Network or United States based Providers equal to at least the average rate paid to Network Providers in the Puerto Rico region where services are provided, for Puerto Rico based providers, and up to $100.00 for United States based providers.

 

	
  

	
7.5.9.4

	
Emergency Room Overuse

 

	
  

	
7.5.9.4.1

	
The Contractor shall establish mechanisms for measuring and counteracting misuse of Emergency Services.  Excessively frequent visits to emergency rooms and seeking treatment in emergency rooms for non-emergent conditions will be considered misuse.

 

	
  

	
7.5.9.4.2

	
The Contractor shall have the capacity to:

 

	
  

	
7.5.9.4.2.1

	
Identify Enrollees who misuse Emergency Services;

 

	
  

	
7.5.9.4.2.2

	
Contact Enrollees by mail or telephone to learn the reasons for their behavior; and

 

	
  

	
7.5.9.4.2.3

	
Inform PCPs about the Enrollee’s behavior so that between the two entities, they can attend to complaints by Enrollees and curb overuse of Emergency Services.

 

  

Page 100 of 327

  

 

	
  

	
7.5.9.4.3

	
The Contractor shall include a clause in Hospital and Emergency Room contracts that prohibits the Provider from refusing to admit MI Salud Enrollees to its Emergency Room, and instead referring them to other Emergency Room facilities.

 

	
  

	
7.5.9.5

	
Post-Stabilization Services

 

	
  

	
7.5.9.5.1

	
The Contractor shall pay Claims for Post-Stabilization Services rendered by any Provider in accordance with applicable federal regulations.  The attending emergency room physician or other treating Provider shall be responsible for determining whether the Enrollee is sufficiently stabilized for transfer or discharge, and that determination is binding on the Contractor with respect to its responsibility for coverage and payment.

 

	
  

	
7.5.9.5.2

	
An Enrollee who has been treated for an Emergency Condition shall not be held liable for any subsequent screening or treatment necessary to stabilize the Enrollee.

 

	
  

	
7.5.9.5.3

	
Any Post-Stabilization Service that requires Prior Authorization shall be processed and granted by the Contractor within one (1) hour of the Service Authorization Request.

 

	
  

	
7.5.9.5.4

	
Any Post-Stabilization Service that requires Prior Authorization shall be deemed authorized if, within one (1) hour of the Service Authorization Request, (i) the Prior Authorization is not granted, or (ii) the Contractor and the treating physician cannot reach an agreement concerning the Enrollee’s care and a Network Provider is not available for consultation.  For the avoidance of doubt, the Contractor must give the treating physician the opportunity to consult with a Network Provider, and the treating physician may continue with care of the Enrollee until a Network Provider is reached.

 

  

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7.5.9.5.5

	
For every Prior Authorization granted pursuant to Section 7.5.9.5.4 above, the Contractor shall (i) review the Service Authorization Request after the corresponding Post-Stabilization Service has been rendered to determine whether the service was Medically Necessary, (ii) document its determination, and (iii) if it has determined that the service was Medically Necessary, submit the Claim to ASES in its next Claims Payment Report, in accordance with Sections 11.1.1.4 and 16.7 of this Contract.  Notwithstanding the above, if the Contractor submits a Claim to ASES for a Post-Stabilization Service and later determines that the service was not Medically Necessary, the Contractor shall recoup any payment made with respect to such Claim from the Provider and return such amount to ASES.

 

	
  

	
7.5.9.5.6

	
ASES or the PMG shall be financially responsible for all Post-Stabilization Services, except that the Contractor shall be financially responsible for any Post-Stabilization Service that requires Prior Authorization with respect to which the Contractor does not follow the procedure established in Section 7.5.9.5.5 above and which is determined not to be Medically Necessary.

 

	
  

	
7.5.9.5.7

	
The Contractor shall not be financially responsible for Post-Stabilization Services that it has not Prior Authorized with respect to any Enrollee for any period after:

 

	
  

	
7.5.9.5.7.1

	
A Network Provider with privileges at the treating hospital assumes responsibility for the Enrollee’s care;

 

	
  

	
7.5.9.5.7.2

	
A Network Provider assumes responsibility for the Enrollee’s care through transfer;

 

	
  

	
7.5.9.5.7.3

	
A Contractor representative and the treating physician reach an agreement concerning the Enrollee’s care; or

 

	
  

	
7.5.9.5.7.4

	
The Enrollee is discharged.

 

	
  

	
7.5.9.6

	
Responsibility of Payment for Emergency Services

 

	
  

	
7.5.9.6.1

	
When an Enrollee (or, as provided in Section 4.4.1.2 of this Contract, an Eligible Person) accesses any hospital emergency room, the responsible party  for the payment of services rendered in this facility shall be as follows:

 

  

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7.5.9.6.1.1

	
When a physician has concluded, after a medical evaluation (including physical or mental evaluation), that the patient has a behavioral health diagnosis, the MBHO shall be responsible for the totality of the payment of all services.

 

	
  

	
7.5.9.6.1.2

	
When a physician has concluded after a medical evaluation (including physical or mental evaluation) that the patient has a physical health diagnosis, the Contractor shall be responsible for the payment of the Claim for the services rendered.

 

	
  

	
7.5.9.6.1.3

	
In both cases, the physicians from the emergency room must include in the patient’s Medical Record the final diagnosis. The payment shall be based on the final diagnosis.

 

	
  

	
7.5.9.6.1.4

	
If the diagnosis includes both mental and physical health diagnoses or conditions, the hospital must include a detailed invoice, by item, which will be used to determine which entity is responsible for the services and for payment.  Both parties, the MBHO and the Contractor, shall be responsible for payment according to the diagnosis listed on the invoice submitted by the hospital.

 

	
  

	
7.5.9.7

	
Coverage of Services Ultimately Determined to be Non-Emergencies.  The Contractor shall not retroactively deny a Claim for an emergency screening examination because the Condition, which appeared to be an Emergency Medical Condition, turned out to be non-emergency in nature.

 

	
  

	
7.5.9.8

	
Enrollee Use of Tele MI Salud.  The Contractor shall train Emergency Services Providers concerning the Tele MI Salud Medical Advice Service, and shall make Providers aware that:

 

	
  

	
7.5.9.8.1

	
An Enrollee who consults this service before visiting the emergency room shall not be responsible for any Co-Payment, provided that he or she presents his or her Tele MI Salud call identification number when he or she arrives at the emergency room;

 

  

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7.5.9.8.2

	
No Co-Payments shall be charged for CHIP children twenty one (21) years of age and under, under any circumstances; and

 

	
  

	
7.5.9.8.3

	
No Co-Payment shall be imposed for the treatment of an Emergency Medical Condition for a Medicaid or CHIP Eligible Person. However, a Co-Payment shall be imposed when a Medicaid Eligible Person seeks care in an emergency room outside the Enrollee’s PPN to treat a condition that does not meet the definition of Emergency Medical Condition as set forth in this Contract; and

 

	
  

	
7.5.9.8.4

	
The Contractor shall not deny a Claim for Emergency Services when the Enrollee seeks Emergency Services at the instruction of the Contractor or its Agent (including a Tele MI Salud representative).

 

	
  

	
7.5.9.9

	
Coverage of Services Provided to an Eligible Person Who Has Not Completed Enrollment.  When an Eligible Person who is a Medicaid - or CHIP Eligible Person (see Sections 1.3.1.1, 1.3.1.2, and 1.3.1.3.1 of this Contract) receives Emergency Services before the date indicated in Section 4.4.1.1 above, the Effective Date of Enrollment shall be deemed to be the date of the first Emergency Service covered by the Contractor or by the MBHO, regardless of whether the Medicaid or CHIP Eligible Person had submitted an Enrollment application to the Puerto Rico Medicaid Program as of that date, provided that ASES provides written notification to the Contractor from the Health Care Reform Eligibility (HCRE) System of (1) the Certification of eligibility for the Eligible Person, and (2) the fact that the Potential Enrollee has accessed Emergency Services.  The Contractor shall promptly, per Section 5.2.3 of this Contract, enroll the person in the MI Salud Plan.  The Contractor shall pay for Claims for such Emergency Services, whether provided within or outside the Service Regions.

 

	
  

	
7.5.9.10

	
Coverage of All Emergency Medical Conditions.

 

	
  

	
7.5.9.10.1

	
The Contractor shall not deny Claims for treatment of an Emergency Medical Condition, including in cases in which the absence of immediate medical attention would not have resulted in the outcomes specified in the definition of Emergency Medical Condition in this Contract and in 42 CFR 438.114(a).

 

  

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7.5.9.10.2

	
The Contractor shall not refuse to pay a Claim for an Emergency Medical Condition on the ground that the emergency room Provider, hospital, or fiscal agent did not notify the Enrollee’s PCP or the Contractor of the Enrollee’s screening or treatment following the Enrollee’s presentation for Emergency Services.

 

	
  

	
7.5.10

	
Hospitalization Services

 

	
  

	
7.5.10.1

	
The Contractor shall make available through its Network Providers hospitalization services, including the following:

 

	
  

	
7.5.10.1.1

	
Nursery;

 

	
  

	
7.5.10.1.2

	
Semi-private room (bed available 24 hours a day, every day of the year);

 

	
  

	
7.5.10.1.3

	
Isolation room for medical reasons;

 

	
  

	
7.5.10.1.4

	
Food, including specialized nutrition services;

 

	
  

	
7.5.10.1.5

	
Regular nursing services;

 

	
  

	
7.5.10.1.6

	
Specialized room use, such as operation, surgical, recovery, treatment and maternity without limitations;

 

	
  

	
7.5.10.1.7

	
Drugs, medicine and contrast agents, without limitations;

 

	
  

	
7.5.10.1.8

	
Materials such as bandages, gauze, plaster or any other therapeutic or healing material;

 

	
  

	
7.5.10.1.9

	
Therapeutic and maintenance care services, including the use of the necessary equipment to offer the service;

 

	
  

	
7.5.10.1.10

	
Specialized diagnostic tests, such as electrocardiograms, electroencephalograms, arterial gases and other specialized tests that are available at the hospital and necessary during Enrollee's hospitalization;

 

	
  

	
7.5.10.1.11

	
Supply of oxygen, anesthetics and other gases including administration;

 

	
  

	
7.5.10.1.12

	
Respiratory therapy, without limitations;

 

  

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7.5.10.1.13

	
Rehabilitation services while patient is hospitalized, including physical, occupational and speech therapy;

 

	
  

	
7.5.10.1.14

	
Outpatient surgery facility use; and

 

	
  

	
7.5.10.1.15

	
Blood and blood plasma, without limitations, including

 

	
  

	
7.5.10.1.15.1

	
authologal and irradiated blood;

 

	
  

	
7.5.10.1.15.2

	
monoclonal factor IX with a certified hematologist Referral;

 

	
  

	
7.5.10.1.15.3

	
intermediate purity concentrated ant hemophilic factor (Factor VIII);

 

	
  

	
7.5.10.1.15.4

	
monoclonal type antihemophilic factor with a certified hematologist’s authorization; and

 

	
  

	
7.5.10.1.15.5

	
activated protrombine complex (Autoflex and Feiba) with a certified hematologist’s authorization.

 

	
  

	
7.5.10.2

	
Hospitalization for services that would normally be considered outpatient services, or for diagnostic purposes only, is not a Covered Service under MI Salud.

 

	
  

	
7.5.11

	
Behavioral Health Services

 

	
  

	
7.5.11.1

	
Behavioral Health Services shall be included in MI Salud, but shall be primarily the responsibility of the MBHO.  The Contractor shall pursue close cooperation with the MBHO, as detailed in Article 8, to facilitate a service delivery model that integrates physical and behavioral health services and that effectively combats substance abuse and addiction.

 

	
  

	
7.5.11.2

	
Covered Behavioral Health Services include the following:

 

	
  

	
7.5.11.2.1

	
Evaluation, screening and treatment to individuals, couples, families and groups;

 

	
  

	
7.5.11.2.2

	
Outpatient services with psychiatrists, psychologists and social workers;

 

	
  

	
7.5.11.2.3

	
Hospital or outpatient services for substance and alcohol abuse disorders;

 

	
  

	
7.5.11.2.4

	
Intensive outpatient services;

 

  

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7.5.11.2.5

	
Immediate access to Emergency Services or services in events of Urgency twenty-four (24) hours a day, seven days a week;

 

	
  

	
7.5.11.2.6

	
Detoxification services for Enrollees intoxicated with illegal substances, whether as a result of substance abuse, a suicide attempt, or accidental poisoning;

 

	
  

	
7.5.11.2.7

	
Long lasting injected medicine clinics;

 

	
  

	
7.5.11.2.8

	
Escort/professional assistance and ambulance services when needed;

 

	
  

	
7.5.11.2.9

	
Prevention and secondary education services;

 

	
  

	
7.5.11.2.10

	
Pharmacy coverage and access to medicine for a maximum of twenty-four (24) hours, in compliance with Act No. 408;

 

	
  

	
7.5.11.2.11

	
Medically Necessary laboratories; and

 

	
  

	
7.5.11.2.12

	
Treatment for Enrollees diagnosed with attention deficit disorder (with or without hyperactivity).

 

	
  

	
7.5.11.3

	
While substance abuse treatment for alcoholism and illegal drugs is considered a Covered Service, smoking cessation treatment is not, except where included in the Pre-Natal and Maternal Wellness Plan set forth in Section 7.5.8.3.7 of this Contract.

 

	
  

	
7.5.11.4

	
The Contractor shall, in addition to the cooperation with the MBHO required by Article 8 of this Contract, establish and strengthen relationships (if needed, through memoranda of understanding) with ASSMCA, ADFAN, the Office of the Women’s Advocate, and other government or nonprofit entities, to improve the delivery of Behavioral Health  Services.

 

	
  

	
7.5.12

	
Pharmacy Services

 

	
  

	
7.5.12.1

	
The Contractor shall make available the following pharmacy services:

 

	
  

	
7.5.12.1.1

	
All costs related to prescribed medications for Enrollees, excluding the Enrollee’s Co-Payment where applicable;

 

	
  

	
7.5.12.1.2

	
Drugs in the Preferred Drug List (PDL);

 

  

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7.5.12.1.3

	
Drugs included in the Master Formulary described in Attachment 5 of this Contract, but not in the PDL (through the exceptions process); and

 

	
  

	
7.5.12.1.4

	
In some instances, through the exceptions process, drugs that are not included in either the PDL or the Master Formulary.

 

	
  

	
7.5.12.2

	
The Contractor may not impose restrictions on available prescription drugs beyond those stated in the PDL, Master Formulary, or any other drug formulary approved by ASES.

 

	
  

	
7.5.12.3

	
The following drugs are excluded from the pharmacy services benefit:

 

	
  

	
7.5.12.3.1

	
Rebetron (to be provided by the Puerto Rico Health Department, upon referral to the Puerto Rico Health Department by a Network Provider; this medication not provided through MI Salud); and

 

	
  

	
7.5.12.3.2

	
Medications delivered directly to Enrollees by a Provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in a doctor’s office, such as injections.

 

	
  

	
7.5.12.4

	
Prescriptions ordered under the pharmacy services benefit are subject to the following utilization controls:

 

	
  

	
7.5.12.4.1

	
Certain prescription drugs may be subject to Prior Authorization, which shall be implemented and managed by the PBM or the Contractor, according to policies and procedures established by the ASES Pharmacy and Therapeutic (“P&T”) Committee and decided in consultation with the Contractor when applicable.

 

	
  

	
7.5.12.4.2

	
The Contractor shall ensure that Prior Authorization for pharmacy services is provided for the Enrollee in the following timeframes, including outside of business hours.  

 

	
  

	
7.5.12.4.2.1

	
The decision whether to grant a Prior Authorization of a prescription must not exceed fourteen (14) days from the time of the Enrollee’s Service Authorization Request for any Covered Service; except that, where the Contractor or the Enrollee’s Provider determines that an Urgency exists, Prior Authorization must be provided no later than within seventy two (72) hours of the Service Authorization Request.

 

  

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7.5.12.4.2.2

	
ASES may, in its discretion, grant an extension of the time allowed for Prior Authorization decisions, where:

 

	
  

	
7.5.12.4.2.2.1

	
The Enrollee, or the Provider, requests the extension; or

 

	
  

	
7.5.12.4.2.2.2

	
The Contractor justifies to ASES a need for the extension in order to collect additional information, such that the extension is in the Enrollee’s best interest.

 

	
  

	
7.5.12.4.3

	
Prescriptions written by a Provider who is  outside the PPN may be filled only upon a Countersignature from the Enrollee’s PCP, or another assigned PCP from the PMG in case of absence or unavailability of the Enrollee’s PCP unless ASES issues a normative letter eliminating this requirement in which case a Countersignature would not be required.  A Countersignature request made to the PCP shall be acted upon within three (3) Calendar Days of the request of the prescribing Provider, or, in the event of an Urgency, within twenty-four (24) hours.

 

	
  

	
7.5.12.4.4

	
Prescriptions written by a Provider within the PPN shall require no PCP Countersignature.

 

	
  

	
7.5.12.5

	
The Contractor shall advise its prescribing Providers to use bioequivalent drugs approved by the Food and Drug Administration (FDA), provided they are classified as “AB” and authorized by regulations, unless the Provider notes a contraindication in the prescription.  Nonetheless, the Contractor shall not deny Claims for a drug solely because the bioequivalent drug is unavailable; nor shall the Contractor impose an additional payment by the Enrollee because the bioequivalent is unavailable.

 

	
  

	
7.5.12.6

	
The Contractor shall observe the following timeframe limits with respect to prescribed drugs:

 

	
  

	
7.5.12.6.1

	
Medication for critical conditions will cover a maximum of thirty (30) Calendar Days; and additional time, where Medically Necessary.

 

  

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7.5.12.6.2

	
Medication for chronic conditions will cover a maximum of thirty (30) Calendar Days, except at the beginning of therapy where, upon a Provider’s recommendation, a minimum of fifteen (15) days shall be prescribed in order to reevaluate compliance and tolerance.  Under a doctor’s orders, a prescription may be refilled up to five (5) times.

 

	
  

	
7.5.12.6.3

	
For maintenance drugs that require Prior Authorization, the Prior Authorization will be effective for six (6) months, unless there are contraindications or side effects.

 

	
  

	
7.5.12.6.4

	
The prescribing Provider shall reevaluate pharmacotherapy as to compliance, tolerance, and dosage within ninety (90) Calendar Days of having prescribed a maintenance drug.  Dosage changes will not require Prior Authorization.  Changes in the drug used may require Prior Authorization.

 

	
  

	
7.5.12.7

	
Special considerations, including cooperation with Puerto Rico governmental entities other than ASES, govern coverage of medications for the following conditions.

 

	
  

	
7.5.12.7.1

	
Medications for Treatment of HIV / AIDS

 

	
  

	
7.5.12.7.1.1

	
The following HIV/AIDS medications are excluded from the ASES PDL: Viread, Emtriva, Truvada, Fuzeon, Atripla, Epzicom, Selzentry, Intelence, and Isentress.

 

	
  

	
7.5.12.7.1.2

	
Because of an agreement between the Health Department and ASES, Enrollees diagnosed with HIV/AIDS may access the medications listed above through Health Department clinics.

 

	
  

	
7.5.12.7.1.3

	
The Contractor shall inform Providers of the ASES/Health Department agreement described in Section 7.5.12.7.1.2 of this Contract, and shall require Providers to refer Enrollees for whom these medications are Medically Necessary to CPTET Centers (Centros de Prevencion y Tratamiento de Enfermedades Transmisibles) or community-based organizations, where the Enrollee may be screened to determine whether the Enrollee is eligible for ADAP. 

 

  

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7.5.12.7.1.4

	
A list of CPTET Centers and community-based organizations that administer these medications is included as Attachment 4 to this Contract.

 

	
  

	
7.5.12.7.2

	
Contraceptive Medications.  Contraceptive medications shall be provided by the Contractor’s Providers under MI Salud, but only for the treatment of menstrual dysfunction and other hormonal conditions.  Contraceptives prescribed for family planning purposes are not included in this Contract and shall be provided separately by the Health Department.

 

	
  

	
7.5.12.7.3

	
Medications for Chronic Conditions for Children with Special Health Needs.  Directions in prescriptions for chronic use drugs for Children with Special Health Needs shall cover therapy for thirty (30) days, and if necessary up to five (5) refills of the original prescription, according to medical opinion.  When Medically Necessary, additional prescriptions will be covered.

 

	
  

	
7.5.12.7.4

	
Medications for Enrollees with Opiate Addictions.  It is the responsibility of the MBHO to cover Buprenorphine medication and associated services and follow-up visits required to treat substance abuse disorders. 

 

	
  

	
7.5.12.8

	
Except as provided in Section 7.5.12.3.2 of this Contract, all prescriptions must be dispensed by a pharmacy under contract with the PBM that is duly authorized under the laws of the Commonwealth, and is freely selected by the Enrollee. The PBM shall maintain responsibility for ensuring that the Pharmacy Services Network complies with the terms specified by ASES.

 

	
  

	
7.5.12.9

	
Prescribed drugs must be dispensed at the time and date, as established by the Puerto Rico Pharmacy Law, when the Enrollee submits the prescription for dispensation.

 

	
  

	
7.5.12.10

	
Use of PDL Medications. The Contractor shall ensure that its Providers prescribe drugs on the PDL whenever possible.

 

  

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7.5.12.10.1

	
In the following two categories of exceptional cases, however, the Contractor shall pay Claims for drugs not included on the PDL, upon submission of acceptable written documentation from the Provider of the medical justification for the drug.

 

	
  

	
7.5.12.10.1.1

	
The Contractor shall pay Claims for drugs included on the Master Formulary (Attachment 5 to this Contract) in lieu of a PDL drug, only as a part of an exceptions process, upon a showing that no drug in the PDL is clinically effective for the Enrollee.

 

	
  

	
7.5.12.10.1.2

	
The Contractor shall pay Claims for a drug that is not included in either the PDL or the Master Formulary, provided that the drug is not in an experimental stage and that the drug has been approved by the FDA for the treatment of the condition.

 

	
  

	
7.5.12.10.2

	
In addition to demonstrating that the drug prescribed has FDA approval and is not considered experimental, a Provider prescribing a drug not on the PDL must demonstrate to the Contractor’s reasonable satisfaction that:

 

	
  

	
7.5.12.10.2.1

	
The drug does not have any bioequivalent on the market; and

 

	
  

	
7.5.12.10.2.2

	
The drug is clinically indicated because of:

 

	
  

	
7.5.12.10.2.2.1

	
Contraindication with some drugs that are in the PDL that the Enrollee is already taking, and scientific literature indicates serious adverse health effects related;

 

	
  

	
7.5.12.10.2.2.2

	
History of adverse reaction by the Enrollee to some drugs that are in the PDL;

 

	
  

	
7.5.12.10.2.2.3

	
Therapeutic failure of all available alternatives in the PDL; or

 

	
  

	
7.5.12.10.2.2.4

	
Other special circumstances.

 

  

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7.5.12.11

	
Role of Pharmacy Benefit Manager

 

	
  

	
7.5.12.11.1

	
Pharmacy services are administered primarily by a Pharmacy Benefit Manager (“PBM”) under contract with ASES.  The Contractor shall work with the PBM as well as the Pharmacy Program Administrator (“PPA”) selected by ASES as needed, and as provided in this Section, in order to ensure a successful pharmacy services benefit.

 

	
  

	
7.5.12.11.2

	
The Contractor shall be obligated to accept the terms and conditions of the contract that ASES awards to a PBM. The Contractor shall use the procedures, guidelines, and other instructions implemented by ASES through the PBM. Notwithstanding the foregoing, to the extent of any conflict between the terms of this Contract, on the one hand, and the terms of the PBM agreement or any procedure, guideline or instruction of the PBM on the other hand, the terms of this Contract shall govern and control.

 

	
  

	
7.5.12.11.3

	
Among other measures, to enhance cooperation with the PBM, the Contractor shall:

 

	
  

	
7.5.12.11.3.1

	
Work with the PBM to improve information flow and to develop protocols for information-sharing;

 

	
  

	
7.5.12.11.3.2

	
Establish, in consultation with the PBM, the procedures to deposit funds for the payment of claims to the pharmacy network according to the payments cycle specified by the PBM;

 

	
  

	
7.5.12.11.3.3

	
Coordinate with the PBM to establish customer service protocols concerning Pharmacy Services; and

 

	
  

	
7.5.12.11.3.4

	
Collaborate with ASES to facilitate the transition between any current PBM, PPA or rebate provider and any successors in the event ASES replaces any of them during the Term of this Contract.

 

	
  

	
7.5.12.12

	
Claims Processing and Administrative Services for Pharmacy.  The Contractor shall:

 

	
  

	
7.5.12.12.1

	
Assume the cost of implementing and maintaining online connection with the PBM;

 

	
  

	
7.5.12.12.2

	
Cover all of its own costs of implementation, including but not limited to payment processes, utilization review and approval processes, connection and line charges, and other costs incurred to implement the payment arrangements for pharmacy claims;

 

  

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7.5.12.12.3

	
Review Claims payments summary reports for each payment cycle and transfer funds required for payment to pharmacies;

 

	
  

	
7.5.12.12.4

	
Review denials and rejections of Claims;

 

	
  

	
7.5.12.12.5

	
Maintain a phone line to provide for Prior Authorization of drugs, according to the established policies and the PDL and Master Formulary; and

 

	
  

	
7.5.12.12.6

	
Electronically submit daily to the PBM a list of all Contractor’s Network Providers and a list of Enrollees.

 

	
  

	
7.5.12.13

	
Fraud Investigations. The Contractor shall develop tracking mechanisms for Fraud, Waste and Abuse issues, and shall forward Fraud, Waste and Abuse complaints regarding pharmacy services from Enrollees to the PBM and to ASES.

 

	
  

	
7.5.12.14

	
Formulary Management Program

 

	
  

	
7.5.12.14.1

	
The Contractor shall select two (2) members of its staff to serve on a cross-functional committee, the Pharmacy Benefit Financial Committee, tasked with rebate maximization.  The Committee will evaluate recommendations on the PDL, from the P&T Committee and the PPA, and will ultimately develop and review the PDL from time to time under the direction of ASES and the PPA.

 

	
  

	
7.5.12.14.2

	
The Contractor shall select a member of its staff to serve on a cross-functional subcommittee tasked with rebate maximization.  The subcommittee will take recommendations on the PDL from the P&T Committee and will ultimately create and manage the PDL.

 

	
  

	
7.5.12.15

	
Utilization Management and Reports.  The Contractor shall:

 

	
  

	
7.5.12.15.1

	
Perform drug utilization review that meets the standards established by both ASES and federal authorities; and

 

  

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7.5.12.15.2

	
Develop and distribute protocols, to be subject to ASES approval, when necessary.

 

	
  

	
7.5.12.16

	
Communication with Providers. The Contractor shall ensure the following communications with Providers:

 

	
  

	
7.5.12.16.1

	
The Contractor shall advise Providers of the use of the PDL as a first option at the moment of prescribing; and of the need to observe the exceptions process when filling a prescription for a drug not on the PDL.

 

	
  

	
7.5.12.16.2

	
The Contractor shall advise Providers that they may not outright deny medication because it is not included on ASES’s PDL.  A medication not on the PDL may be provided through the exceptions process described in Section 7.5.12.10 of this Contract.

 

	
  

	
7.5.12.16.3

	
The Contractor shall advise Providers on the use of brand-name drugs, and the availability of the bio-equivalent version, if any.

 

	
  

	
7.5.12.17

	
Cooperation with the Pharmacy Program Administrator (“PPA”)

 

	
  

	
7.5.12.17.1

	
The Contractor shall receive from the PPA updates to the PDL. The Contractor shall adhere to these updates.

 

	
  

	
7.5.12.17.2

	
Any rebates shall be negotiated by the PPA and retained in their entirety by ASES.  The Contractor shall neither negotiate, collect, nor retain, any pharmacy rebate for the utilization by Enrollees of brand drugs included in the ASES PDL.

 

7.6     Dental Services

 

	
  

	
7.6.1

	
Dental Services shall include the following:

 

	
  

	
7.6.1.1

	
All preventative and corrective services for children under age 21 mandated by the EPSDT requirement;

 

	
  

	
7.6.1.2

	
Pediatric Pulp Therapy (Pulpotomy) for children under age 21;

 

	
  

	
7.6.1.3

	
Stainless Steel Crowns for use in primary teeth following a Pediatric Pulpotomy;

 

	
  

	
7.6.1.4

	
Preventive dental services for adults;

 

  

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7.6.1.5

	
Restorative dental services for adults;

 

	
  

	
7.6.1.6

	
One comprehensive oral exam;

 

	
  

	
7.6.1.7

	
One periodical exam every six months;

 

	
  

	
7.6.1.8

	
One defined problem-limited oral exam;

 

	
  

	
7.6.1.9

	
One full series of intra-oral radiographies, including bite, every three years;

 

	
  

	
7.6.1.10

	
One initial periapical intra-oral radiography;

 

	
  

	
7.6.1.11

	
Up to five additional periapical/intra-oral radiographies per year;

 

	
  

	
7.6.1.12

	
One single film-bite radiography per year;

 

	
  

	
7.6.1.13

	
One two-film bite radiography per year;

 

	
  

	
7.6.1.14

	
One panoramic radiography every three years;

 

	
  

	
7.6.1.15

	
One adult cleanse every six months;

 

	
  

	
7.6.1.16

	
One child cleanse every six months;

 

	
  

	
7.6.1.17

	
One topical fluoride application every six month for Enrollees under 19 years old;

 

	
  

	
7.6.1.18

	
Fissure sealants for life for Enrollees up to 14 years old (including decidual molars up to 8 years old when Medically Necessary because of cavity tendencies);

 

	
  

	
7.6.1.19

	
Amalgam restoration;

 

	
  

	
7.6.1.20

	
Resin restorations;

 

	
  

	
7.6.1.21

	
Root canal;

 

	
  

	
7.6.1.22

	
Palliative treatment; and

 

	
  

	
7.6.1.23

	
Oral surgery.

 

7.7     Special Coverage

 

	
  

	
7.7.1

	
The Special Coverage benefit is designed to provide services for Enrollees with special health care needs caused by serious illness.

 

  

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7.7.2

	
The Contractor shall provide to ASES the strategy implemented for the identification of populations with special health care needs in order to identify any ongoing special conditions of Enrollees that require a treatment plan and regular care monitoring by appropriate health care professionals.

 

	
  

	
7.7.3

	
The Contractor shall implement a system for screening Enrollees for Special Coverage and registering Enrollees who qualify.  The Contractor shall design a form to be used by Providers in submitting a registration for Special Coverage.

 

	
  

	
7.7.4

	
The registration system for Special Coverage shall emphasize speedy processing of the registration.

 

	
  

	
7.7.5

	
Once a Provider supplies all the required information for the Contractor to process a registration, Special Coverage shall take effect retroactively as of the date the Provider reaches a diagnosis, including documentation of test results, for any condition included in Special Coverage.  In case information is submitted to Contractor after diagnosis was reached, coverage can be made retroactive up to sixty (60) Calendar Days before the date on which Provider submitted the registration request.

 

	
  

	
7.7.6

	
According to the timeframes specified in Attachment 12 to this Contract, the Contractor shall submit to ASES for approval proposed protocols to be established for Special Coverage and any subsequent changes to the proposed protocols for Special Coverage must be previously approved in writing by ASES.  The proposed protocols must be established for, at a minimum, the following:

 

	
  

	
7.7.6.1

	
Registration procedures;

 

	
  

	
7.7.6.2

	
Formats established for registration forms;

 

	
  

	
7.7.6.3

	
Forms of notices to be issued to the Enrollee and to the Provider to inform them of the Contractor’s decision concerning Special Coverage;

 

	
  

	
7.7.6.4

	
Protocols for the development of treatment plan;

 

	
  

	
7.7.6.5

	
Provisions for ensuring that Enrollees with Special Coverage have timely access to specialists appropriate for the Enrollee’s condition and identified needs; and

 

	
  

	
7.7.6.6

	
A summary of the Contractor’s strategy for the identification of populations with special health care needs.

 

  

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7.7.7

	
The protocols shall emphasize both the need for a speedy determination and the need for screening evaluations to be conducted by competent Health Care Professionals with appropriate expertise.

 

	
  

	
7.7.8

	
The Contractor shall complete, monitor, and routinely update a treatment plan for each Enrollee who is registered for Special Coverage.

 

	
  

	
7.7.8.1

	
The treatment plan shall be developed by the Enrollee’s PCP, with the Enrollee’s participation, and in consultation with any specialists caring for the Enrollee.  The Contractor shall require, in its Provider Contracts with PCPs, that Special Registration treatment plans be submitted to the Contractor for review and approval in a timely manner.

 

	
  

	
7.7.8.2

	
The Contractor shall coordinate with the MBHO in development of the treatment plan, and shall consider any impact treatment provided by the MBHO may have on the treatment plan.

 

	
  

	
7.7.9

	
Autism

 

	
  

	
7.7.9.1

	
The physical health services that the autism population need to access through specialists as gastroenterologists, neurologists, allergists, and dentists, will be offered through Special Coverage.  The Uniform Guide for Special Coverage (Attachment 7 to this Contract) includes the procedures to follow for this condition.  The MBHO will cover all Behavioral Health Services relating to autism, including collaboration and integration with any treatment plan developed by the Contractor.  The Contractor shall submit, according to the timeframes set forth in Attachment 12 to this Contract, a plan for coordination with the MBHO to meet the integration requirement.

 

	
  

	
7.7.9.2

	
The Contractor shall require in its Provider Contracts with PCPs that the PCP carry out the M-CHAT screen to detect Autism in Enrollees under age eighteen (18) months, or in any other age range established by the Department of Health.  Once the PCP diagnoses autism, the PCP will refer the patient to the mental health Provider.  The M-CHAT test may be accessed through the Internet, and does not entail any cost, nor does it infringe any copyright.

 

	
  

	
7.7.9.3

	
The Contractor shall also require, through its Provider Contracts, that PCPs administer the Ages and Stages Questionnaire (ASQ) to the parents of child Enrollees.  This questionnaire must be completed when the child is nine (9), eighteen (18), and thirty (30) months old, or at any other age established by the Department of Health.  ASES acquired the license for the exclusive use child Enrollees in MI Salud and will provide the questionnaires to the Contract, which shall transmit the questionnaire to PCPs and mentor them in its use.

 

  

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7.7.9.4

	
The Contractor shall audit PCPs’ use of the M-CHAT and ASQ as part of its Physician Incentive Plan.

 

	
  

	
7.7.10

	
Services provided under Special Coverage shall be subject to Prior Authorization by the Contractor as specified in Section 7.7.11 of this Contract.

 

	
  

	
7.7.11

	
Special Coverage shall include in its scope the following services; provided, however, that an Enrollee shall be entitled only to those services Medically Necessary to treat the condition that qualified the Enrollee for Special Coverage:

 

	
  

	
7.7.11.1

	
Coronary and intensive care services, without limit;

 

	
  

	
7.7.11.2

	
Maxillary surgery;

 

	
  

	
7.7.11.3

	
Neurosurgical and cardiovascular procedures, including pacemakers, valves and any other instrument or artificial devices;

 

	
  

	
7.7.11.4

	
Peritoneal dialysis, hemodialysis and related services;

 

	
  

	
7.7.11.5

	
Pathological and clinical laboratory tests that are required to be sent outside Puerto Rico for processing;

 

	
  

	
7.7.11.6

	
Neonatal intensive care unit services, without limit;

 

	
  

	
7.7.11.7

	
Radioisotope, chemotherapy, radiotherapy and cobalt treatments;

 

	
  

	
7.7.11.8

	
Treatment of gastrointestinal conditions and allergies and nutritional services in autism patients;

 

	
  

	
7.7.11.9

	
The following procedures and diagnostic tests, when Medically Necessary (Prior Authorization required):

 

	
  

	
7.7.11.9.1

	
Computerized Tomography;

 

	
  

	
7.7.11.9.2

	
Magnetic resonance test;

 

	
  

	
7.7.11.9.3

	
Cardiac catheters; (no prior authorizations required)

 

	
  

	
7.7.11.9.4

	
Holter test; (no prior authorizations required)

 

  

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7.7.11.9.5

	
Doppler test; (no prior authorizations required)

 

	
  

	
7.7.11.9.6

	
Streest test; (no prior authorizations required)

 

	
  

	
7.7.11.9.7

	
Lithotripsy;

 

	
  

	
7.7.11.9.8

	
Electromyography;

 

	
  

	
7.7.11.9.9

	
SPECT test;

 

	
  

	
7.7.11.9.10

	
OPG test; and

 

	
  

	
7.7.11.9.11

	
Impedance Plesthymography;

 

	
  

	
7.7.11.10

	
Other neurological, cerebrovascular and cardiovascular procedures, invasive and noninvasive;

 

	
  

	
7.7.11.11

	
Nuclear medicine imaging;

 

	
  

	
7.7.11.12

	
Diagnostic endoscopies;

 

	
  

	
7.7.11.13

	
Genetic studies;

 

	
  

	
7.7.11.14

	
Up to fifteen (15) additional (beyond the services provided under Basic Coverage) physical therapy treatments per Enrollee condition per year when indicated by an orthopedist or physiatrist after Contractor Prior Authorization;

 

	
  

	
7.7.11.15

	
General anesthesia, including for dental treatment of special needs children;

 

	
  

	
7.7.11.16

	
Hyperbaric Chamber;

 

	
  

	
7.7.11.17

	
Immunosuppressive medicine and laboratories required for maintenance treatment of post-surgical patients or transplant patients, to ensure the stability of the Enrollee's health, and for emergencies that may occur after said surgery; and

 

	
  

	
7.7.11.18

	
Treatment for the following conditions after confirmed laboratory results and established diagnosis:

 

	
  

	
7.7.11.18.1

	
HIV Positive factor and/or Acquired Immunodeficiency Syndrome (AIDS) (Outpatient and hospitalization services are included; no Referral or Prior Authorization is required for Enrollee visits and treatment at the Health Department's Regional Immunology Clinics and other qualified Providers);

 

	
  

	
7.7.11.18.2

	
Tuberculosis;

 

  

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7.7.11.18.3

	
Leprosy;

 

	
  

	
7.7.11.18.4

	
Lupus;

 

	
  

	
7.7.11.18.5

	
Cystic Fibrosis;

 

	
  

	
7.7.11.18.6

	
Cancer;

 

	
  

	
7.7.11.18.7

	
Hemophilia; and

 

	
  

	
7.7.11.18.8

	
Special conditions of children, including the prescribed conditions in the Special Needs Children Codes (see Attachment 13), except:

 

	
  

	
7.7.11.18.8.1

	
Asthma and diabetes, which are included in the Disease Management program;

 

	
  

	
7.7.11.18.8.2

	
Mental Disorders; and

 

	
  

	
7.7.11.18.8.3

	
Mental Retardation (Behavioral manifestations shall be managed by behavioral health Providers within the Basic Coverage, with the exception of situations of catastrophic disease);

 

	
  

	
7.7.11.18.9

	
Scleroderma;

 

	
  

	
7.7.11.18.10

	
Multiple Sclerosis;

 

	
  

	
7.7.11.18.11

	
Conditions resulting from self-inflicted damage or as a result of a felony by an Enrollee or negligence; and

 

	
  

	
7.7.11.18.12

	
Chronic renal disease in levels three (3), four (4) and five (5) (Levels 1 and 2 are included in the Basic Coverage); these levels of renal disease are defined as follows:

 

	
  

	

7.7.11.18.12.1

	

Level 3 – GFR (Glomerular Filtration – ml/min. per 1.73m2 per corporal surface area) between 30 and 59, a moderate decrease in kidney function;

 

	
  

	

7.7.11.18.12.2

	

Level 4 - GFR between 15 and 29, a severe decrease in kidney function; and

 

	
  

	

7.7.11.18.12.3

	

Level 5 – GFR under 15, renal failure that will probably require either dialysis or a kidney transplant.

 

  

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7.7.11.19

	
Required medication for the outpatient treatment of Tuberculosis and Leprosy is included under Special Coverage.  Medication for the outpatient treatment or hospitalization for AIDS-diagnosed Enrollees or HIV-positive Enrollees is also included, with the exception of Protease inhibitors which will be provided by CPTET Centers.

 

	
  

	
7.7.12

	
An Enrollee may register for Special Coverage based on one of the conditions listed in Attachment 7 to this Contract (Uniform Guide to Special Coverage).  The Contractor must seek ASES authorization for any other special condition not listed in Attachment 7, which the Enrollee, PCP, or PMG requests to be the basis of Special Coverage for an Enrollee. The request must include sufficient documentation of Enrollee(s) need for services and the cost-effectiveness of the care option. ASES will consult with the Health Department and issue a decision which will be binding between the parties.

 

	
  

	
7.7.13

	
Except as expressly noted in this Section 7.7, the exclusions applied to Basic Coverage apply to Special Coverage.

 

7.8     Case and Disease Management

 

	
  

	
7.8.1

	
Benefits under MI Salud include Case Management and Disease Management, which are intended to coordinate care for Enrollees with intense health service needs.

 

	
  

	
7.8.2

	
Case Management

 

	
  

	
7.8.2.1

	
The Contractor shall be responsible for the Case Management of Enrollees who have the greatest need, including those who have catastrophic, high-cost, or high-risk conditions.

 

	
  

	
7.8.2.2

	
The Contractor’s case management system shall emphasize prevention, continuity of care, and coordination of care.  The system will advocate for, and link Enrollees to, services as necessary across Providers and settings.  Case Management functions include:

 

	
  

	
7.8.2.2.1

	
Early identification of Enrollees who have or may have special needs, including through use of the screening tools M-CHAT and ASQ-SE;

 

	
  

	
7.8.2.2.2

	
Assessment of an Enrollee’s risk factors including identification of any behavioral health needs;

 

	
  

	
7.8.2.2.3

	
Development of a plan of care;

 

  

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7.8.2.2.4

	
Coordination and assistance to ensure timely Access to Providers;

 

	
  

	
7.8.2.2.5

	
Coordination of care actively linking the Enrollee to Providers, medical services, residential, social and other support services where needed;

 

	
  

	
7.8.2.2.6

	
Monitoring;

 

	
  

	
7.8.2.2.7

	
Continuity of care;

 

	
  

	
7.8.2.2.8

	
Follow-up and documentation; and

 

	
  

	
7.8.2.2.9

	
Coordination with the MBHO for any Enrollee with behavioral health needs, including autism, attention deficit disorders, and substance or alcohol abuse disorders.

 

	
  

	
7.8.2.3

	
The Contractor shall develop policies and procedures for Case Management that include, at a minimum, the following elements:

 

	
  

	
7.8.2.3.1

	
The provision of an individual needs assessment and diagnostic assessment;

 

	
  

	
7.8.2.3.2

	
The development of an individual treatment plan, as necessary, based on the needs assessment;

 

	
  

	
7.8.2.3.3

	
The establishment of treatment objectives;

 

	
  

	
7.8.2.3.4

	
The monitoring of outcomes;

 

	
  

	
7.8.2.3.5

	
A process to ensure that treatment plans are revised as necessary;

 

	
  

	
7.8.2.3.6

	
A strategy to ensure that all Enrollees or Authorized Representatives, as well as any specialists caring for the Enrollee, are involved in a treatment planning process coordinated by the PCP;

 

	
  

	
7.8.2.3.7

	
Procedures and criteria for making Referrals to specialists and subspecialists;

 

	
  

	
7.8.2.3.8

	
Procedures and criteria for maintaining care plans and Referral services when the Enrollee changes PCPs;

 

  

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7.8.2.3.9

	
Capacity to implement, when indicated, case management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up, monitoring of outcomes, or revision of treatment plan; and

 

	
  

	
7.8.2.3.10

	
Process for referring Enrollees into Disease Management.

 

	
  

	
7.8.2.4

	
These procedures must be designed to include consultation and coordination with the MBHO and any behavioral health Providers when the Enrollee is receiving behavioral health services or is identified to require behavioral health services.

 

	
  

	
7.8.2.5

	
As part of its Case Management Program, the Contractor shall maintain statistical reports in the following areas:

 

	
  

	
7.8.2.5.1

	
Number of Enrollees receiving intensive one-on-one counseling interventions by case managers;

 

	
  

	
7.8.2.5.2

	
Number of Prior Authorizations and denials of Prior Authorization for the conditions included in Special Coverage;

 

	
  

	
7.8.2.5.3

	
Number of Enrollees screened for depression using the PHQ-9 (Patient Health Questionnaire-9) in adults and the ASQ-SE (Ages and Stages Questionnaire Socio-Emotional) in children; and

 

	
  

	
7.8.2.5.4

	
The number of Enrollees with chronic behavioral health conditions.

 

	
  

	
7.8.2.6

	
The Contractor shall submit its Case Management policies and procedures to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to Case Management policies and procedures must be previously approved in writing by ASES.

 

	
  

	
7.8.3

	
Disease Management

 

	
  

	
7.8.3.1

	
The Contractor shall develop a Disease Management program for individuals with Chronic Conditions, including the following:

 

	
  

	
7.8.3.1.1

	
Asthma;

 

	
  

	
7.8.3.1.2

	
Depression (to be handled by the MBHO in its Disease Management Program);

 

	
  

	
7.8.3.1.3

	
Diabetes Type 1 or 2;

 

  

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7.8.3.1.4

	
Congestive heart failure and other cardiovascular disease;

 

	
  

	
7.8.3.1.5

	
Hypertension;

 

	
  

	
7.8.3.1.6

	
Obesity; and

 

	
  

	
7.8.3.1.7

	
Chronic renal disease, levels 1 and 2 (see definition at Section 7.5.6.1.18.1 of this Contract).

 

	
  

	
7.8.3.2

	
The Contractor shall identify and categorize Enrollees using clinical protocols of the Health Department and protocols developed by the Committee for Management of Conditions established by ASES.

 

	
  

	
7.8.3.3

	
The Contractor shall report quarterly on the number of Enrollees diagnosed with each of these conditions.

 

	
  

	
7.8.3.4

	
The Contractor shall develop Disease Management policies and procedures detailing its program, including how Enrollees are identified for and referred to Disease Management, Disease Management program descriptions, and monitoring and evaluation activities.

 

	
  

	
7.8.3.5

	
The Contractor shall submit its Disease Management policies and procedures to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to Disease Management policies and procedures must be previously approved in writing by ASES.

 

	
  

	
7.8.3.6

	
The Contractor shall require in its policies and procedures that an individualized treatment plan be developed for each Enrollee who receives Disease Management services.  The policies and procedures shall include a strategy to ensure that all Enrollees or Authorized Representatives, as well as any specialists caring for the Enrollee, are involved in a treatment planning process coordinated by the PCP.

 

7.9     Early and Periodic Screening, Diagnosis and Treatment Requirements (“EPSDT”)

 

	
  

	
7.9.1

	
The Contractor shall arrange with the Network Providers for the provision of EPSDT Program services to Enrollees who are less than twenty-one (21) years of age (“EPSDT Eligible Children”), as specified below.

 

  

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7.9.1.1

	
The Contractor and ASES shall develop an EPSDT plan that sets forth those Administrative Services that the Contractor shall perform in connection with EPSDT (the “EPSDT Plan”), pursuant to applicable provisions of section 1902(a)(43) of the Social Security Act.  The EPSDT Plan shall address the following:

 

	
  

	
7.9.1.1.1

	
EPSDT screening standards and guidelines;

 

	
  

	
7.9.1.1.2

	
Education programs for Network Providers regarding the requirements to (i) track gaps in care,  (ii) promote follow-up to ensure that Network Providers comply with the Healthy Child Care periodicity schedules, and (iii) provide the information necessary for ASES to produce its CMS 416 reports; and

 

	
  

	
7.9.1.1.3

	
Outreach and education programs for parents.

 

	
  

	
7.9.1.2

	
The EPSDT Plan shall emphasize outreach and compliance monitoring for children and adolescents (young adults), taking into account the multi-lingual, multi-cultural nature of the population, as well as other unique characteristics of this population.

 

	
  

	
7.9.1.3

	
The EPSDT Plan shall include procedures for tracking gaps in care and follow up for annual dental examinations and visits.  The Contractor shall submit its EPSDT Plan for review and approval according to the timeframe specified in Attachment 12 to this Contract.

 

	
  

	
7.9.1.4

	
The EPSDT Plan shall require that quarterly reports compiled by the Contractor on EPSDT screening, based on Claims data submitted by Network Providers for EPSDT Eligible Children, will be submitted in accordance with the requirements of the CMS 416 reports to be prepared by ASES.

 

	
  

	
7.9.2

	
Outreach and Education

 

	
  

	
7.9.2.1

	
The Contractor’s EPSDT outreach and education process for EPSDT Eligible Children and their families shall include:

 

	
  

	
7.9.2.1.1

	
The importance of preventive care;

 

	
  

	
7.9.2.1.2

	
The periodicity schedule and the depth and breadth of services;

 

	
  

	
7.9.2.1.3

	
How and where to access services; and

 

	
  

	
7.9.2.1.4

	
A statement that services are provided without cost.

 

  

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7.9.2.2

	
The Contractor shall inform its newly enrolled families with EPSDT Eligible Children about the EPSDT program upon Enrollment with the MI Salud Plan.  This requirement includes inform pregnant women and new mothers, either before or within fourteen (14) Calendar Days after the birth of their children, that EPSDT services are available.

 

	
  

	
7.9.2.3

	
The Contractor will coordinate through its clinical programs necessary covered preventive services upon member request.

 

	
  

	
7.9.2.4

	
[Intentionally left blank]

 

	
  

	
7.9.2.5

	
The Contractor shall provide to each PCP, at least three (February, June and October) times per year, a list of the PCP’s EPSDT Eligible Children who are not in compliance with the EPSDT periodicity schedule.

 

	
  

	
7.9.2.6

	
The Contractor will ensure that the PCP receives a Gaps in Care analysis for at least eighty percent (80%) of his or her EPSDT Eligible Children.  For purposes of this Contract, “Gaps in Care analysis” shall mean the comparison of the actual provision of preventive services for EPSDT Eligible Children with the recommended preventive services according to evidence-based clinical practice guidelines.

 

	
  

	
7.9.2.7

	
Outreach and education shall include a combination of written and oral (on the telephone, face-to-face, or films/tapes) methods, and may be done by Contractor personnel or by Providers.  All outreach and education shall be documented and shall be conducted in non-technical language at or below a fourth (4th) grade reading level.  The Contractor shall use accepted methods for informing persons who are blind or deaf, or cannot read or understand the Spanish language.

 

	
  

	
7.9.3

	
Screening

 

	
  

	
7.9.3.1

	
The Contractor will promote periodic screens (“EPSDT Checkups”) in accordance with the Puerto Rico Medicaid Program’s periodicity schedule and the American Academy of Pediatrics EPSDT periodicity schedule.  Such EPSDT Checkups shall include, but not be limited to, the Healthy Child Care checkups described in Section 7.5.3.1 of this Contract.

 

	
  

	
7.9.3.2

	
The Contractor shall arrange for the provision of an initial health and screening visit to all newly enrolled EPSDT Eligible Children for all newborns within twenty-four (24) hours of birth.

 

  

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7.9.3.3

	
The Contractor shall advise the EPSDT Enrollee and his or her parents, or his or her legal guardian, of his or her right to have an EPSDT Checkup as well will provide a written notification of preventive care according to the EPSDT protocols.

 

	
  

	
7.9.3.4

	
EPSDT Checkups must include all of the following:

 

	
  

	
7.9.3.4.1

	
A comprehensive health and developmental history;

 

	
  

	
7.9.3.4.2

	
Developmental assessment, including mental, emotional, and behavioral health development;

 

	
  

	
7.9.3.4.3

	
Measurements (including head circumference for infants);

 

	
  

	
7.9.3.4.4

	
An assessment of nutritional status;

 

	
  

	
7.9.3.4.5

	
A comprehensive unclothed physical exam;

 

	
  

	
7.9.3.4.6

	
Immunizations according to the guidance issued by the Advisory Committee on Immunization Practices (ACIP)  (the vaccines themselves are paid for by the Department of Health; the Contractor shall cover Providers’ administration of the vaccines, under the fee schedule established by the Department of Health);

 

	
  

	
7.9.3.4.7

	
Certain laboratory tests;

 

	
  

	
7.9.3.4.8

	
Anticipatory guidance and health education;

 

	
  

	
7.9.3.4.9

	
Vision screening;

 

	
  

	
7.9.3.4.10

	
Tuberculosis;  as applicable

 

	
  

	
7.9.3.4.11

	
Hearing screening;

 

	
  

	
7.9.3.4.12

	
Dental and oral health assessment; and

 

	
  

	
7.9.3.4.13

	
Lead Screening.

 

	
  

	
7.9.3.5

	
The Contractor shall promote and inform providers of the requirements for the appropriate screening of lead toxicity. Regardless of health risk, the Contractor shall require in its Provider Contracts that Network Providers arrange for a blood lead screening test for all EPSDT Eligible children at twelve (12) and twenty-four (24) months of age.  Children between twenty-four (24) and seventy-two (72) months of age should receive a blood lead screening test if there is no record of a previous test.

 

  

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7.9.3.6

	
The Contractor shall have procedures that ensure appropriate access to care of EPSDT Eligible Children in need of further diagnostic and/or treatment services to correct or ameliorate defects, and physical and mental illnesses and conditions discovered by the EPSDT Checkup.  Referral and follow up may be made from the Provider conducting the screening or to another Provider, as appropriate.

 

	
  

	
7.9.3.7

	
The Contractor will include EPSDT level of compliance of the population assigned to every PCP as one of the qualifying criteria for the Physician Incentive Program.

 

	
  

	
7.9.3.8

	
The Contractor shall monitor Providers’ compliance with EPSDT guidelines according with CMS objectives and report on such compliance every quarter pursuant to its EPSDT Plan.

 

	
  

	
7.9.4

	
Tracking

 

	
  

	
7.9.4.1

	
The Contractor shall establish a tracking system using the Gaps in Care analysis that provides information on compliance with the following EPSDT requirements:

 

	
  

	
7.9.4.1.1

	
Preventive diagnostic services; and

 

	
  

	
7.9.4.1.2

	
Immunizations and dental services.

 

	
  

	
7.9.4.1.3

	
[Intentionally left blank]

 

	
  

	
7.9.4.2

	
All information generated and maintained in the tracking system shall be consistent with Encounter Data requirements as specified in Section 16.8 of this Contract.

 

	
  

	
7.9.5

	
Diagnostic and Treatment Services

 

	
  

	
7.9.5.1

	
If a suspected problem is detected by a screening EPSDT Checkup, the child shall be evaluated as necessary for further diagnosis.  This diagnosis is used to determine treatment needs.

 

	
  

	
7.9.5.2

	
The MI Salud Plan will provide access for all follow-up diagnostic and treatment services under this coverage deemed Medically Necessary to ameliorate or correct a problem discovered during the Checkup.  The Contractor shall arrange for the provision of Medically Necessary Covered Services through its Network Providers.

 

  

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7.10     Advance Directives

 

	
  

	
7.10.1

	
In compliance with 42 CFR 438.6 (i) (1)-(2), and with Law No. 160 of November 17, 2001, and with 42 CFR 489.100, the Contractor shall maintain written policies and procedures for Advance Directives.  The Contractor shall require Network Providers to: (i) include Advance Directives in each Enrollee’s Medical Record, (ii) provide these policies and procedures to all Enrollees eighteen (18) years of age and older and (iii) advise Enrollees of:

 

	
  

	
7.10.1.1

	
Their rights under the law of Puerto Rico, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives;

 

	
  

	
7.10.1.2

	
The Contractor’s written policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of Advance Directives as a matter of conscience; and

 

	
  

	
7.10.1.3

	
The Enrollee’s right to file complaints concerning the Advance Directive requirements directly with ASES or with the Puerto Rico Office of the Patient Advocate.

 

	
  

	
7.10.2

	
The information must include a description of Puerto Rico law and must reflect changes in laws as soon as possible, but no later than ninety (90) Calendar Days after the effective change.

 

	
  

	
7.10.3

	
The Contractor shall contractually require its Network Providers to educate their staff about its policies and procedures on Advance Directives, situations in which Advance Directives may be of benefit to Enrollees, and their responsibility to educate Enrollees about this tool and assist them to make use of it.

 

	
  

	
7.10.4

	
The Contractor shall educate Enrollees about their ability to direct their care using Advance Directives and shall specifically designate which staff members or Network Providers are responsible for providing this education.

 

7.11     Enrollee Cost-Sharing

 

	
  

	
7.11.1

	
The Contractor shall ensure that Network Providers collect Enrollee cost-sharing only as specified in Attachment 8 to this Contract.

 

	
  

	
7.11.2

	
The Contractor shall ensure that it accurately differentiates the categories of MI Salud Enrollees in its Marketing Materials and communications, to clarify the cost-sharing rules that are applied to each group.  The Contractor shall ensure that the Enrollee’s eligibility category appears on the Enrollee ID Card, so that cost-sharing is correctly determined.

 

  

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7.11.3

	
The Contractor shall ensure that, in keeping with the Co-Payment policies included in Attachment 8, Medicaid and CHIP Eligible Persons bear no cost-sharing responsibility under MI Salud for services provided within the Contractor’s PPN or for the treatment of an Emergency Medical Condition.

 

	
  

	
7.11.4

	
As provided in Attachment 8 to this Contract, the Contractor shall impose Co-Payments for services provided in an emergency room outside the Enrollee’s PPN, but only in limited circumstances.

 

	
  

	
7.11.4.1

	
For Medicaid and CHIP Eligible Persons, the Contractor shall not impose any Co-Payment for the treatment of an Emergency Medical Condition.  The Contractor shall, however, as provided in Attachment 8 to this Contract, impose Co-Payments for services provided in an emergency room to treat a condition that does not meet the definition of Emergency Medical Condition as set forth in this Contract.

 

	
  

	
7.11.4.2

	
No Co-Payments shall be charged for CHIP children under eighteen years of age under any circumstances; and

 

	
  

	
7.11.4.3

	
For Other Eligible Persons, the Contractor shall impose a Co-Payment for any emergency room visit outside the Enrollee’s PPN, if the Enrollee does not consult the Tele MI Salud Medical Advice Line before visiting the emergency room, and provide his or her call identification number at the emergency room. If the Enrollee presents the call identification number, no Co-Payment may be imposed.

 

	
  

	
7.11.5

	
As provided in 42 CFR 447.53(e), if a Medicaid or CHIP Eligible Person expresses his or her inability to pay the established Co-Payment at the time of service, the Contractor (through its contracted Providers) shall not deny the service.

 

	
  

	
7.11.6

	
An Indian as defined in Article 2, is exempt from all Co-Payments.

 

7.12     Dual Eligible Beneficiaries

 

	
  

	
7.12.1

	
Dual Eligible Beneficiaries enrolled in MI Salud are eligible, with the limitations provided below, for the Covered Services described in this Article, in addition to some coverage of Medicare cost-sharing.

 

	
  

	
7.12.1.1

	
Dual Eligible Beneficiaries Who Receive Medicare Part A Only

 

  

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7.12.1.1.1

	
The Contractor shall arrange for the provision of Basic Coverage as provided in this Article 7, excluding services covered under Medicare Part A (hospitalization); except that MI Salud shall cover hospitalization services after the Medicare Part A coverage limit has been reached.

 

	
  

	
7.12.1.1.2

	
The Contractor shall not cover the Medicare Part A premium or deductible.

 

	
  

	
7.12.1.2

	
Dual Eligible Beneficiaries Who Receive Medicare Part A and Part B

 

	
  

	
7.12.1.2.1

	
The Contractor shall arrange for the provision of the following Basic Coverage services only: Dental Services, Pharmacy Services, and Hospitalization Services (after the Medicare Part A coverage limit has been reached).

 

	
  

	
7.12.1.2.2

	
The Contractor shall not pay Claims for the Medicare Part A premium or deductible.

 

	
  

	
7.12.1.2.3

	
The Contractor shall pay Claims for Medicare Part B deductibles and co-insurance.

 

	
  

	
7.12.1.3

	
Dual Eligible Beneficiaries Enrolled in a Medicare Part C Plan

 

	
  

	
7.12.1.3.1

	
Medicare Platino is a Medicare Part C Plan that includes a supplementary package of MI Salud benefits for Dual Eligible Beneficiaries.  A Dual Eligible Beneficiary enrolled in a Platino plan is eligible for the Benefits listed in Sections 7.12.1.1 and 7.12.1.2 above.

 

	
  

	
7.12.1.3.2

	
An Enrollee who is independently enrolled in a private Medicare Advantage plan is also eligible for the Benefits listed in Sections 7.12.1 and 7.12.2 above.

 

	
  

	
7.12.2

	
Any MI Salud cost-sharing for Dual Eligible Beneficiaries shall be determined according to Section 7.11 and Attachment 8 of this Contract.

 

7.13     Moral or Religious Objections

 

	
  

	
7.13.1

	
If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor elects not to arrange for the provision of, not to reimburse for, or not to provide a Referral or Prior Authorization for a service that is a Covered Service, because of an objection on moral or religious grounds, the Contractor shall notify:

 

  

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7.13.1.1

	
ASES within one hundred and twenty (120) Calendar Days before adopting the policy with respect to any service;

 

	
  

	
7.13.1.2

	
Enrollees within ninety (90) Calendar Days after adopting the policy with respect to any service; and

 

	
  

	
7.13.1.3

	
Enrollees before and during Enrollment.

 

	
  

	
7.13.2

	
The Contractor acknowledges that such objection will be grounds for recalculation of rates paid to the Contractor.

 

	
ARTICLE 8

	
INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES

 

  8.1       General Provisions

 

	
  

	
8.1.1

	
The “integration model” of MI Salud refers to the program goal of ensuring that physical and behavioral health services are closely interconnected, to ensure optimal detection, prevention, and treatment of physical and mental illness.

 

	
  

	
8.1.2

	
The Contractor (through contracted PCPs and PMGs, and other Network Providers) shall be jointly responsible, along with the MBHO, for identifying Enrollees’ needs and coordinating proper Access to both physical and behavioral health services.

 

	
  

	
8.1.3

	
In implementing an integrated model of service delivery, the Contractor shall strive to observe all the protections of the Mental Health Code (Act 408) and the Puerto Rico Patient’s Bill of Rights Act, as well as other applicable federal and Commonwealth legislation.

 

	
  

	
8.1.4

	
The Contractor shall ensure a collaborative relationship with the MBHO and shall develop protocols that define the relationship and include, at a minimum, the process for making referrals to the MBHO and providing the appropriate supporting documentation, the process for receiving referrals from the MBHO and requesting the appropriate supporting documentation, and the process for monitoring Enrollees referred to the MBHO.

 

8.2        Co-Location of Staff

 

	
  

	
8.2.1

	
The Contractor shall coordinate with the MBHO to facilitate the placement of a psychologist or other behavioral health Provider in each PMG setting.  The behavioral health Provider shall be present, to the extent feasible, between the hours of 8:00 a.m. and 5:00 p.m. each Business Day and one Saturday per month; but at a minimum, sixteen (16) hours per week.

 

  

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8.2.2

	
The Contractor shall ensure that the PMG provides adequate space and resources for the behavioral health Provider to provide care and consultations in a confidential setting.

 

	
  

	
8.2.3

	
The salary costs for the behavioral health Provider within the PMG shall be borne by the MBHO; however, the Contractor and the MBHO shall negotiate the associated administrative costs.

 

	
  

	
8.2.4

	
The behavioral health Provider housed within the PMG shall conduct screening evaluations, crisis intervention, and limited psychotherapy (between four (4) and six (6) sessions, according to the needs of the Enrollee).

 

	
  

	
8.2.5

	
The Contractor shall share with the MBHO Behavioral Health Provider stationed within the PMG, the screening instruments for intervention and early detection of mental health conditions.

 

8.3     Referrals

 

	
  

	
8.3.1

	
MI Salud Enrollees with chronic or severe mental health conditions, which require more intensive or continuous care than can be provided within the PMG environment as set forth in Section 8.2 of this Contract, shall be referred to the MBHO for services.

 

	
  

	
8.3.2

	
An Enrollee may access behavioral health services through the MBHO through the following means:

 

	
  

	
8.3.2.1

	
A Referral from the PCP or other PMG physician;

 

	
  

	
8.3.2.2

	
Self-referral (walk-in);

 

	
  

	
8.3.2.3

	
Visiting a Comprehensive Health Center (“CCuSAI”);

 

	
  

	
8.3.2.4

	
Visiting Central Access Units;

 

	
  

	
8.3.2.5

	
The Tele MI Salud Service;

 

	
  

	
8.3.2.6

	
The telephone Call Center provided by ASSMCA, known as “Linea Pas”;

 

	
  

	
8.3.2.7

	
MBHO clinics;

 

	
  

	
8.3.2.8

	
Hospitals; and

 

	
  

	
8.3.2.9

	
Emergency rooms.

 

  

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8.4      Information Sharing

 

	
  

	
8.4.1

	
The Contractor and the MBHO shall share documents in the possession of each (including agreements, processes, guidelines and clinical protocols), in order for each to understand the other’s operations to ensure optimal cooperation.

 

	
  

	
8.4.2

	
The Contractor and the MBHO shall jointly develop forms to facilitate electronic communications, such as:

 

	
  

	
8.4.2.1

	
Information sheet for Enrollees on HIPAA requirements;

 

	
  

	
8.4.2.2

	
Referral sheet; and

 

	
  

	
8.4.2.3

	
Informed consent form.

 

	
  

	
8.4.3

	
The Contractor shall establish a process for monitoring exchange of information, documenting receipt of information and following up on information not submitted in a timely manner.

 

	
  

	
8.4.4

	
The Contractor shall require PMG staff to follow up with MBHO staff concerning the care of Enrollees referred by the PMG to the MBHO.

 

8.5      Staff Education

 

	
  

	
8.5.1

	
The Contractor shall train PMG staff on the goals and operational details of the integrated model of care, and, as appropriate, identification of behavioral health issues and conditions.

 

	
  

	
8.5.2

	
The Contractor shall require PMGs to Immediately refer Enrollees to the Behavioral Health Professional located within the PMG (or, if the professional is not available, to the Emergency Room) when an Enrollee manifests suicidal behavior.

 

8.6      Cooperation With Puerto Rico and Federal Government Agencies

 

The Contractor shall ensure that government entities including ASSMCA and SAMHSA shall be consulted where appropriate and shall acknowledge that these entities participate, as appropriate, in the regulation of Behavioral Health Services under MI Salud.

 

8.7      Contractor and MBHO Coverage of Hospitalization Services

 

In the event of any dispute between the Contractor and the MBHO concerning whether a Covered Service provided in a hospital or other inpatient facility falls within the scope of Behavioral Health Services covered by the MBHO, or within the scope of other Basic and Special Coverage covered by the Contractor, the terms of ASES Normative Letter 04-0130, dated February 13, 2004 (Attachment 13 to this Contract), shall govern.

 

  

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8.8      Integration Plan

 

The Contractor shall submit to ASES, for its review and approval, an Integration Plan incorporating the elements in this Article 8, according to the timeframe specified in Attachment 12 to this Contract.

 

	
ARTICLE 9

	
PROVIDER NETWORK

 

9.1      General Provisions

 

	
  

	
9.1.1

	
The Contractor shall have an adequate network of available Providers, in accordance with the timeframe specified in Attachment 12, meeting all Contract requirements in order: 1) to ensure timely Access to Covered Services (including complying with all federal and Puerto Rico requirements concerning timeliness, amount, duration, and scope of services); and 2) to provide sufficient Network Providers to satisfy the demand of Covered Services with adequate capacity and quality service delivery.

 

	
  

	
9.1.2

	
The Contractor shall ensure that its General Network of Providers is adequate to assure Access to all Covered Services, and that all Providers are appropriately Credentialed, maintain current licenses, and have appropriate locations to provide the Covered Services.

 

	
  

	
9.1.2.1

	
Besides complying with the Federal and Puerto Rico laws regarding the physical condition of medical facilities, the Provider’s facilities must also comply with ASES’s requirements including, but not limited to, accessibility, cleanliness and proper hygiene according to the criteria established in the Health Facilities Act, Act No. 101 of June 24, 1965.  . ASES reserves the right to evaluate the appropriateness of such facilities to provide the Covered Services.  After receiving a written notice from ASES, the Contractor must timely notify the Provider and propose and enforce a corrective plan to be completed within ninety (90) Calendar Days to make the facilities appropriate  to provide the Covered Services.

 

	
  

	
9.1.3

	
The Contractor shall also develop, as a subset of its General Network of Providers, a Preferred Provider Network (“PPN”).  The objectives of the PPN model are to increase Access to Providers and needed services, improve availability of Covered Services on a timely basis, improve the quality of Enrollee care, enhance continuity of care, and facilitate effective exchange of health information between Providers and the Contractor.

 

  

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9.1.3.1

	
The Contractor’s PPN shall include a sufficient number of PMGs, PCPs, specialists, hospitals, surgery centers, clinical laboratories and other Providers to adequately address the needs of Enrollees.

 

	
  

	
9.1.3.2

	
At a minimum, except as indicated below, the General Network standards will also apply to the PPN.

 

	
  

	
9.1.3.3

	
The PPN does not include Dental and Pharmacy Services.

 

	
  

	
9.1.4

	
The Contractor shall collaborate with the MBHO to provide integrated MI Salud mental and physical health services in order to achieve a proper management of both services.

 

	
  

	
9.1.5

	
The Contractor’s Network shall not include a Provider if the Provider, or any person or entity that has  an ownership or control interest in the Provider, or is an agent or managing employee of the Provider, has been excluded from participation in Medicaid, Medicare, or CHIP by HHS, the HHS Office of Inspector General, or who are on the EPLS or on Puerto Rico’s list of excluded Providers.  The Contractor is responsible for checking the exclusions list and providing notice of any exclusions pursuant to Section 9.4.9 of this Contract.

 

	
  

	
9.1.6

	
Each Provider shall have a unique National Provider Identifier (“NPI”) and shall be under contract with the Contractor’s Network.

 

	
  

	
9.1.7

	
With respect to Dental Services, the Contractor shall include in its Network any Provider that is qualified, per the requirements in this Article 9, and willing to participate.

 

9.2     Network Criteria

 

	
  

	
9.2.1

	
When establishing and maintaining an adequate network of Providers the Contractor shall consider and comply with each of  the following criteria, in accordance with 42 CFR 438.206(b)(1):

 

	
  

	
9.2.1.1

	
Estimated eligible population and number of Enrollees;

 

	
  

	
9.2.1.2

	
Estimated use of services, considering the specific characteristics of the population and special needs for health care;

 

	
  

	
9.2.1.3

	
Number and type of Providers required to offer services, taking experience, training and specialties into account;

 

	
  

	
9.2.1.4

	
Maximum number of patients per Provider;

 

  

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9.2.1.5

	
Number of Providers in the PPN and General Network that are not accepting new patients; and

 

	
  

	
9.2.1.6

	
Geographic location of Providers and Enrollees, taking into account distance as permitted by law, the duration of trip, the means of transportation commonly used by Enrollees, and whether the facilities provide physical access for Enrollees with physical disabilities or special needs.

 

	
  

	
9.2.2

	
These provisions shall not be construed to:

 

	
  

	
9.2.2.1

	
Require the Contractor to contract with Providers beyond the number necessary to meet the needs of its Enrollees; or

 

	
  

	
9.2.2.2

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

 

	
  

	
9.2.3

	
If the Contractor declines to include a Provider or group of Providers that have requested inclusion in its Network, the Contractor shall give the affected Provider(s) written notice of the reason for its decision.

 

	
  

	
9.2.4

	
The Contractor will use Reasonable Efforts to negotiate health services using state facilities, academic medical centers, municipal health services and facilities.  The Contractor will keep ASES informed about the status of such negotiations and ASES will cooperate with the Contractor’s efforts.

 

9.3     Provider Qualifications

 

	
  

	
9.3.1

	
The following requirements apply to specific Providers in the Contractor’s Network:

 

	
  FQHC

 

  Federal Qualified Health Centers

 

 

	
A Federally Qualified Health Center is an entity that provides outpatient care under Section 330 of the Public Health Service Act (42 USC 254b) and complies with the standards and regulations established by the federal government and is an eligible Provider enrolled in the Medicaid Program.

 

	
  PHYSICIAN

 

	
A person with a license to practice medicine as an

M.D. or a D.O. in Puerto Rico, whether as a PCP or in the area of specialty under which he or she will provide medical services through a contract with the Contractor; and that it is a Provider enrolled in the Puerto Rico Medicaid Program; and has a valid registration number from the Drug Enforcement Agency and the Certificate of Controlled Substances of Puerto Rico, if required in his or her practice.

 

 

  

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  HOSPITAL

	
An institution licensed as a general or special hospital by the Puerto Rico Health Department under Chapter 241 of the Health and Safety Code or Private Psychiatric Hospitals under Chapter 577 of the Health and Safety Code (or who is a Provider which is a component part of the Puerto Rico or local government entity which does not require a license under the laws of the Commonwealth) which is enrolled as a Provider in the Puerto Rico Medicaid Program.

 

	
  NON-MEDICAL PRACTICING

  PROVIDER

	
A person who possesses a license issued by the licensing agency of the Commonwealth enrolled in the Puerto Rico Medicaid Program or a properly trained person who practices under the direct supervision of a licensed professional offering support in health services.

 

	
  CLINICAL LABORATORY

	
An entity that has a valid certificate issued by the Clinical Laboratory Improvement Act (CLIA) and which has a license issued by the Health Department, licensing agency of the Commonwealth.

 

	
  RURAL HEALTH CLINIC (RHC)

	
A health facility that the Secretary of Health and Human Services has determined meets the requirements of Section 1861(aa)(2) of the Social Security Act; and that has entered into an agreement with the Secretary to provide services in Rural Health Clinics or Centers under Medicare and in accordance with 42 CFR 405.2402.

 

	
  LOCAL HEALTH DEPARTMENT

 

	
Local Health Department established under Act 81 from March 14, 1912.

 

	
  NON-HOSPITAL PROVIDING

  FACILITY

 

	
A health care service Provider which is duly licensed and credentialed to provide services and enroll in the Puerto Rico Medicaid program.

	
  SCHOOLS OF MEDICINE

 

	
Clinics located in the medicine campus that provide primary and preventive care to children and adolescents.

 

 

  

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9.3.2

	
The Contractor shall require the Network Providers to comply with any additional Provider qualifications as prescribed by ASES.

 

9.4      Provider Credentialing

 

The Contractor shall be responsible for Credentialing and re-Credentialing its Providers.

 

	
  

	
9.4.1

	
The Contractor shall ensure that all Network Providers are appropriately Credentialed and qualified to provide services per the terms of this Contract and comply with CMS Credentialing Requirements included on CMS Chapter VI of the Medicare Managed Care Manual.

 

	
  

	
9.4.2

	
The Contractor shall contract with all available private Providers that meet its Credentialing process (based on the Contractor’s evaluation of the materials listed in Section 9.4.3 of this Contract) and agree to its contractual terms, in order to ensure sufficient Network Providers to address Enrollee needs.

 

	
  

	
9.4.3

	
At a minimum, the file documenting the Contractor’s Credentialing process shall include, as applicable, the following:

 

	
  

	
9.4.3.1

	
Written application;

 

	
  

	
9.4.3.2

	
A current valid license to practice: Verification must show that the license was in effect at the time of the credentialing decision with a copy of a Good Standing or with the Junta de Licenciamiento Médico / Junta de Profesionales de la Salud CD;

 

	
  

	
9.4.3.3

	
Education and training records, including, but not limited to, Internship, Residency, Fellowships, Specialty Boards etc.: As per CMS chapter VI, section 60, education verification is required only for the highest level of education or training attained;

 

	
  

	
9.4.3.4

	
Board certification, when applicable, in each clinical specialty area for which the health care professional is being credentialed;

 

  

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9.4.3.5

	
Clinical privileges in good standing at the hospital designated by the health care professional, when applicable, as the primary admitting facility: This information may be obtained by contacting the facility, obtaining a copy of the participating facility directory or attestation by the health care professional;

 

	
  

	
9.4.3.6

	
Current, adequate malpractice insurance: This information may be obtained via the malpractice carrier, a copy of the insurance face sheet or attestation by the health care professional;

 

	
  

	
9.4.3.7

	
A valid Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS) certificate in effect at the time of the credentialing: This information can be obtained through confirmation with CDS, entry into the National Technical Information Service (NTIS) database, or by obtaining a copy of the certificate.;

 

	
  

	
9.4.3.8

	
A history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the health care professional: This information can be obtained from the malpractice carrier or from the National Practitioner Data Bank;

 

	
  

	
9.4.3.9

	
For physicians, any other information from the National Practitioner Data Bank;

 

	
  

	
9.4.3.10

	
Information about sanctions or limitations on licensure from the applicable state licensing agency or board, or from a group such as the Federation of State Medical Boards

 

	
  

	
9.4.3.11

	
Eligibility for participation in Medicare, when applicable;

 

	
  

	
9.4.3.12

	
Site Visits: The organization’s site visit policy will be reviewed pursuant to CMS’ monitoring protocol. At a minimum, the organization should consider requiring initial credentialing site visits of the offices of primary care practitioners, obstetrician- gynecologists, or other high-volume providers, as defined by the organization;

 

	
  

	
9.4.3.13

	
Disclosure of the information concerning the Provider and fiscal agents about participation and control including: name, address, participation percentage, familial relationships and others (as required by 42 CFR Part 455.104);

 

	
  

	
9.4.3.14

	
Provider’s disclosure of the information related to business transactions, in compliance with the 42 CFR Part 455.105;

 

  

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9.4.3.15

	
Disclosure of the information about criminal convictions of the Provider or a person or entity with an ownership or control interest in the Provider, or who is an agent or managing employee of the Provider, in compliance with 42 CFR Part 455.106.

 

	
  

	
9.4.4

	
Credentialing of health care facilities shall be governed by, but not limited to, Law 101 of June 26, 1965, as amended, known as “Law of Facilities of Puerto Rico.”

 

	
  

	
9.4.5

	
The Contractor shall re-Credential its Network Providers every three (3) years. Requirement documents are considered current at the time of the initial credentialing or recredentialing.  As per CMS regulations and manuals the organization is not required to monitor and account for any expiration dates on a continuous basis unless required to do by the State.

 

	
  

	
9.4.6

	
The re-Credentialing process shall include, at a minimum, verification and/or updating of Sections 9.4.3.1 – 9.4.3.16 of this Contract, as appropriate, in order to ensure continued adequacy of the Network.

 

	
  

	
9.4.7

	
The Contractor shall maintain a Provider file for all Network Providers. The Provider file shall be updated annually and shall consist of, at a minimum, the following documents: annual state review, DEA license, malpractice insurance and ASSMCA license.  Corroboration data will also be required quarterly as provided by the National Practitioner Data Bank, HHS OIG (Office of Inspector General), EPLS (Excluded Parties List System).

 

	
  

	
9.4.8

	
The Contractor shall ensure, and be able to demonstrate at the request of ASES, that:  (a) Out-of-Network Providers are duly licensed to provide the Covered Services for which they submit Claims; and (b) the Contractor’s internal Credentialing and re-Credentialing processes are in accordance with 42 CFR 438.214 (Provider Selection).

 

	
  

	
9.4.9

	
If the Contractor determines, through the Credentialing or re-Credentialing process, or otherwise, that a Provider could be excluded pursuant to 42 CFR 1001.1001, or if the Contractor determines that the Provider has failed to make full and accurate disclosures as required in Sections 9.4.3.19–9.4.3.21 above, the Contractor shall deny the Provider’s request to participate in the Network, or, for a current Network Provider, as provided in Section 10.4.1.2.2 of this Contract, terminate the Provider Contract.  The Contractor shall notify ASES of such a decision, and shall provide documentation of the bar on the Provider’s Network participation, within twenty (20) Business Days of communicating the decision to the Provider.  The Contractor shall screen its employees, Network Providers, and other subcontractors under this Contract as required by law to determine whether any of them has been excluded from participation in Medicare, Medicaid, CHIP, or any other Federal health care program (as defined in Section 1128B(f) of the Social Security Act).  ASES or the Puerto Rico Medicaid Program shall, upon receiving notification from the Contractor that the Contractor has denied Credentialing, notify the HHS Office of the Inspector General of the denial with twenty (20) Business Days of the date it receives the information, in conformance with 42 CFR 1002.3.

 

  

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9.4.10

	
The Contractor shall report to ASES on a monthly basis the Credentialing and re Credentialing status of all the Providers.

 

	
9.5

	
Provider Ratios

 

	
  

	
9.5.1

	
The Contractor shall comply with the following minimum Provider ratios.

 

	
  

	
9.5.1.1  

	
One PCP per 1,700 Enrollees (1:1,700) (ratio applicable to PPN) (a ratio of 1:2,800 will apply to gynecologist-obstetricians selected as an Enrollees PCP);

 

	
  

	
9.5.1.2  

	
One specialty of the ones mentioned below for each 2,200 Enrollees (1:2,200) (ratio to be calculated per specialty per Service Region; e.g. one cardiologist per 2,200 enrollees) (ratio applicable to both, General Network and PPN) (a ratio of 1:2,800 will apply to gynecologist-obstetricians selected as an Enrollees PCP); and

 

9.5.1.2.1  For the purpose of this section, for the PPN the Contractor shall have available and under contract within each Service Region, the following types of Network Providers:

 

9.5.1.2.1.1 Cardiologists

 

9.5.1.2.1.2 Gastroenterologists

 

9.5.1.2.1.3 Pneumologists

 

9.5.1.2.1.4. Endocrinologists

 

9.5.1.2.1.5. Urologists

 

  

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9.5.1.2.2

	
In the event that this ratio cannot be achieved by the Contractor due to lack of providers of a determined specialty in the Service Region or due to specialists’ refusal to contract as part of the PPN for the Service Region, the Contractor must carry out all efforts to contract with those specialists within contiguous regions; provided that before recurring to contiguous regions Contractor must validate and submit all supporting documents evincing the lack of providers or refusal to contract.  ASES shall approve that specialist’s contract before its execution, after Contractor has accredited such need with supporting documents.

	
  

	
9.5.1.2.3

	
If after carrying out those efforts referred to in the previous section the Contractor still cannot comply with the ratio stated in section 9.5.1.2, such compliance may be waived by ASES, provided that this waiver shall be notified to Contractor in written form and signed by the Executive Director or Legal Director of ASES. Lack of this waiver will result in default of section 9.5.1.2.

	
  

	
9.5.1.3

	
One dentist for each 1,350 Enrollees (1:1,350) (ratio applicable only to the General Network).  If there are not enough dentists in the Service Region, the Contractor must contract with dentists within contiguous Service Regions.

 

	
  

	
9.5.1.4

	
The Parties acknowledge that there are shortages of certain specialists in the Service Regions.  The Contractor will work with the Provider community to address Enrollee access to specialists to the extent possible.   The Contractor will then develop policies and procedures to ensure Enrollees have access to specialty services as necessary.

 

	
  

	
9.5.2

	
The Contractor shall also ensure that the PPN, in addition to meeting the requirements set forth above, adheres to the following minimum Provider ratios:

 

	
  

	

9.5.2.1

	

One X-ray facility per 10,000 Enrollees (1:10,000) in each Service Region;

 

	
  

	
9.5.2.2  

	
One (1) clinical laboratory per 5,000 Enrollees (1:5,000) in each Service Region; and

 

	
  

	
9.5.2.3  

	
Two (2) hospitals in each Service Region.

 

  

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9.5.3

	
Subject to Section 10.5.5 of this Contract, the aforementioned ratios must be maintained for Enrollees, regardless of whether the PMG offers treatment to other private patients.

    

	
9.6

	
Network Providers

 

	
  

	
9.6.1

	
PCPs

 

	
  

	
9.6.1.1

	
The Contractor shall establish a system of coordinated care in which the Primary Care Physician (PCP), will be part of a Primary Medical Group (PMG). PCPs will be responsible for providing, managing and coordinating all the services of the Enrollee, including the coordination with behavioral health personnel, in a timely manner, and in accordance with the guidelines, protocols and practices generally accepted in medicine.

 

	
  

	
9.6.1.2

	
The PCP is responsible for maintaining each Enrollee’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services, which may be maintained through a certified EHR system meeting the specifications set forth in Attachment 15 to this Contract.

 

	
  

	
9.6.1.3

	
The following shall be considered PCPs for purposes of contracting with a PMG:

 

	
  

	
9.6.1.3.1

	
General practitioners;

 

	
  

	
9.6.1.3.2

	
Internists;

 

	
  

	
9.6.1.3.3

	
Family doctors;

 

	
  

	
9.6.1.3.4

	
Pediatricians (optional for minors under the age of 21); and

 

	
  

	
9.6.1.3.5

	
Gynecologists-obstetricians (obligatory when the woman is pregnant or of reproductive age; this Provider will also be selected for usual gynecological visits).

 

	
  

	
9.6.1.4

	
Every PMG will have, according to the ratios established in Section 9.5.1, at least three (3) of the medical services providers previously mentioned, including  one (1) obstetrician/gynecologist, and one (1) pediatrician to provide the Covered Services to the different categories of Enrollees.

 

  

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9.6.1.5

	
The Contractor shall promote the selection, by women who are pregnant, of a gynecologist-obstetrician as their PCP.  Additionally, the Contractor will permit female Enrollees to select a gynecologist-obstetrician for their routine gynecological visits at initial Enrollment.

 

	
  

	
9.6.1.6

	
The PCP shall be available to attend to the health needs of the Enrollee twenty-four (24) hours a day, seven (7) days a week.  On-call or telephone answering services will suffice to meet this requirement.

 

	
  

	
9.6.1.7

	
The Contractor shall offer its Enrollees freedom of choice in selecting a PCP.  The Contractor shall have policies and procedures describing how Enrollees select their PCP.  The Contractor shall submit these policies and procedures to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.

 

	
  

	
9.6.1.8

	
No PCP may own any financial control or have a direct or indirect economic interest (as defined in Act 101 of July 26, 1965) in any Ancillary Services facility or any other Provider (including laboratories, pharmacies, etc.) under contract with the PMG.

 

	
  

	
9.6.1.9

	
Nurse practitioners and physician’s assistants may not be PCPs.

 

	
  

	
9.6.2

	
Specialists and Other Providers

 

	
  

	
9.6.2.1

	
For either and/or both the General Network and the PPN (except as specifically indicated below), the Contractor shall have available and under contract within each Service Region the following types of Network Providers, including but not limited to:

 

	
  

	
9.6.2.1.1

	
Podiatrists;

 

	
  

	
9.6.2.1.2

	
Optometrists;

 

	
  

	
9.6.2.1.3

	
Ophthalmologists;

 

	
  

	
9.6.2.1.4

	
Radiologists;

 

	
  

	
9.6.2.1.5

	
Endocrinologists

 

	
  

	
9.6.2.1.6

	
Nephrologists

 

  

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9.6.2.1.7

	
Pneumologists

 

	
  

	
9.6.2.1.8

	
Cardiologists

 

	
  

	
9.6.2.1.9

	
Urologists

 

	
  

	
9.6.2.1.10

	
Gastroenterologists

 

	
  

	
9.6.2.1.11

	
Rheumatologists

 

	
  

	
9.6.2.1.12

	
Dermatologists

 

	
  

	
9.6.2.1.13

	
Hematologist Oncologist

 

	
  

	
9.6.2.1.14

	
Clinical Laboratories (the Contractor shall ensure that all of the laboratories under contract have a registration certificate (Clinical Laboratory Improvement Amendment, CLIA) and the registration number (CLIA) or a waiver certificate);

 

	
  

	
9.6.2.1.15

	
X-Ray Facilities;

 

	
  

	
9.6.2.1.16

	
Hospitals;

 

	
  

	
9.6.2.1.17

	
Other Health Care Professionals, provided they are duly licensed and credentialed as required by ASES;

 

	
  

	
9.6.2.1.18

	
Specialized Service Providers;

 

	
  

	
9.6.2.1.19

	
Urgent care centers and emergency rooms; and

 

	
  

	
9.6.2.1.20

	
Any other Providers needed to offer services under Basic Coverage (except that Pharmacy Services are not included within the PPN) and Special Coverage, considering the specific health needs of the Service Region.

 

	
  

	
9.6.2.2

	
In the event that a determined type of health care provider cannot be contracted by the Contractor due to lack of such providers in the Service Region or due to such provider’s refusal to contract for this MI Salud Program, the Contractor must carry out all efforts to contract with those providers within contiguous regions; provided that before recurring to contiguous regions Contractor must validate and submit all supporting documents evincing the lack of providers or refusal to contract.

 

  

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9.6.2.3

	
The Contractor shall offer its Enrollees freedom of choice in selecting a dentist.

     

	
9.7

	
Out-of-Network Providers

 

	
  

	
9.7.1

	
If the Contractor’s network is unable to provide Medically Necessary Covered Services or FQHC Services to an Enrollee, the Contractor shall adequately and timely cover these services using Providers outside of its Network.

 

	
  

	

9.7.1  Except as provided with respect to Emergency Services (see Section 7.5.9.3.1.2 of this Contract) and FQHC Services, if the Contractor offers the service through a Provider in the Network but the Enrollee chooses to access the service from an Out-of-Network Provider, the Contractor is not responsible for payment of such Claims.

 

	
  

	

9.7.2  The Contractor must ensure that Out-of-Network Providers are duly licensed to provide the Covered Services for which they submit Claims.

 

	
  

	

9.7.3  ASES shall ensure, in setting Co-Payments, that in the event that a Co-Payment is imposed on Enrollees for an Out-of-Network service, the Co-Payment shall not exceed the Co-Payment that would apply if services were provided by a Provider in the General Network.

 

	
9.8

	
Minimum Requirements for Access to Providers

 

	
  

	
9.8.1

	
The Contractor shall provide Access to Covered Services in accordance with the following terms:

 

	
  

	
9.8.1.1  

	
Emergency Services shall be provided within twenty-four (24) hours of the moment service is requested.

 

	
  

	
9.8.1.2  

	
Specialist services shall be provided within thirty (30) Calendar Days of           the Enrollee’s original request for the service.

 

	
  

	
9.8.1.3  

	
Routine physical exams shall be provided for adults within ten (10) weeks of the Enrollee’s request for the service, taking into account the medical need and condition.  For minors 21 years of age and under, routine physical exams shall be provided within the timeframes specified in Section 7.9.3 of this Contract.

 

  

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9.8.1.4 Covered Services, other than those listed in Sections 9.8.1.1 – 9.8.1.3 of this Contract, shall be provided within fourteen (14) Calendar Days following the request for service.

 

	
  

	
 

	

9.8.1.5 FQHC Services.  FQHC Services shall be provided in an FQHC.  The Contractor shall adequately and timely cover these services out-of-network at no cost to Enrollees for as long as the FQHC Services are unavailable in the Contractor’s Network.  All Out-of-Network services require a Referral from the Enrollee’s PCP.

 

	
9.9

	
Referrals

 

	
  

	
9.9.1

	
The Contractor shall not require a Referral from a PCP when an Enrollee seeks care from a Provider in the Contractor’s PPN.

 

	
  

	

9.9.2

	
A written Referral from the PCP shall be required:

 

	
  

	
  9.9.2.1

	
for the Enrollee to access specialty care and services within the Contractor’s General Network but outside the PPN; and

 

	
  

	
  9.9.2.2

	
For the Enrollee to access any service outside of the Provider Network (with the exception of Emergency Services).

 

	
  

	
9.9.3

	
A Referral for either General Network services or Out-of-Network services will be provided within five (5) Calendar Days of the Enrollee’s request; except that if the Enrollee’s life or health could be endangered by a delay in accessing services, the Referral shall be provided within three (3) Calendar Days of the request.

 

	
  

	
9.9.4

	
Neither the Contractor nor any Provider may impose a requirement that Referrals be submitted for the approval of Committees, Boards, Medical Directors, etc.  The Contractor shall strictly enforce this directive and shall issue Administrative Referrals (see Section 11.3 of this Contract) whenever it deems Medically Necessary.

 

	
  

	
9.9.5

	
If the Provider Access requirements of Section 9.8.1.2 of this Contract cannot be met within the PPN within thirty (30) Calendar Days of the Enrollee’s request for the Service, the PMG shall refer the Enrollee to a specialist within the General Network, without the imposition of Co-Payments.  However, the Enrollee shall return to the PPN specialist once the PPN specialist is available to treat the Enrollee.

 

	
  

	
9.9.6

	
The Contractor shall ensure that PMGs comply with the rules stated in this Section concerning Referrals, so that Enrollees are not forced to change PMGs in order to obtain needed Referrals.

 

	
  

	
9.9.7

	
The Contractor shall be responsible for the development and implementation of written policies and procedures that ensure a system of Referrals to Providers outside of the Network and the processing of authorizations for requested services.  These policies will be included in the Provider guidelines (see Section 10.2.1 of this Contract).

 

  

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9.9.8

	
If the Referral system that is developed by the Contractor requires the use of electronic media, such equipment shall be installed in PMG offices at the Contractor’s expense.

 

	
9.10

	

Timeliness of Prior Authorization

 

	
  

	
9.10.1

	
The Contractor shall ensure that Prior Authorization is provided for the Enrollee in the following timeframes, including on holidays and outside of business hours.  

 

	
  

	

9.10.1.1      The decision to grant or deny a Prior Authorization must not exceed fourteen (14) days from the time of the Enrollee’s Service Authorization Request for any Covered Service; except that, where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be endangered by a delay in accessing services, Prior Authorization must be provided as expeditiously as the Enrollee’s health requires, and no later than seventy two (72) hours of the Service Authorization Request.

 

	
  

	

9.10.1.2      ASES may, in its discretion, grant an extension of the time allowed for Prior Authorization decisions, where:

 

	
  

	
9.10.1.2.1

	
the Enrollee, or the Provider, requests the extension; or

 

	
  

	
9.10.1.2.2

	
the Contractor justifies to ASES a need for the extension in order to collect additional information, such that the extension is in the Enrollee’s best interest.

 

	
  

	
9.10.2

	
For services that require Prior Authorization by the Contractor, the Service Authorization Request shall be submitted promptly by the PCP for the Contractor’s approval, so that Prior Authorization may be provided in compliance within the timeframe set forth in Section 9.10.1 of this Contract.

 

	

9.11

	

Behavioral Health Services

 

	
  

	
9.11.1

	
The Contractor shall implement procedures in conjunction with the MBHO to ensure that each Enrollee has Access to outpatient and inpatient Behavioral Health Services.

 

  

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9.11.2

	
The Contractor shall develop policies and procedures that ensure timely Access to Behavioral Health Services and integration of care.

 

	
  

	
9.11.3

	
The Contractor shall submit its policies and procedures to ASES for prior approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the policies and procedures must be previously approved in writing by ASES.

 

	
  

	
9.11.4

	
Notwithstanding that the MI Salud Program is an integrated mental and physical health services program, the Parties acknowledge that to the extent of any conflict between the terms of this Contract and the terms of any MBHO policy or procedure, the terms of this Contract shall govern and control.

 

	

9.12

	

Hours of Service

 

	
  

	
9.12.1

	
The Contractor shall prohibit its Network Providers from having different hours and schedules for Enrollees than what is offered to patients with commercial coverage.

 

	
  

	
9.12.2

	
The Contractor shall prohibit its Providers from establishing specific days for the delivery of Referrals and requests for Prior Authorization for MI Salud Enrollees, and the Contractor shall monitor compliance with this rule.

 

	

9.13

	

Prohibited Actions

 

Any denial, unreasonable delay, or rationing of Medically Necessary Services to Enrollees is expressly prohibited.  The Contractor shall monitor compliance with this prohibition by Network Providers related to their provision of Covered Services to Enrollees.

 

	

9.14

	

Access to Services for Enrollees with Special Health Needs

 

	
  

	
9.14.1

	
The Contractor shall require that its Network Providers evaluate any progressive condition of an Enrollee with special health needs that requires a course of regular monitored care or treatment.  This evaluation will include the use of Health Care Professionals for each identified case.

 

	
  

	
9.14.2

	
The Contractor shall establish a protocol to screen Enrollees for Special Coverage and for the Case Management and Disease Management benefits, in order to facilitate direct Access to specialists.  The Contractor shall submit its operational protocol to ASES for prior approval according to the timeframe specified in Attachment 12 to this Contract.

 

  

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9.15

	

Preferential Turns

 

The Contractor shall agree to establish a system of Preferential Turns for residents of the island municipalities of Vieques and Culebra.  Preferential Turns refers to a policy of requiring Providers to give priority in treating Enrollees from these island municipalities, so that they may be seen by a physician within a reasonable time after arriving in the Provider’s office.  This priority treatment is necessary because of the remote locations of these municipalities, and the greater travel time required for their residents to seek medical attention.  This requirement was established in Laws No. 86 enacted on August 16, 1997 (Arts. 1 through 4) and Law No. 200 enacted on August 5, 2004 (Arts. 1 through 5).  The Contractor shall include this requirement in the Provider guidelines (see Section 10.2.1 of this Contract).

 

	

9.16

	

Contracting with Government Facilities

 

	
  

	
9.16.1

	
The Contractor shall contract, as a first option, with the following government health facilities:

 

	
  

	
9.16.1.1

	
State Facilities;

 

	
  

	
9.16.1.2

	
CCuSaI Centers;

 

	
  

	
9.16.1.3

	
Municipal Centers;

 

	
  

	
9.16.1.4

	
Federally Qualified Health Centers (FQHC);

 

	
  

	
9.16.1.5

	
Schools of Medicine;

 

	
  

	
9.16.1.6

	
Puerto Rico Medical Center; and

 

	
  

	
9.16.1.7

	
Public Health Corporations of the Commonwealth.

 

	
  

	
9.16.2

	
These health facilities shall be contracted under the same conditions as any other Provider, in the same level of service and shall have to comply with all applicable requirements.

 

	

9.17

	

Contracting with Other Providers

 

The Contractor shall comply with Capitated contract rules established by PRICO, in accordance with Normative Letter  CA-I-2-1232-91 (Attachment 13 to this Contract), which provides that every contract based on a Capitated payment arrangement prohibits the Provider from in turn subcontracting on a Capitated basis.

 

	

9.18

	

PMG Additions or Mergers

 

	
  

	
9.18.1

	
In order to ensure the reasonableness of the risk allocation, the Contractor shall not be bound to contract with new PMGs unless ASES so requires after an actuarial analysis, and as long as it does not place other PMGs in a position of harm.

 

  

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9.18.2

	
The creation, cancellation, fusion, and merger of PMGs are administrative matters.  ASES is not responsible for these processes, except in specific conditions to guarantee that the continuity of services to Enrollees is not affected.  These mergers may not under any circumstances exceed the established Provider requirements regarding ratios, or create Committees or Boards for the approval of Referrals to services outside of the Network.  Issuing Referrals outside of the PPN shall be the sole and exclusive responsibility of the PCP.  The Contractor shall be the only entity authorized to issue administrative referrals when these are medically required.

 

	

9.19

	

Extended Schedule of PMGs

 

	
  

	
9.19.1

	
PMGs shall provide primary care services Monday through Saturday from 8:00 a.m. to 6:00 p.m.

 

	
  

	
9.19.2

	
In addition, each PMG shall have sufficient personnel to offer urgent care services during extended periods Monday through Friday from 6:00 p.m. to 9:00 p.m., in order to provide Enrollees greater Access to their PCPs and to urgent care services.

 

	
  

	
9.19.3

	
PMGs may collaborate with each other to establish extended office hours at one facility.

 

	
  

	
9.19.4

	
The Contractor shall submit to ASES its policies and procedures for how it will determine the adequacy and appropriateness of such arrangements, approve such arrangements and monitor their operation.  The policies and procedures shall be submitted for prior approval according to the timeframe specified in Attachment 12 to this Contract.

 

	

9.20

	

Direct Relationship

 

	
  

	
9.20.1

	
The Contractor shall ensure that all Network Providers have knowingly and willingly agreed to participate in the Contractor’s Network.

 

	
  

	
9.20.2

	
The Contractor shall be prohibited from acquiring established networks without contacting each individual Provider to ensure knowledge of the requirements of this Contract and the Provider’s complete understanding and agreement to fulfill all terms of the Provider Contract.

 

	
  

	
9.20.3

	
ASES reserves the right to confirm and validate, through collection of information, documentation from the Contractor and on-site visits to Network Providers, the existence of a direct relationship between the Contractor and the Network Providers.

 

  

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9.21

	

Additional PPN Standards

 

	
  

	
9.21.1

	
In addition to the Provider Network requirements prescribed in this Section, the Contractor shall adhere to additional standards for the PPN.

 

	
  

	
9.21.2

	
The Contractor shall establish policies and procedures that, at a minimum, include:

 

	
  

	
9.21.2.1

	
Criteria for participating in the PPN versus the General Network;

 

	
  

	
9.21.2.2

	
Standards for monitoring Provider performance;

 

	
  

	
9.21.2.3

	
Methodologies for measuring Access to care;

 

	
  

	
9.21.2.4

	
Methodologies for identifying issues; and

 

	
  

	
9.21.2.5

	
Measures to address identified issues.

 

	
  

	
9.21.3

	
The Contractor shall submit its policies and procedures to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract. Any subsequent changes to the policies and procedures must be previously approved in writing by ASES.

 

	

9.22

	

Contractor Documentation of Adequate Capacity and Services

 

	
  

	
9.22.1

	
Before the Effective Date of this Contract, as well as on the occasions listed in Section 9.22.2 of this Contract, the Contractor shall provide documentation demonstrating that:

 

	
  

	
9.22.1.1

	
The Network Providers offer an appropriate range of preventive, primary care, and specialty services that is adequate for the anticipated number of Enrollees in each of the Contractor’s Service Regions; and

 

	
  

	
9.22.1.2

	
It maintains a Provider Network that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of Enrollees in each of the Contractor’s Service Regions.

 

	
  

	
9.22.2

	
The Contractor shall provide documentation of the Network adequacy conditions stated in this Section (see, Attachment 12), at any time that there has been a significant change in the Contractor’s operations that would affect adequate capacity and services, including

 

  

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9.22.2.1

	
When there is a change in Benefits, geographic Service Regions, or payments; or

 

	
  

	
9.22.2.2

	
Upon the Enrollment of a new eligibility group in the MI Salud Plan.

 

	
ARTICLE  10

	
PROVIDER CONTRACTING

 

	
10.1

	
General Provisions

 

	
  

	
10.1.1

	
The Contractor shall establish a coordinated care model in which the PCP, located within a PMG, directs the Enrollee’s care.

 

	
  

	
10.1.2

	
The PCP shall provide, manage and coordinate services to the Enrollee, including coordination with behavioral health personnel, in a timely manner, and in accordance with the guidelines, protocols, and practices generally accepted in medicine.

 

	
  

	
10.1.3

	
The Contractor and each of its Network Providers shall work to ensure that physical and behavioral health services are delivered in a coordinated manner, and each shall cooperate with the MBHO to achieve effective integration of physical and behavioral health services, as provided in Article 8.

 

	
  

	
10.1.4

	
The Contractor shall contract with enough PMGs to serve the Enrollees in each of its Service Regions.  As a precondition to executing any Provider Contract, the Contractor shall comply with the requirements stated in Section 10.1.6 of this Contract regarding submitting model Provider Contracts to ASES.

 

	
  

	
10.1.5

	
The Contractor shall not contract with any Provider without ascertaining that the Provider meets all of the credentialing requirements specified in Article 9 of this Contract.

 

	
  

	
10.1.6

	
Model Provider Contracts

 

	
  

	
10.1.6.1

	
The Contractor shall submit to ASES for review and approval a model for each type of Provider Contract, according to the timeframe specified in Attachment 12 to this Contract.  The Contractor shall include in such submission, at a minimum, model contracts for PMGs, PCPs, Ancillary Service Providers, Hospitals, Emergency Rooms, and Ambulance Services.  The Contractor shall deliver to ASES an electronic copy of each finalized Provider Contract within thirty (30) Calendar Days of the effective date of such contract.

 

  

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10.1.6.2

	
ASES shall review each executed Provider Contract against the approved model Provider Contracts.  ASES reserves the right to cancel Provider Contracts or to impose sanctions against the Contractor for the omission of clauses required in the contracts with Providers.

 

	
  

	
10.1.6.3

	
On an ongoing basis, any material modifications to model Provider Contracts shall be submitted to ASES for review and approval, before the amendment may be executed.  Similarly, any amendments to Provider Contracts shall be submitted to ASES for review and prior approval.

 

	
  

	
10.1.7

	
The Contractor shall not discriminate against a Provider that is acting within the scope of its license or certification under applicable Puerto Rico law, in decisions concerning contracting, solely on the basis of that license or certification.  This subsection shall not be construed as precluding the Contractor from using different payment amounts for different specialties, or for different Providers in the same specialty.

 

	
  

	
10.1.8

	
To comply with Section 9.22.1 of this Contract, the Contractor may comply with Section 10.1.6.1 of this Contract by submitting to ASES, for its review and approval, the Contractor’s current contracts with Providers, including any amendments thereto, containing the provisions required under Sections 10.3 and 10.4 of this Contract.

 

	
10.2

	
Provider Training

 

	
  

	
10.2.1

	
Provider guidelines

 

	
  

	
10.2.1.1

	
The Contractor shall prepare Provider guidelines, to be distributed to all Network (General Network and PPN), summarizing the MI Salud Program.  The Provider guidelines shall, in accordance with 42 CFR 438.236, (1) be based on valid and reliable clinical evidence or a consensus of health care professionals in the particular field; (2) consider the needs of the Contractor’s Enrollees; (3) be adopted in consultation with Providers; and (4) be reviewed and updated periodically, as appropriate.

 

	
  

	
10.2.1.2

	
The Provider guidelines shall describe the procedures to be used to comply with the Provider’s duties and obligations pursuant to this Contract, and under the Provider Contract.

 

	
  

	
10.2.1.3

	
The Contractor shall submit the Provider guidelines to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the Provider guidelines must be previously approved in writing by ASES.

 

  

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10.2.1.4

	
The content of the Provider guidelines will include, without being limited to, the following topics: the duty to verify eligibility; selection of Providers by the Enrollee; Covered Services; procedures for Access to and provision of services; Preferential Turns; coordination of Access to Behavioral Health Services; required service schedule; Medically Necessary services available 24 hours (see Section 9.6.1.5 of this Contract); Report requirements; Medical Record maintenance requirements; Complaint, Grievance, and Appeal procedures (see Article 14); Co-Payments; HIPAA requirements; the prohibition on denial of Medically Necessary services; and sanctions or fines applicable in cases of non-compliance.

 

	
  

	
10.2.1.5

	
The Provider guidelines shall be delivered to each Provider as part of the Provider contracting process, and shall be made available to Enrollees and to Potential Enrollees upon request.  The Contractor shall provide evidence of having delivered the guidelines to all of its Providers within fifteen (15) Calendar Days of award of the Provider Contract.  The evidence of receipt shall include the legible name of the Provider, Provider number, date of delivery, and signature of the Provider.

 

	
  

	
10.2.1.6

	
The Contractor shall have a process in place (including both updates to the Provider guidelines and other communications) to inform its Provider Network, in a timely manner, of programmatic changes such as changes to drug formularies, Covered Services, and protocols.

 

	
  

	
10.2.2

	
Provider Education Program

 

	
  

	
10.2.2.1

	
The Contractor shall develop a continuing education curriculum of twenty (20) hours per year divided into five (5) hours per quarter.  The curriculum shall be submitted to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the curriculum must be previously approved in writing by ASES.

 

	
  

	
10.2.2.2

	
The Contractor shall coordinate topics with the PBM’s Academic Detailing Program to develop educational activities addressing:

 

	
  

	
10.2.2.2.1

	
Management and implications of polypharmacy;

 

	
  

	
10.2.2.2.2

	
Condition management;

 

  

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10.2.2.2.3

	
Management of prescriptions; and

 

	
  

	
10.2.2.2.4

	
Working with patients with conditions of special concern, including autism, ADHD, depression, and diabetes among others.

 

	
  

	
10.2.2.2.5

	
10.2.2.2.5

	
Drug utilization statistics.

 

	
  

	

10.2.2.3      The Contractor shall use various forms of delivery for Providers’ training sessions, including web-based sessions, group workshops, and face-to-face individualized education.

 

	
  

	

10.2.2.4      The Contractor shall make available to Providers dates and locations of sessions, as soon as possible, but no later than five (5) Business Days prior to the event.

 

	
  

	

10.2.2.5      The Contractor shall have a process to document Provider participation in continuing education.

 

	
  

	

10.2.2.6      The Contractor shall participate in the strategies to be developed by the PBM to promote the development of educational activities and shall coordinate with the PBM for its participation in the Contractor’s educational activities.

 

	
  

	

10.2.2.7      Within ninety (90) Calendar Days from the Effective Date of the Contract, the Contractor shall present to ASES for approval, the Plan to promote the active participation of the PBM in the development of educational activities.

 

	
10.3

	
Required Provisions in Provider Contracts

 

	
  

	
10.3.1

	
All Provider Contracts shall be labeled with the Provider’s NPI, if applicable. In general, the Contractor’s Provider Contracts shall:

 

	
  

	

10.3.1.1      Include a section summarizing the Contractor’s obligations under this Contract, as they affect the delivery of Health Care services under MI Salud, and describing Covered Services and populations (or, include the Provider guidelines as an attachment);

 

	
  

	

10.3.1.2      Require that the Provider cooperate and collaborate with the MBHO in serving Enrollees, and work to advance the integrated model of physical and behavioral health services;

 

	
  

	

10.3.1.3      Require that the Provider comply with the federal and Puerto Rico laws, rules, regulations, statutes, policies or procedures, including but not limited to those listed in Attachment 1 to this Contract, to the extent applicable, and with all CMS requirements;

 

  

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10.3.1.4

	
Require that the Provider verify the Enrollee’s Eligibility before providing services or making a Referral;

 

	
  

	
10.3.1.5

	
Prohibit any unreasonable denial, delay, or rationing of Covered Services to Enrollees, and provide that any violation of this prohibition shall be subject to the provisions of Article VI, Section 6 of Act 72 and of 42 CFR Part 438, Subpart I (Sanctions);

 

	
  

	
10.3.1.6

	
Prohibit the Provider from claiming for any non-allowed administrative expenses, as listed in Article 22;

 

	
  

	
10.3.1.7

	
Prohibit the unauthorized sharing or transfer of ASES Data, as defined in Section 28.1 of this Contract;

 

	
  

	
10.3.1.8

	
Notify the Provider that the terms of the contract for services under the MI Salud Program are subject to subsequent changes in legal requirements that are outside of the control of ASES;

 

	
  

	
10.3.1.9

	
Require the Provider to comply with all reporting requirements contained in Article 18 of this Contract, and particularly with the requirements to submit Encounter Data for all services provided, and to report all instances of suspected Fraud or Abuse;

 

	
  

	
10.3.1.10

	
Require the Provider to acknowledge that ASES Data (as defined in Section 28.1.1 of this Contract) belongs exclusively to ASES, and that the Provider may not give access to, assign, or sell such data to third parties, without prior authorization from ASES. The Contractor shall include penalty clauses in its Provider Contracts to prohibit this practice, and require that the fines be paid to ASES;

 

	
  

	
10.3.1.11

	
Prohibit the Provider from seeking payment from the Enrollee for any Covered Services provided to the Enrollee within the terms of the Contract, and require the Provider to look solely to the Contractor for compensation for services rendered to Enrollees, with the exception of any nominal cost-sharing, as provided in Section 7.11 of this Contract;

 

	
  

	
10.3.1.12

	
Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Management activities;

 

  

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10.3.1.13

	
Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of an Enrollee for the Enrollee’s health status, medical care, or treatment or non-treatment options;

 

	
  

	
10.3.1.14

	
Not prohibit a Provider from advocating on behalf of the Enrollee in any Grievance System or Utilization Management process, or individual authorization process to obtain necessary health care services;

 

	
  

	
10.3.1.15

	
Require Providers to meet the timeframes for Access to services pursuant to Sections 9.8 and 9.9 of this Contract;

 

	
  

	
10.3.1.16

	
Provide for continuity of treatment in the event that a Provider’s participation in the Contractor’s Network terminates during the course of an Enrollee’s treatment by that Provider;

 

	
  

	
10.3.1.17

	
Require Providers to monitor Enrollee patients to determine whether they have a Medical Condition that suggests Case Management or Disease Management services are warranted;

 

	
  

	
10.3.1.18

	
Prohibit Provider discrimination against high-risk populations or Enrollees requiring costly treatments;

 

	
  

	
10.3.1.19

	
Prohibit Providers who do not have a pharmacy license from directly dispensing medications, as required by the Puerto Rico Pharmacy Act (with the exception noted in Section 7.5.12.3.2 of this Contract);

 

	
  

	
10.3.1.20

	
Specify that HHS and its sub-agencies and ASES shall have the right to inspect, evaluate, and audit any pertinent books, financial records, documents, papers, and records of any Provider involving financial transactions related to the MI Salud Program;

 

	
  

	
10.3.1.21

	
Include the definition and standards for Medical Necessity, pursuant to the definition in Section 7.2.1 of this Contract;

 

	
  

	
10.3.1.22

	
Require that the Provider attend promptly to requests for Prior Authorizations and Referrals, when Medically Necessary, in compliance with the timeframes set forth in Section 9.10 of this Contract and in 42 CFR 438.210 and the Puerto Rico Patient’s Bill of Rights;

 

	
  

	
10.3.1.23

	
Prohibit the Provider from establishing specific days for the delivery of Referrals or requests for Prior Authorization;

 

  

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10.3.1.24

	
Notify the Provider that, in order to participate in the Medicare Platino Program, the Provider must accept MI Salud Enrollees;

 

	
  

	
10.3.1.25

	
Specify rates of payment, as detailed in Section 10.5 of this Contract, and require that Providers accept such payment as payment in full for Covered Services provided to Enrollees, less any applicable Enrollee Co-Payments pursuant to Section 7.11 of this Contract;

 

	
  

	
10.3.1.26

	
Specify acceptable billing and coding requirements;

 

	
  

	
10.3.1.27

	
Require that the Provider comply with the Contractor’s Cultural Competency plan;

 

	
  

	
10.3.1.28

	
Require that any marketing materials developed and distributed by the Provider be submitted to the Contractor to submit to ASES for prior approval;

 

	
  

	
10.3.1.29

	
Specify that the Contractor shall be responsible for any payment owed to Providers for services rendered after the Effective Date of Enrollment, as provided in Section 4.4.1 of this Contract, including during the period described in Section 4.4.1.2;

 

	
  

	
10.3.1.30

	
Require Providers to collect Enrollee Co-Payments as specified in Attachment 8;

 

	
  

	
10.3.1.31

	
Require that Providers not employ or subcontract with individuals on the Puerto Rico or Federal Exclusions list, or with any entity that could be excluded from the Medicaid program under 42 CFR 1001.1001 (ownership or control in sanctioned entities) and 1001.1051 (entities owned or controlled by a sanctioned person);

 

	
  

	
10.3.1.32

	
Require that Medically Necessary services shall be available twenty-four (24) hours per day, seven (7) days per week, to the extent feasible;

 

	
  

	
10.3.1.33

	
Prohibit the Provider from operating on a different schedule for MI Salud Enrollees than for other patients, and from in any other way discriminating in an adverse manner between MI Salud Enrollees and other patients;

 

	
  

	
10.3.1.34

	
Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is an FQHC or RHC;

 

  

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10.3.1.35

	
Provide notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event that the Executive Director of ASES directs the Contractor to make such adjustments in order to reflect budgetary changes to the Medical Assistance program;

 

	
  

	
10.3.1.36

	
Impose fees or penalties if the Provider breaches the contract or violates federal or Puerto Rico laws or regulations;

 

	
  

	
10.3.1.37

	
Require that the Provider make every effort to cost-avoid claims and identify and communicate to the Contractor available Third Party resources, as required in Section 23.4 of this Contract, and require that the Contractor cover no health services that are the responsibility of the Medicare program;

 

	
  

	
10.3.1.38

	
Provide that the Contractor shall not pay claims for services covered under the Medicare Program, and that the Provider may not bill both MI Salud and the Medicare Program for a single service to a Dual Eligible Beneficiary;

 

	
  

	
10.3.1.39

	
Require the Provider to sign a release giving ASES access to the Provider’s Medicare billing data for MI Salud Enrollees who are Dual Eligible Beneficiaries, provided that such access is authorized by CMS, and subject to compliance with all HIPAA requirements;

 

	
  

	
10.3.1.40

	
Set forth the Provider’s obligations under the Physician Incentive Plan outlined in Section 10.7 of this Contract;

 

	
  

	
10.3.1.41

	
Require the Provider to notify the Contractor Immediately if or whether the Provider falls within the prohibition stated in Sections 29.1, 29.2 or 29.6 of this Contract or has been excluded from the Medicare, Medicaid, or Title XX Services Programs;

 

	
  

	
10.3.1.42

	
Include a penalty clause to require the return of public funds paid to a Provider that falls within the prohibition stated in Sections 29.1, 29.2 or 29.6 of this Contract;

 

	
  

	
10.3.1.43

	
Require that all Reports and all Claims submitted by the Provider to the Contractor be labeled with the Provider’s NPI; and

 

	
  

	
10.3.1.44

	
Require the Provider to furnish complete Encounter Data to the Contractor on a monthly basis.

 

  

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10.3.2

	
In addition to the required provisions in Section 10.3.1 of this Contract, the following requirements apply to specific categories of Provider Contracts.

 

	
  

	
10.3.2.1

	
The Contractor’s contracts with PMGs shall:

 

	
  

	
10.3.2.1.1

	
Require that the PMG provide services on a regular time schedule, Monday through Saturday, from 8:00 a.m. to 6:00 p.m.;

 

	
  

	
10.3.2.1.2

	
Require that the PMG employ enough personnel to offer urgent care services between 6:00 and 9:00 p.m., Monday through Friday;

 

	
  

	
10.3.2.1.3

	
Require that the PMG coordinate with MBHO personnel to ensure integrated physical and behavioral health services, as provided in Article 8;

 

	
  

	
10.3.2.1.4

	
Require the PMG to work, to the extent possible, within the Contractor’s established PPN, in directing care for Enrollees and coordinating services;

 

	
  

	
10.3.2.1.5

	
Authorize the Contractor to adjudicate disputes between the PMG and its Network Providers about the validity of claims by any Network Provider;

 

	
  

	
10.3.2.1.6

	
Require PMGs to provide assurances that the Encounter Data submitted by the PMG to the Contractor encompass all services provided to MI Salud Enrollees, including laboratories; and

 

	
  

	
10.3.2.1.7

	
Include the provisions set forth in Sections 7.5.8.3.12, 7.10.1, 10.5.4, 10.5.5, 10.5.7, 16.10.2, 16.10.3, 16.10.5, and 23.1.8 of this Contract.

 

	
  

	
10.3.2.2

	
The Contractor’s contracts with PCPs shall require the PCP to inform and distribute information to Enrollee patients about instructions on Advance Directives, and shall require the PCP to notify Enrollees of any changes in federal or Puerto Rico law relating to Advance Directives, no more than ninety (90) Calendar Days after the effective date of such change.

 

	
  

	
10.3.2.3

	
The Contractor’s contract with a Provider who is a member of the PPN shall prohibit the Provider from collecting cost-sharing payments from MI Salud Enrollees, subject only to the exceptions established in Article 9 of this Contract and the Attachment 8 to this Contract (Co-Payment Chart).

 

  

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10.3.2.4

	
The Contractor’s contracts with Hospitals and Emergency Rooms shall prohibit the Hospital or Emergency Room from placing a lower priority on MI Salud Enrollees than on other patients, and from referring MI Salud Enrollees to other facilities for reasons of economic convenience.  Such contracts must include sanctions penalizing this practice.

 

	
  

	
10.3.2.5

	
The Contractor’s contracts with PCPs and PPN physician specialists shall require such Providers to maintain Enrollees’ Medical Records through an EHR system that is ONC and CCHIT certified and meets the specifications set forth in Attachment 15.  The contracts shall provide that the EHR system be operational on or before July 1, 2012 or such later date as set forth in his/her Provider Contract.  The contracts shall require the Contractor to assist the PCPs and PPN physician specialists in the acquisition and installation of an appropriate EHR system, at the Contractor’s expense. The Contractor’s contracts with such Providers shall also specify that the Contractor shall provide each such Provider with information on the benefits of the EHR system and the costs of maintaining the EHR system.

 

	
10.4

	
Termination of Provider Contracts

 

	
  

	
10.4.1

	
The Contractor shall comply with all Puerto Rico and federal laws regarding Provider termination.  The Provider Contracts shall:

 

	
  

	
10.4.1.1

	
Contain provisions allowing immediate termination of the contract by the Contractor “for cause.”  Cause for termination includes gross negligence in complying with the contractual considerations or obligations; insufficiency of funds of ASES or the Contractor, which prevents them from continuing to pay for their obligations; termination of this Contract for any reason; and changes in federal law.

 

	
  

	
10.4.1.2

	
Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, ASES may demand Provider termination Immediately, or the Contractor may Immediately terminate on its own, a Provider’s participation under the Provider Contract if:

 

	
  

	
10.4.1.2.1

	
A Provider fails to abide by the terms and conditions of the Provider Contract, as determined by ASES, or, in the sole discretion of ASES, if the Provider fails to come into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof; or

 

  

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10.4.1.2.2

	
The Contractor or ASES learns that the Provider:

 

	
  

	
10.4.1.2.2.1

	
Falls within the prohibition stated in Sections 29.1 or 29.2 of this Contract, or has a criminal conviction as provided in Section 29.6 of this Contract;

 

	
  

	
10.4.1.2.2.2

	
Has been or could be excluded from participation in the Medicare, Medicaid, or CHIP Programs; or

 

	
  

	
10.4.1.2.3

	
Could be excluded from the Medicaid program under 42 CFR 1001.1001 (ownership or control in sanctioned entities) and 1001.1051 (entities owned or controlled by a sanctioned person).

 

	
  

	
10.4.1.3

	
Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable appeals procedures outlined in the Provider Contract.  No additional or separate right of appeal to ASES or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract.  Notwithstanding the termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers.

 

	
  

	
10.4.2

	
The Contractor shall notify ASES at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from participation in the Network.  If the termination was for cause, the Contractor shall provide to ASES the reasons for termination.

 

	
  

	
10.4.3

	
The Contractor shall, within fifteen (15) Calendar Days of issuance of a notice of termination to a Provider, notify Enrollees of the termination, and shall assist the Enrollee as needed in finding a new Provider.

 

  

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10.5

	
Provider Payment

 

	
  

	
10.5.1

	
General Provisions

 

	
  

	
10.5.1.1

	
ASES guarantees payment for all Medically Necessary services rendered by Providers after a person’s Effective Date of Enrollment, including during the period described in Section 4.4.1.2 of this Contract.

 

	 	
10.5.1.2

	
The insolvency, liquidation, bankruptcy, or breach of contract of any Provider will not release ASES from its obligation to pay for all services rendered as authorized under this Contract.

 

	
  

	
10.5.1.3

	
ASES shall provide to the Contractor maximum rates for certain Covered Service on or before the Implementation Date of this Contract. The Contractor shall negotiate rates with Providers, which rates shall be specified in the corresponding Provider Contracts, utilizing as a reference the rate information established by ASES’s actuaries and contained in Attachment 10 to this Contract.  If such rates adversely affect the Provider ratios required to be maintained under Section 9.5 of this Contract, the Parties agree to negotiate in good faith to make such adjustments to the rates as required to comply with Section 9.5 of this Contract.  Further, such rates shall be subject to Section 10.5.5 of this Contract.  Payment arrangements may take any form allowed under federal law and the law of Puerto Rico, including capitation payments, fee-for-service payment, and salary, subject to Section 10.6 of this Contract concerning permitted risk arrangements.  The Contractor shall inform ASES in writing when it enters any Provider payment arrangement other than fee-for-service.  Payment arrangements other than fee-for-service shall be prohibited for Dental Services.

 

	
  

	
10.5.1.4

	
All capitation payment arrangements in Provider Contracts must comply with Normative Letter CA-1-2-1232-91 of the Puerto Rico Office of the Insurance Commissioner (Attachment 13 to this Contract).

 

	
  

	
10.5.1.5

	
Any capitation payment made by the Contractor to Providers shall be based on sound actuarial methods. The Contractor shall establish its Capitation methodology utilizing the information provided by ASES in Attachment 10 to this Contract as a reference to develop its capitated rates.  The Contractor shall provide its Capitation methodology to ASES for approval in the timeframe allotted in Attachment 12. All Provider payments by the Contractor shall be reasonable, and the amount paid shall not jeopardize or infringe upon the quality of the services provided.

 

  

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10.5.1.6

	
Even if the Contractor does not enter into a Capitated payment arrangement with a Provider, the Provider shall nonetheless be required to submit to the Contractor detailed Encounter Data.

 

	
  

	
10.5.1.7

	
The Contractor shall be responsible for issuing to the Providers the forms required by the Department of the Treasury, in accordance with all Puerto Rico laws, regulations and guidelines.  In addition, the Contractor, in accordance with all Puerto Rico laws, regulations, and guidelines, must also withhold taxes when appropriate and shall remit such taxes to the Department of Treasury.

 

	
  

	
10.5.1.8

	
The Contractor shall submit its provider fee schedule to ASES for approval in the timeframe set forth in Attachment 12.  Any subsequent changes must be previously approved in writing by ASES.

 

	
  

	
10.5.2

	
Payments to FQHCs, RHCs, and CCuSaI. When the Contractor negotiates a contract with an FQHC and/or an RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, or with a Comprehensive Health Care Center (“CCuSaI”), the Contractor shall pay to the FQHC, RHC, or CCuSaI rates that are comparable to rates paid to other similar Providers providing similar services. If an FQHC is not included in the Contractor’s Network and the Enrollee requests FQHC Services, the Contractor shall make these out-of-network services available to the Enrollee through a referral from his or her PCP, and the FQHC shall be paid as an out-of-network Provider for FQHC Services (as defined in Article 2 of this Contract).  The Contractor shall cooperate with ASES and the Health Department in ensuring that payments to FQHCs and RHCs are consistent with Sections 1902(a)(15) and 1902(bb)(5) of the Social Security Act.  Pursuant to 42 U.S.C. 1396a(bb)(5), the Puerto Rico Health Department shall pay the FQHCs applicable wrap-around payments to make up the difference, if any, between the Capitation Contractor pays to the FQHC under this Contract, and the amounts Puerto Rico Health Department pays to the FHQCs under the prospective payment system formula.

 

	
  

	
10.5.3

	
Requirement To Verify Eligibility. The Contractor will require that all of its Network Providers verify the eligibility of Enrollees before the Provider provides Covered Services.  This verification of eligibility is a condition of receiving payment from the Contractor for Covered Services.

 

  

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10.5.4

	
Payments to Providers Owing Funds to the Government.  ASES and the Contractor will agree to a process to recoup money owed by Providers to the Government.  All of the Contractor’s Provider Contracts shall contain a provision giving notice of the agreed to procedures, such that the Provider’s execution of the Contract shall constitute agreement with the agreed to procedures.

 

	
  

	
10.5.5

	
Payment Rates Subject to Change. The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes, as directed by the Executive Director of ASES, to the extent that such adjustments can be made within funds appropriated to ASES and available for payment to the Contractor; provided, however, that if such rates adversely affect the Provider ratios required to be maintained under Section 9.5 of this Contract, the Parties agree to negotiate in good faith to make such adjustment to the rates as required to comply with such Section 9.5 of this Contract. The Contractor’s Provider contracts shall contain a provision giving notice to the Provider that its rates are subject to adjustment, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to ASES.

 

	
  

	
10.5.6

	
Payments for Hospitalization Services or Services Extending for More than Thirty (30) Days. In the event of hospitalization or extended services that exceed thirty (30) Calendar Days, the Provider may bill and collect at least once per month for services rendered to the Enrollee.  These services shall be paid according to the procedures specified in this Article 10.  The Contractor shall implement Medicare hospital readmission payment policies and shall require all hospital Providers to implement the Medicare hospital readmission guidelines.

 

	
  

	
10.5.7

	
Payments for Services to Dual Eligible Beneficiaries. The Contractor shall include in its Provider Contracts a notice that the Contractor shall not pay claims for services covered under the Medicare Program.  No Provider may bill both MI Salud and the Medicare Program for a single service to a Dual Eligible Beneficiary.

 

	
  

	
10.5.8

	
Payment for Pharmacy Services. The Contractor shall abide by and comply with following payment process hereby established:

 

	
  

	
10.5.8.1

	
Except as provided in Section 7.5.12 of this Contract, the PMG shall accept the financial risk of ingredient cost and dispensing fees for pharmacy services relating to Basic Coverage.  ASES shall accept the financial risk of ingredient cost and dispending fees for pharmacy services relating to Special Coverage.

 

	
  

	
10.5.8.2

	
In covering Pharmacy Services, the Contractor shall adhere to the Retail Pharmacy Reimbursement Levels established in Attachment 6 to this Contract.

 

  

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10.5.8.3

	
On a semi-monthly payment cycle to be set by the PBM, the PBM will provide the Contractor with the proposed claims listing.  The Contractor shall promptly review the payment listing and submit it to ASES within five (5) Business Days with a certification from the Authorized Signatory.

 

	
  

	
10.5.8.4

	
ASES shall transmit funds to the Contractor on account of the PBM Claims no later than five (5) Business Days after receipt of the proposed claims listing.  The Contractor shall then submit funds for claims payment to the PBM’s zero-balance account. The Contractor shall provide funds or wire transfers to a bank account established for the payment of the claims, or otherwise submit payment, within two (2) Business Days of the date that the prescription was filled.

 

	
  

	
10.5.8.5

	
The Contractor, ASES, and the PBM shall cooperate to identify additional savings opportunities, including special purchasing opportunities, changes in network fees, etc.

 

	
  

	
10.5.9

	
Payments to State Health Facilities. ASES will establish a payment system to improve cash flow to health facilities administered or operated by the Central Government, State Academic Medical Centers, and certain facilities in the San Juan Municipality that participate in the Network.  To that end, at the request of ASES, the Contractor shall make advance payments directly (based on historical payments, not on billings) to health facilities.  The Contractor shall submit a reconciliation report on a quarterly basis that is certified by the Authorized Signatory pursuant to the terms of this Contract. The following health facilities may participate, subject to reaching agreement with the Contractor under contracts to be approved by ASES:

 

	
  

	
10.5.9.1

	
Cardiovascular Hospital;

 

	
  

	
10.5.9.2

	
Pediatric Hospital;

 

	
  

	
10.5.9.3

	
University Hospital;

 

	
  

	
10.5.9.4

	
Medical Center Trauma Room;

 

	
  

	
10.5.9.5

	
Mayagüez Center Trauma Room;

 

	
  

	
10.5.9.6

	
Dr.Ramón Ruiz-Arnau University Hospital (HURRA, acronym in Spanish);

 

	
  

	
10.5.9.7

	
Dr. Federico Trilla UPR Hospital; and

 

	
  

	
10.5.9.8

	
San Juan Municipal Hospital.

 

  

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10.5.10

	
Payments to Providers Outside the PPN. The Contractor shall provide for adequate payment in its contracts with Providers outside the PPN.

 

	
10.6

	
Acceptable Risk Arrangements

 

	
  

	
10.6.1

	
The Contractor’s Provider Contracts with PMGs shall comply with the following guidelines concerning the apportionment of financial risk between ASES and the PMG for MI Salud services.  Any sharing of risk between ASES and PMGs other than as expressly provided in this 10.6 shall require prior written approval by ASES.

 

	
  

	
10.6.2

	
The distribution of risks for Covered Services between and ASES and the PMGs shall be in accordance with Attachment 16 of this Contract.   Any proposed arrangement between the Contractor and a PMG that changes such risk distribution shall require prior written approval from ASES.

 

	
  

	
10.6.3

	
The risk associated with Emergency Services related to Basic Coverage Services shall be borne by the PMG.  The risk associated with Emergency Services related to Special Coverage Services shall be borne by ASES.  The risk associated with Emergency Services received outside of Puerto Rico that are covered under this Contract shall be borne by ASES.

 

	
  

	
10.6.4

	
The risk associated with Basic Coverage services, including Diagnostic Test Services in Special Coverage which are not related to high risk registered members and excluding those services mentioned in Sections 10.6.2 and 10.6.3 of this Contract, shall be borne in full by the PMG.

 

	
  

	
10.6.5

	
Notwithstanding Sections 10.6.2-10.6.4 of this Contract, ASES shall assume full risk for services provided in the Virtual Region.

 

	
10.7

	
Physician Incentive Plan

 

	
  

	
10.7.1

	
The Contractor will design and implement a plan that evaluates the quality of care delivered by PCPs and provides financial incentives to promote PCPs’ commitment to Preventive Services (the “Physician Incentive Plan”).  The Contractor will submit such plan to ASES for approval at on or before December 1, 2011, and ASES shall approve it no later than thirty (30) Calendar Days after its submission.  The Provider Incentive Plan will include, at a minimum, the following components:

 

	
  

	
10.7.1.1

	
The Contractor shall allocate three cents ($0.03) PMPM of the Per Member Per Month Administrative Fee received from ASES to the Provider Incentive Plan (the “Provider Incentive Pool”).

 

  

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10.7.1.2

	
Each PCP who reaches the minimum target, which shall be mutually established between ASES and the Contractor, for each of the criteria set forth below (the “Qualification Criteria”) shall receive a pro-rata portion of the Provider Incentive Pool.

 

	
  

	
10.7.1.3

	
The Contractor will review the Medical Records at the PMG or PCP level to ascertain and evidence the Preventive Services provided by the PCPs to Enrollees.  ASES requires through this review that the PCPs comply with the documentation requirements established by the Health Department and EPSDT guidelines.

 

	
  

	
10.7.2

	
The Qualification Criteria shall be based, to the extent applicable, on certain HEDIS measures to be mutually agreed by the Parties and may include, without limitation, the following additional criteria:

 

	
  

	
10.7.2.1

	
That the PCP performs preventive screening to its population according to evidence based on clinical practice guidelines.

 

	
  

	
10.7.2.2

	
That the PCP provides early detection of population with neuro-developmental disorders and autism.

 

	
  

	
10.7.2.3

	
That the PCP adopts a certified EHR system meeting the specifications contained in Attachment 15 to this Contract.

 

	
  

	
10.7.2.4

	
That the PCP complies with the EPSDT screening and parent education requirements.

 

	
  

	
10.7.2.5

	
That the PCP complies with the requirements of a mental and physical health integration program to be mutually agreed between the Parties.

 

	
  

	
10.7.3

	
The Contractor will provide a quarterly report on the Physician Incentive Plan to ASES, which report shall contain, with respect to each Provider:

 

	
  

	
10.7.3.1

	
Service Region

 

	
  

	
10.7.3.2

	
PMG Name

 

	
  

	
10.7.3.3

	
PMG Number

 

	
  

	
10.7.3.4

	
Provider ID

 

	
  

	
10.7.3.5

	
Provider Name

 

	
  

	
10.7.3.6

	
Preventive Services Compliance Percentage

 

  

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10.7.3.7

	
Provider’s Education Contact Hours

 

	
  

	
10.7.3.8

	
Provider’s percentage of Compliance with Qualification Criteria

 

	
  

	
10.7.4

	
The Contractor will provide the incentive based on a mathematically sound formula, which shall have the prior written approval of ASES, which approval shall not be unreasonably withheld, conditioned or delayed.

 

	
  

	
10.7.5

	
The Contractor will grant the incentive to those PCPs that comply with the preceding requirements, based on a twelve month natural year measuring period, or as otherwise provided in the Physician Incentive Plan with respect to any partial natural year, plus a three month Claims run out period and a three month period for incentive calculation and analysis.

 

	
  

	
10.7.6

	
The Physician Incentive Plan shall comply with federal and Puerto Rico regulations, including 42 CFR 422.208, 42 CFR 422.210, and 42 CFR 438.6(h).

 

	
10.8

	
Required Information Regarding Providers

 

	
  

	
10.8.1

	
The Contractor shall provide to ASES, according to the timeframe specified in Attachment 12 to this Contract, an electronic file and a list of all of the Network Providers, listed by municipality, indicating the capacity of each Provider, as well as the specialty or subspecialty of physicians.  This file must be updated in accordance with Section 18.2 of this Contract.

 

	
  

	
10.8.2

	
Electronic files shall be provided on compact discs (CD) in Microsoft Excel format (.XLS or .XLSX) without column titles.  Two hard copies will be included in the same submission.

 

	
  

	
10.8.3

	
List of Doctors and Providers Who Are Individuals. This list will include all available doctors and other Health Care Professionals who are individuals, such as optometrists, podiatrists, psychologists, social workers, health educators, physical therapists, speech therapists, occupational therapists, respiratory therapists, dietitians, nutritionists, and any other health service Provider who is an individual, as applicable.  The information file shall include all of the following information:

 

	
  

	
10.8.3.1

	
EIN or SSN;

 

	
  

	
10.8.3.2

	
Whether the Provider is a member of the PPN (list “Y” for yes or “N” for no);

 

  

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10.8.3.3

	
Last name;

 

	
  

	
10.8.3.4

	
Mother’s maiden name;

 

	
  

	
10.8.3.5

	
First name;

 

	
  

	
10.8.3.6

	
Municipality (The Provider’s municipality is the place where his or her office is located.  If the Provider maintains more than one office, he or she will have to appear more than once in the list and file.  Similarly, a physician or Provider with more than one specialty has to be listed for each specialty.);

 

	
  

	
10.8.3.7

	
Specialty Code (see Attachment 9 for a list of Specialty Codes);

 

	
  

	
10.8.3.8

	
Provider license number; and

 

	
  

	
10.8.3.9

	
Provider’s National Provider ID (“NPI”), if applicable.

 

	
  

	
10.8.4

	
List of Providers That Are Not Individuals. In another separate list, the Contractor shall include a list of all Providers that are not individuals, such as PMGs, Clinics, Hospitals (identified as private or government), laboratories, x-ray facilities, dialysis facilities, blood banks, and others, using the following format.

 

	
  

	
10.8.4.1

	
EIN;

 

	
  

	
10.8.4.2

	
Name of Entity;

 

	
  

	
10.8.4.3

	
Municipality Code;

 

	
  

	
10.8.4.4

	
Provider Type Code; and

 

	
  

	
10.8.4.5

	
Provider’s National Provider ID (“NPI”), if applicable.

 

	
  

	
10.8.5

	
With these two (2) files, the Contractor shall submit a control sheet that includes (1) a general description of the content of each file, and (2) the total number of records in each file, i.e. “control totals.”  The Contractor shall submit all information required in this paragraph to ASES according to the timeframe specified in Attachment 12 to this Contract.

 

  

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ARTICLE 11

	
UTILIZATION MANAGEMENT

 

	
11.1

	
Utilization Management Policies and Procedures

 

	
  

	
11.1.1

	
The Contractor shall provide assistance to Enrollees and Providers to ensure the appropriate utilization of resources.  The Contractor shall have written Utilization Management Policies and Procedures that:

 

	
  

	
11.1.1.1

	
Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over-Utilization and under-Utilization.  Such protocols and criteria shall comply with federal and Puerto Rico laws and regulations.

 

	
  

	
11.1.1.2

	
Address which services require PCP Referral, which services require Prior Authorization and how requests for initial and continuing services are processed, and which services will be subject to concurrent, retrospective or prospective review.

 

	
  

	
11.1.1.3

	
Describe mechanisms in place that ensure consistent application of review criteria for Prior Authorization decisions.

 

	
  

	
11.1.1.4

	
Provide that all Medical Necessity determinations made by the Contractor be made in accordance with ASES’s Medical Necessity definition as stated in Section 7.2 of this Contract.

 

	
  

	
11.1.2

	
The Contractor shall submit its Utilization Management Policies and Procedures to ASES for review and prior approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to Utilization Management Policies and Procedures must be previously approved in writing by ASES, which approval shall not be unreasonably withheld, conditioned, or delayed.

 

	
  

	
11.1.3

	
Providers may participate in Utilization Management activities in their own Service Region to the extent that there is not a conflict of interest.  The Utilization Management Policies and Procedures shall define when such a conflict may exist and shall describe the remedy.

 

	
  

	
11.1.4

	
The Contractor, and any delegated Utilization Management agent, shall not permit or provide compensation or anything of value to its employees, agents, or contractors based on:

 

	
  

	
11.1.4.1

	
Either a percentage of the amount by which a Claim is reduced for payment or the number of Claims or the cost of services for which the person has denied authorization or payment; or

 

  

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11.1.4.2

	
Any other method that encourages a decision to deny or limit a service.

 

 

	
11.2

	
Utilization Management Guidance to Enrollees.

 

As provided in Section 6.4.4.22 of this Contract, the Contractor shall provide clear guidance in its Enrollee Handbook on Utilization Management policies.

 

	
11.3

	
Prior Authorization and Referral Policies

 

	
  

	
11.3.1

	
Prior Authorization is authorization granted by the Contractor, including based on an Enrollee’s Service Authorization Request, in advance of the rendering of a service after review to determine whether the service is Medically Necessary.

 

	
  

	
11.3.2

	
A Referral is a request by a PCP or other Provider in the PMG for an Enrollee to be evaluated or treated by a different Provider, usually a specialist.  Referrals shall be required only for services outside the Contractor’s PPN.

 

	
  

	
11.3.3

	
In situations, as set forth below in this Section 11.3 of this Contract, where a Provider Referral is permitted or required:

 

	
  

	
11.3.3.1

	
The Contractor shall not impose any requirement of Contractor review of the Provider’s Referral decision; and

 

	
  

	
11.3.3.2

	
The Contractor shall ensure that a Referral shall be either made or refused by the PCP or other Provider in the PMG within five (5) Calendar Days of the Enrollee’s request for the Referral.  Referrals shall be made expeditiously in the event that a Provider perceives that an Enrollee’s life or health could be endangered by a delay in accessing services; in such situations, a Referral must be made, at a maximum, three (3) Calendar Days from the Enrollee’s request for the Referral (in compliance with 42 CFR 438.210, and a higher standard than that regulation, which refers to working days).

 

	
  

	
11.3.4

	
In situations, as set forth in this Section 11.3 of this Contract, in which Prior Authorization is required, the Contractor shall ensure that Prior Authorization is provided for the Enrollee in the following timeframes, including on holidays and outside of business hours.  

 

  

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11.3.4.1

	
The decision whether to grant a Prior Authorization must not exceed fourteen (14) days  from the time of the Enrollee’s Service Authorization Request for any Covered Service; except that, where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be endangered by a delay in accessing services, Prior Authorization must be provided as expeditiously as the Enrollee’s health requires, and no later than within seventy two (72)  hours of the Service Authorization Request.

 

	
  

	
11.3.4.2

	
ASES may, in its discretion, grant an extension of the time allowed for Prior Authorization decisions, where:

 

	
  

	
11.3.4.2.1

	
the Enrollee, or the Provider, requests the extension; or

 

	
  

	
11.3.4.2.2

	
the Contractor justifies to ASES a need for the extension in order to collect additional information, such that the extension is in the Enrollee’s best interest.

 

	
  

	
11.3.5

	
The Contractor shall use appropriately licensed professionals to supervise all Prior Authorization decisions, and shall in its policies and procedures specify the type of personnel responsible for each type of Prior Authorization.  Any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested shall be made by a Health Care Professional who has appropriate clinical expertise in treating the Enrollee’s condition, and for Service Authorization Requests for Dental Services, only licensed dentists may make such decisions.

 

	
  

	
11.3.6

	
Emergency Services

 

	
  

	
11.3.6.1

	
Neither a Referral nor Prior Authorization shall be required for any Emergency Service, no matter whether the Provider is within the PPN, and notwithstanding whether there is ultimately a determination that the condition for which the Enrollee sought treatment in the emergency room was not an Emergency Medical Condition.

 

  

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11.3.7

	
Basic Coverage and Dental Services

 

	
  

	
11.3.7.1

	
No Referral shall be required for any service category of Basic Coverage other than Pharmacy and Behavioral Health Services; or for Dental Services, so long as the service is provided within the PPN.

 

	
  

	
11.3.7.2

	
The Contractor shall require a Referral for the services listed in this subsection 11.3.7, where the Enrollee seeks such services outside of the PPN.  Such Referral shall be provided by the PCP or other PMG Provider.  The Referral shall serve as a determination that the service for which the Referral is being made is Medically Necessary.

 

	
  

	
11.3.7.3

	
Where a Provider does not make in the required timeframe specified, or refuses to make a Referral, the Contractor may issue an Administrative Referral.

 

	
  

	
11.3.8

	
Pharmacy Services

 

	
  

	
11.3.8.1

	
The Contractor shall require Prior Authorization for filling a drug prescription for certain drugs specified on the PDL, as provided in Section 7.5.12.10 of this Contract.

 

	
  

	
11.3.8.2

	
The Contractor shall require a Countersignature of the Enrollee’s PCP in order to fill a prescription written by a Provider who is not in the PPN.

 

	
  

	
11.3.8.3

	
Any required Prior Authorization or Countersignature for Pharmacy Services shall be conducted within the timeframes provided in Sections 11.3.4 and 7.5.12.4.2 of this Contract.

 

	
  

	
11.3.9

	
Special Coverage

 

	
  

	
11.3.9.1

	
In order to obtain services under Special Coverage, an Enrollee must register, as provided in Section 7.7.6 of this Contract.  Registration is a form of utilization control, to determine whether the Enrollee’s health condition warrants Access to the expanded services included in Special Coverage.

 

	
  

	
11.3.9.2

	
In addition, as noted in Section 7.7.12 of this Contract, some individual Special Coverage services require Prior Authorization for an Enrollee who has registered under Special Coverage.

 

  

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11.3.10

	
Behavioral Health Services.  Referrals shall be required for Behavioral Health Services as provided in Section 8.3 of this Contract.

 

 

	
11.4

	
Use of Technology to Promote Utilization Management

 

	
  

	
11.4.1

	
ASES strongly encourages the Contractor to develop electronic, web-based Referral processes and systems. In the event that a Referral is made via the telephone, the Contractor shall ensure that Referral data are maintained in a data file that can be accessed electronically by the Contractor, the Provider and ASES.

 

	
  

	
11.4.2

	
In conjunction with its other Utilization Management policies, the Contractor shall submit the Referral processes to ASES for review and approval.

 

 

	
11.5

	
Court-Ordered Evaluations and Services

 

	
  

	
11.5.1

	
In the event that an Enrollee requires Medicaid-covered services ordered by a court, the Contractor shall fully comply with all court orders while maintaining appropriate Utilization Management practices.

 

 

	
11.6

	
Second Opinions

 

	
  

	
11.6.1

	
The Contractor shall adopt procedures to obtain a second opinion in any situation when there is a question concerning a diagnosis or the options for surgery or other treatment of a health Condition when requested by any Enrollee, or by a parent, guardian, or other person exercising a custodial responsibility over the Enrollee.

 

	
  

	
11.6.2

	
The second opinion must be provided by a qualified Network Provider, or, if a Network Provider is unavailable, the Contractor shall arrange for the Enrollee to obtain a second opinion from an Out-of-Network Provider.

 

	
  

	
11.6.3

	
The second opinion shall be provided at no cost to the Enrollee.

 

 

	
11.7

	
Utilization Reporting Program.

 

	
  

	
11.7.1

	
The Contractor shall submit to ASES on a monthly basis by Service Region health care data reports that should include, among other things:

 

	
  

	
11.7.1.1

	
Useful data of Claim experience broken down by diagnosis and health care providers;

 

	
  

	
11.7.1.2

	
Claim experience by Enrollee and by coverage (basic, special, dental and pharmacy);

 

  

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11.7.1.3

	
Claim cost and benefit utilization levels;

 

	
  

	
11.7.1.4

	
Benefits utilization levels or indicators, as well as comparative data such as: (i) hospital inpatient days per year per 1,000 Enrollees, (ii) hospital admission rate per 1,000 Enrollees, (iii) average length of inpatient stays, (iv) number of inpatient and outpatient surgeries, (v) number of outpatient visits per year per Enrollee, and (vi) emergency room visits per 1,000 Enrollee;

 

	
  

	
11.7.1.5

	
Cost measures, such as (i) average annual cost per Enrollee, (ii) total hospital inpatient payments, (iii) total surgical payments and (iv) total out of hospital payments; and

 

	
  

	
11.7.1.6

	
Demographics of the population of the Service Region.

 

	
  

	
11.7.2

	
The Contractor shall assist ASES in analyzing the utilization report data to determine trends, necessary plan design modifications, effectiveness of educations programs for both Enrollees and Providers, the impact of cost-control measures and the appropriateness of cost-management programs.

 

	
  

	
11.7.3

	
As part of this program, and in conformance with 42 CFR 438.240(2)(b)(3), the Contractor shall submit to ASES, on a quarterly basis, utilization statistical reports.  ASES requires the following reports, with data to be submitted according to specifications determined by ASES:

 

	
  

	
11.7.3.1

	
Provider Credentialing Report;

 

	
  

	
11.7.3.2

	
Network Providers and Out-of-Network Providers;

 

	
  

	
11.7.3.3

	
Ratio of Enrollees to PCPs;

 

	
  

	
11.7.3.4

	
Utilization of Diabetes Disease Management;

 

	
  

	
11.7.3.5

	
Utilization of Asthma Disease Management;

 

	
  

	
11.7.3.6

	
Utilization of Hypertension Disease Management;

 

	
  

	
11.7.3.7

	
EPSDT Utilization;

 

	
  

	
11.7.3.8

	
Tele MI Salud Utilization;

 

	
  

	
11.7.3.9

	
Preventive Services Utilization;

 

  

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11.7.3.10

	
Pharmacy Services Utilization;

 

	
  

	
11.7.3.11

	
Dental Services Utilization;

 

	
  

	
11.7.3.12

	
ER Utilization by Region and by PMG;

 

	
  

	
11.7.3.13

	
Prenatal Care; and

 

	
  

	
11.7.3.14

	
Covered Population by Municipality, Group, Age, and Gender.

 

	
ARTICLE 12

	
QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM

 

	
12.1

	
General Provisions

 

	
  

	
12.1.1

	
The Contractor shall provide for the delivery of quality care to all Enrollees with the primary goal of improving health status or, in instances where the Enrollee’s health is not amenable to improvement, maintaining the Enrollee’s current health status by implementing measures to prevent any further deterioration of health status.

 

	
  

	
12.1.2

	
The Contractor shall seek input from, and work with, Enrollees, Providers and community resources and agencies to actively improve the quality of care provided to Enrollees.

 

	
  

	
12.1.3

	
The Contractor shall ensure that its Quality Improvement and Performance Program effectively monitors the program elements listed in 42 CFR 438.66.

 

	
12.2

	
Quality Assessment Performance Improvement (QAPI) Program

 

	
  

	
12.2.1

	
The Contractor shall have in place a quality assessment and performance improvement program (QAPI) that specifies the Contractor’s quality measurement and performance improvement activities.

 

	
  

	
12.2.2

	
For Medicaid and CHIP Eligible Persons, the QAPI program shall be in compliance with federal requirements specified at 42 CFR 438.240.

 

	
  

	
12.2.3

	
The Contractor’s QAPI program shall be based on the latest available research in the area of quality assurance and at a minimum shall include:

 

	
  

	
12.2.3.1

	
A method of monitoring, analyzing, evaluating and improving the delivery, quality and appropriateness of health care furnished to all Enrollees (including under and over utilization of services), including those with special health care needs;

 

  

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12.2.3.2

	
Written policies and procedures for quality assessment, utilization management and continuous quality improvement that are periodically assessed for efficacy;

 

	
  

	
12.2.3.3

	
A health information system sufficient to support the collection, integration, tracking, analysis and reporting of data, in compliance with 42 CFR 438.242;

 

	
  

	
12.2.3.4

	
Designated staff with expertise in quality assessment, Utilization Management and continuous quality improvement;

 

	
  

	
12.2.3.5

	
Reports that are evaluated, indicated recommendations that are implemented, and feedback provided to Providers and Enrollees;

 

	
  

	
12.2.3.6

	
A methodology and process for conducting Provider profiling, Credentialing and re-Credentialing;

 

	
  

	
12.2.3.7

	
Procedures for validating completeness and quality of Encounter Data;

 

	
  

	
12.2.3.8

	
Annual performance improvement projects (PIPs) as provided in Section 12.3 below;

 

	
  

	
12.2.3.9

	
Development of an emergency room (ER) quality initiative program (see Section 12.4 of this Contract);

 

	
  

	
12.2.3.10

	
Development of a quality incentive program (see Section 12.5 of this Contract);

 

	
  

	
12.2.3.11

	
Reporting on specified performance measures, including specified HEDIS measures (see Section 12.6 of this Contract);

 

	
  

	
12.2.3.12

	
Conducting Provider and Enrollee surveys (see Section 12.7 of this Contract);

 

  

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12.2.3.13

	
Quarterly reports on program results, conclusions, recommendations and implemented system changes, as specified by ASES; and

 

	
  

	
12.2.3.14

	
Process for evaluating the impact of the Contractor’s QAPI program.

 

	
  

	
12.2.4

	
The Contractor’s QAPI program shall be submitted to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the QAPI program must be previously approved in writing by ASES, which approval shall not be unreasonably withheld, conditioned, or delayed.

 

	
  

	
12.2.5

	
The Contractor shall submit any changes to its QAPI program to ASES for review and approval sixty (60) Calendar Days prior to implementation of the change.

 

	
  

	
12.2.6

	
Upon the request of ASES, the Contractor shall provide any information and documents related to the implementation of the QAPI program.

 

	
12.3

	
Performance Improvement Projects

 

	
  

	
12.3.1

	
As part of its QAPI program the Contractor shall conduct performance improvement projects (PIPs) in accordance with ASES and, as applicable, federal protocols.

 

	
  

	
12.3.2

	
The Contractor shall perform the following required PIPs ongoing for the duration of this Contract Term:

 

	
  

	
12.3.2.1

	
One (1) in the area of diabetes;

 

	
  

	
12.3.2.2

	
One (1) in the area of kidney disease;

 

	
  

	
12.3.2.3

	
One (1) in the area of asthma;

 

	
  

	
12.3.2.4

	
One (1) in the area of Developmental Screening for Children; and

 

	
  

	
12.3.2.5

	
The Contractor shall conduct such additional PIPs as mutually agreed by the Parties.

 

	
  

	
12.3.3

	
In designing its PIPs, the Contractor shall:

 

  

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12.3.3.1

	
Show that the selected area of study is based on a demonstration of need and is expected to achieve measurable benefit to Enrollee (rationale);

 

	
  

	
12.3.3.2

	
Establish clear, defined and measurable goals and objectives that the Contractor shall achieve in each year of the project;

 

	
  

	
12.3.3.3

	
Measure performance using quality indicators that are objective, measurable, clearly defined and that allow tracking of performance and improvement over time;

 

	
  

	
12.3.3.4

	
Implement interventions designed to achieve quality improvements;

 

	
  

	
12.3.3.5

	
Evaluate the effectiveness of the interventions;

 

	
  

	
12.3.3.6

	
Establish standardized performance measures (such as HEDIS or another similarly standardized product);

 

	
  

	
12.3.3.7

	
Plan and initiate activities for increasing or sustaining improvement; and

 

	
  

	
12.3.3.8

	
Document the data collection methodology used (including sources) and steps taken to assure data is valid and reliable.

 

	
  

	
12.3.4

	
The Contractor shall submit all descriptions of PIPs and program details to ASES as part of the QAPI program.

 

	
  

	
12.3.5

	
Each performance improvement project shall be completed in a time period to be specified by ASES to allow information on the success of the project in the aggregate to produce new information on quality of care each year.

 

	
  

	
12.3.6

	
When requested, the Contractor shall submit data to ASES for standardized PIPs, within specified timelines and according to the established procedures data collection and reporting. The Contractor shall collect valid and reliable data, using qualified staff and personnel to collect the data. Failure of the Contractor to follow data collection and reporting requirements may result in sanctions under this Contract.

 

	
12.4

	
ER Quality Initiative Program

 

	
  

	
12.4.1

	
The Contractor shall develop an Emergency Room (ER) Quality Initiative Program, implementing efficient and timely monitoring of Enrollees’ use of the emergency room, including whether such use was justified by a legitimate Medical Emergency.

 

  

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12.4.2

	
The ER Quality Initiative Program shall be designed to identify high users of Emergency Services for non-emergency situations and to allow for early interventions in order to ensure appropriate utilization of services and resources.

 

	
  

	
12.4.3

	
The ER Quality Initiative Program shall specify all strategies to be used by the Contractor to address high users of inappropriate Emergency Services and include, at a minimum, the following components:

 

	
  

	
12.4.3.1

	
Description of system(s) for tracking, monitoring and reporting high users of ER services for non-emergency situations;

 

	
  

	
12.4.3.2

	
Criteria for defining non-emergency situations;

 

	
  

	
12.4.3.3

	
Educational component to inform: (1) Enrollees about the proper use of ER services and how to access ER services; and (2) PCPs about identifying high users or potential high users of ER services and reporting to the Contractor;

 

	
  

	
12.4.3.4

	
Protocols for identifying high users of inappropriate ER services and referring them to Case Management for needs assessment and identification of other more appropriate services and resources;

 

	
  

	
12.4.3.5

	
Process for coordinating with and referring to MBHO upon identification of the need for behavioral health services and interventions based upon a needs assessment.

 

	
  

	
12.4.3.6

	
Quarterly reporting on ER services utilization; and

 

	
  

	
12.4.3.7

	
Process for monitoring and evaluating program effectiveness, identifying issues and modifying the ER Quality Initiative Program as necessary to improve service utilization.

 

	
  

	
12.4.4

	
The Contractor shall submit its ER Quality Initiative Program to ASES as part of its QAPI program.

 

  

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12.5

	
Quality Incentive Program

 

	
  

	
12.5.1

	
The Contractor shall establish and implement a Quality Incentive Program as a mechanism to improve the quality of services provided to Enrollees.  The Quality Incentive Program shall be based on a work plan to be submitted to ASES by the Contractor as part of its QAPI program, pursuant to Attachment 12 of this Contract.  The Contractor shall implement the Quality Incentive Program within thirty (30) Calendar Days of its approval by ASES.

 

	
  

	12.5.2	
The Quality Incentive Program shall consist of three (3) categories of performance indicators:  performance measures, preventive clinical program measures and ER Utilization measures.  ASES will Withhold a total of one and a half percent (11⁄2%) of Contractor’s Administrative Fee (hereinafter the “Retention Fund”), and will reimburse the Contractor according to compliance with each of the categories of performance indicators in this Section 12.5. Before any withholding may take place, the parties shall have agreed on a Quality Improvement Program Procedure Manual to be effective within thirty (30) calendar days of the Effective Date of the Contract. Such Manual will contain the mutual agreements of the parties on reasonable and achievable performance indicators for each category to be measured under the program.  Once the Manual is approved by both parties the performance indicators therein stated will be effective during the Term of the Contract, unless that amendments might be required by law or regulation, or reached by mutual agreement during such Term.

 

	
  

	
12.5.3

	
The Contractor shall, within thirty (30) Calendar Days after the end of each calendar quarter, submit a quarterly report for each of the performance indicators to be evaluated by ASES.  For each measure, ASES shall, within thirty (30) Calendar Days after receipt of the Contractor’s quarterly report, make a determination whether the Contractor has met the applicable performance objectives for the quarter.  In addition, the Contractor shall submit an annual report within thirty (30) Calendar Days after the end of the year for which the performance is measured.  If the Contractor is then in compliance with the applicable performance targets or portions thereof for said period, ASES shall then release to the Contractor, no later than thirty (30) Calendar Days after ASES determines compliance with the performance objectives, the portion of the Retention Fund associated with each measure for such period, or the portion corresponding to the percentage of compliance with each such indicator, as the case may be.

 

  

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12.5.4

	
The following is a description of each of the three categories of performance indicators and the associated reimbursement level for each.

 

	
  

	
12.5.4.1

	
Performance Measures

 

	
  

	
12.5.4.1.1

	
The Contractor shall demonstrate a three percent (3%) annual increase in performance measures (measured by ASES reporting protocol and HEDIS coding for each measure) using base line measures to be provided by ASES within fifteen (15) Calendar Days of the Effective Date of the Contract, which measures shall be based on actual and verifiable information for the following HEDIS measures of effectiveness for medical care and Access:

 

	
  

	
12.5.4.1.1.1

	
Effectiveness of medical care;

 

	
  

	
12.5.4.1.1.2

	
Prevention and screening metrics;

 

	
  

	
12.5.4.1.1.3

	
Respiratory condition metrics;

 

	
  

	
12.5.4.1.1.4

	
Cardiovascular conditions; and

 

	
  

	
12.5.4.1.1.5

	
Comprehensive Diabetes Care (with all its components).

 

	
  

	
12.5.4.1.1.6

	
Access;

 

	
  

	
12.5.4.1.1.7

	
Metrics for availability of health services.

 

	
  

	
12.5.4.1.2

	
The Contractor shall demonstrate a five percent (5%) annual increase in EPSDT screenings (measured by ASES reporting protocol and HEDIS coding for each measure) using baseline measures to be provided by ASES within fifteen (15) Calendar Days of the Effective Date of the Contract, which measures shall be based on actual and verifiable information.

 

	
  

	
12.5.4.1.3

	
ASES shall release to the Contractor, in accordance with Section 12.5.3 above, forty percent (40%) of the Retention Fund for compliance with the above quality performance measures of this Contract.

 

  

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12.5.4.1.3.1

	
The foregoing notwithstanding, the Contractor shall comply with the HEDIS measures as required by CMS.  The Contractor shall prepare (i) the HEDIS activity for 2012 measure year 2011 provided that ASES delivers on a timely basis the data required to accurately complete such report and (ii) the HEDIS activity for 2013 measure year 2012.  The Contractor shall continue to collect HEDIS measures throughout the term of the Contract.

 

	
  

	
12.5.5

	
Preventive Clinical Programs

 

	
  

	
12.5.5.1

	
The Contractor shall comply with objectives to be established by mutual agreement of the Parties for each of the following preventive clinical programs:

 

	
  

	
12.5.5.1.1

	
Case Management;

 

	
  

	
12.5.5.1.2

	
Disease Management;

 

	
  

	
12.5.5.1.3

	
Pre-Natal and Maternal Wellness Program; and

 

	
  

	
12.5.5.1.4

	
Provider Education Program, including EPSDT and Provider and Enrollee based education.

 

	
  

	
12.5.5.2

	
ASES shall release to the Contractor, in accordance with Section 12.5.3, twenty percent (20%) of the retained Retention Fund for compliance with these objectives.

 

	
  

	
12.5.6

	
Emergency Room Use Indicators

 

	
  

	
12.5.6.1

	
As described in Section 12.4 above, the Contractor shall develop an ER Quality Initiative Program to reduce the inappropriate use of ER services for non-emergency situations.  ASES will provide the Contractor with the related baseline measures within fifteen (15) Calendar Days of the Effective Date of the Contract, which measures shall be based on actual and verifiable information.

 

	
  

	
12.5.6.2

	
[Intentionally left blank].

 

  

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12.5.6.3

	
ASES shall release to the Contractor, in accordance ith Section 12.5.3, forty percent (40%) of the retained Retention Fund for compliance with this objective.

 

	
  

	
12.5.7

	
The Contractor shall submit its Quality Incentive Program as part of its QAPI program.  The program description shall include, at a minimum:

 

	
  

	
12.5.7.1

	
How the Contractor will educate Providers regarding the program requirements; and

 

	
  

	
12.5.7.2

	
Strategies for ensuring and monitoring program compliance.

 

	
  

	
12.5.8

	
During the Contract Term ASES may issue from time to time normative or policy letters setting forth the terms and conditions it may deem necessary or convenient for the purpose of implementing the Quality Incentive Program described in this Article 12.

 

	
12.6

	
HEDIS Measures

	
  

	
12.6.1

	
The Contractor shall report, annually, on the following HEDIS measures in the format specified by ASES.

 

	
  

	
12.6.1.1

	
Effectiveness of Care: Prevention and Screening Measures

 

	
  

	
12.6.1.1.1

	
Childhood immunization;

 

	
  

	
12.6.1.1.2

	
Breast cancer screening;

 

	
  

	
12.6.1.1.3

	
Cervical cancer screening;

 

	
  

	
12.6.1.1.4

	
Chlamydia screening;

 

	
  

	
12.6.1.1.5

	
Adult BMI assessment; and

 

	
  

	
12.6.1.1.6

	
Weight assessment and counseling for nutrition and physical activities for children and adolescents.

 

	
  

	
12.6.1.2

	
Effectiveness of Care: Respiratory Condition Measures

 

	
  

	
12.6.1.2.1

	
Use of appropriate medication for people with asthma.

 

  

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12.6.1.2.2

	
Appropriate treatment for children with upper respiratory conditions.

 

	
  

	
12.6.1.3

	
Effectiveness of Care: Cardiovascular Conditions

 

	
  

	
12.6.1.3.1

	
Cholesterol management for people with cardiovascular conditions;

 

	
  

	
12.6.1.3.2

	
Controlling high blood pressure; and

 

	
  

	
12.6.1.3.3

	
Comprehensive diabetes care (with all its components).

 

	
  

	
12.6.1.4

	
Access/Availability of Care Measures

 

	
  

	
12.6.1.4.1

	
Adult Access to preventive/outpatient health services;

 

	
  

	
12.6.1.4.2

	
Annual dentist visit;

 

	
  

	
12.6.1.4.3

	
Children and adolescent Access to PCPs;

 

	
  

	
12.6.1.4.4

	
Prenatal and postpartum care;

 

	
  

	
12.6.1.4.5

	
Frequency of ongoing prenatal care;

 

	
  

	
12.6.1.4.6

	
Well Child visits in the first 15 months of life; and

 

	
  

	
12.6.1.4.7

	
Adolescent well care visits.

 

	
  

	
12.6.1.5

	
ASES may add, change, or remove reporting requirements with sixty (60) Calendar Days notice in advance of the effective date of the addition, change, or removal.

 

	
  

	
12.6.1.6

	
The Contractor shall contract with an NCQA certified HEDIS auditor to validate the processes of the Contractor in accordance with NCQA requirements.  For Medicaid and CHIP Eligible Persons, the validation procedures shall be consistent with federal requirements specified at 42 CFR 438.358(b)(2).

 

	
  

	
12.6.1.7

	
When requested, the Contractor shall submit data to ASES for standardized performance measures, within specified timelines and according to the established procedures for data collection and reporting. The Contractor shall collect valid and reliable data, using qualified staff and personnel to collect the data. Failure of the Contractor to follow data collection and reporting requirements may result in sanctions under this Contract.

 

  

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12.7

	
Provider and Enrollee Satisfaction Surveys

	
  

	
12.7.1

	
During the Contract Term, the Contractor shall perform at least two (2) satisfaction surveys of Providers and Enrollees.  The first survey will encompass the period to be ended on December 31, 2013 and shall be delivered to ASES by January 31, 2014.  The second survey will encompass the period to be ended on June 30, 2014 and shall be delivered to ASES by July 31, 2014. The survey for Enrollees shall use the CAHPS survey instrument.

 

	
  

	
12.7.2

	
The sample size for both surveys shall equal the number of respondents needed for a statistical confidence level of ninety-five percent (95%) with a margin of error not more than five percent (5%) and shall not have a response rate less than fifty percent (50%).

 

	
  

	
12.7.3

	
The results of the surveys shall be submitted to ASES and to the Puerto Rico Medicaid Program.

 

	
  

	
12.7.4

	
The Contractor shall have a process for notifying Providers and Enrollees about the availability of survey findings and making survey findings available upon request.

 

	
  

	
12.7.5

	
The Contractor shall have a process for utilizing the results of the Provider and Enrollee surveys for monitoring service delivery and quality of services and for making program enhancements.

 

	
12.8

	
External Quality Review

	
  

	
12.8.1

	
In compliance with federal requirements at 42 CFR 438.358(b)(3), ASES will contract with an External Quality Review Organization (EQRO) to conduct annual, external, independent reviews of the quality outcomes, timeliness of, and Access to, the services covered in this Contract.  The Contractor shall collaborate with ASES’s EQRO to develop studies, surveys and other analytic activities to assess the Quality of care and services provided to Enrollees and to identify opportunities for program improvement.  To facilitate this process the Contractor shall supply data, including but not limited to claims data and medical records, to the EQRO. Upon the request of ASES, the Contractor shall provide its protocols for providing information, participating in review activities, and using the results of the reviews to improve the quality of the services and programs provided to Enrollees.

 

  

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12.8.2

	
The EQRO will evaluate the following program components:

 

	
  

	
12.8.2.1

	
Enrollee rights and protection;

 

	
  

	
12.8.2.2

	
Availability of services;

 

	
  

	
12.8.2.3

	
Coordination and continuity of care;

 

	
  

	
12.8.2.4

	
Coverage and authorization of services;

 

	
  

	
12.8.2.5

	
Provider selection;

 

	
  

	
12.8.2.6

	
Enrollee information;

 

	
  

	
12.8.2.7

	
Confidentiality;

 

	
  

	
12.8.2.8

	
Enrollment and Disenrollment;

 

	
  

	
12.8.2.9

	
Grievance System;

 

	
  

	
12.8.2.10

	
Subcontracts;

 

	
  

	
12.8.2.11

	
Provider guidelines; and

 

	
  

	
12.8.2.12

	
Health Information Systems.

 

	
ARTICLE 13

	
FRAUD, WASTE AND ABUSE

 

	
13.1

	
General Provisions

	
  

	
13.1.1

	
The Contractor shall have in place on the Effective Date internal controls and policies and procedures designed to prevent, detect, and timely and adequately investigate and report known or suspected Fraud, Waste and Abuse.

 

	
  

	
13.1.2

	
For Medicaid and CHIP Eligible Persons, the Contractor’s internal controls, policies and procedures shall comply with all federal requirements regarding Fraud, Waste and Abuse and program integrity, including but not limited to Sections 1128, 1156, and 1902(a)(68) of the Social Security Act and 42 CFR 438.606.  The Contractor shall exercise diligent efforts to ensure that no payments are made to any person or entity that has been excluded from participation in Federal health care programs.  (See State Medicaid Director Letter #09-001, January 16, 2009.)

 

	
  

	
13.1.3

	
The Contractor shall submit its Fraud, Waste and Abuse policies and procedures, its proposed compliance plan, and its Program Integrity Plan to ASES for approval according to the timeframe specified in Attachment 12 to this Contract.

 

  

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13.1.4

	
Any changes to the Contractor’s Fraud, Waste and Abuse policies and procedures must be submitted to ASES for approval within fifteen (15) Calendar Days of the date the Contractor plans to implement the changes; and the changes shall not go into effect until ASES gives written approval.

 

	
13.2

	
Compliance Plan

	
  

	
13.2.1

	
The Contractor shall have a written Fraud, Waste and Abuse compliance plan with stated program goals and objectives, program scope and methodology to evaluate program performance.

 

	
  

	
13.2.2

	
At a minimum, the Contractor’s Fraud, Waste and Abuse compliance plan shall:

 

	
  

	
13.2.2.1

	
Ensure that all of its officers, directors, managers and employees know and understand the provisions of the Contractor’s Fraud, Waste and Abuse compliance plan;

 

	
  

	
13.2.2.2

	
Require the designation of a compliance officer and a compliance committee that are accountable to senior management;

 

	
  

	
13.2.2.3

	
Ensure and describe effective training and education for the compliance officer and the organization’s employees;

 

	
  

	
13.2.2.4

	
Ensure that Providers and Enrollees are educated about Fraud, Waste and Abuse identification and reporting in Provider and Enrollee materials;

 

	
  

	
13.2.2.5

	
Ensure effective lines of communication between the Contractor’s compliance officer and the Contractor’s employees;

 

	
  

	
13.2.2.6

	
Ensure enforcement of standards through well-publicized disiplinary guidelines;

 

	
  

	
13.2.2.7

	
Ensure internal monitoring and auditing with provisions for prompt response to potential offenses, and for the development of corrective action initiatives relating to the Contractor’s Fraud, Waste and Abuse efforts;

 

	
  

	
13.2.2.8

	
Describe standards of conduct that articulate the Contractor’s  commitment to comply with all applicable Puerto Rico and federal requirements and standards;

 

  

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13.2.2.9

	
Ensure that no individual who reports Provider violations or suspected Fraud, Waste and Abuse is retaliated against; and

 

	
  

	
13.2.2.10

	
Include a monitoring program that is designed to prevent, detect and timely and adequately investigate and report all instances of potential, suspected or known Fraud, Waste and Abuse.  This monitoring program shall include but not be limited to:

 

	
  

	
13.2.2.10.1

	
Monitoring the Claims of its Providers to ensure Enrollees receive services for which the Contractor is administering Claims and ASES is required to pay under this Contract;

 

	
  

	
13.2.2.10.2

	
Requiring that a preliminary investigation of said potential, suspected or known Fraud, Waste, and Abuse and/or  over billings, be performed within forty five (45) Calendar days after receiving first notification, subject to an additional one hundred and twenty (120) Calendar days extension, if needed, to complete a thorough investigation;

 

	
  

	
13.2.2.10.3

	
Reviewing Providers for over or under-utilization;

 

	
  

	
13.2.2.10.4

	
Verifying with Enrollees the delivery of services as claimed; and

 

	
  

	
13.2.2.10.5

	
Reviewing and trending Enrollee complaints regarding Providers.

 

	
  

	
13.2.2.11

	
The Contractor shall include in any employee handbook a specific discussion of its Fraud, Waste and Abuse policies and procedures, the rights of whistleblowers, and the Contractor’s procedures for detecting and preventing Fraud, Waste and Abuse.

 

	
  

	
13.2.2.12

	
The Contractor shall include in the Enrollee Handbook instructions on how to report Fraud, Waste and Abuse and the protections for whistleblowers.

 

  

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13.3

	
Program Integrity Plan

	
  

	
13.3.1

	
The Contractor shall develop a Program Integrity Plan that at a minimum:

 

	
  

	
13.3.1.1

	
Defines Fraud, waste and Abuse;

 

	
  

	
13.3.1.2

	
Specifies methods to detect Fraud, waste and Abuse,

 

	
  

	
13.3.1.3

	
Describes a process to perform investigations on each suspected case of Fraud, waste and Abuse;

 

	
  

	
13.3.1.4

	
Describes persons responsible for conducting these investigations;

 

	
  

	
13.3.1.5

	
Includes a variety of methods for identifying, investigating and referring suspected cases to appropriate entities;

 

	
  

	
13.3.1.6

	
Includes a systematic approach to data analysis;

 

	
  

	
13.3.1.7

	
Defines mechanisms to monitor frequency of Encounters and services rendered to Enrollees billed by Providers; and

 

	
  

	
13.3.1.8

	
Identifies requirements to complete the preliminary investigation of Providers and Enrollees.

 

	
  

	
13.3.2

	
The Contractor’s Program Integrity Plan shall comply in all respects with the ASES Guidelines for the Development of Program Integrity Plan, included as Attachment 14 to this Contract.  Upon review of the Contractor’s Program Integrity Plan (see Section 13.1.3 of this Contract), ASES will promptly (within twenty (20) Business Days) notify the Contractor of any needed revisions in order for the Program Integrity Plan to comply with the Guidelines for the Development of Program Integrity Plan (Attachment 14) and with federal law.  The Contractor, in turn, shall promptly (within twenty (20) Business Days of receipt of the ASES comments) re-submit its Plan for ASES review and approval.

 

	
  

	
13.3.3

	
The Contractor shall notify ASES within twenty (20) Business Days of any initiated investigation of a suspected case of Fraud, waste, or Abuse.  The Contractor shall subsequently report preliminary results of such investigations activities to ASES and other appropriate Puerto Rico and federal entities.  ASES will provide the Contractor with guidance during the pendency of the investigation and will refer the matter to the U.S. Department of Justice.

 

  

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13.4

	
Prohibited Affiliations with Individuals Debarred by Federal Agencies

	
  

	
13.4.1

	
The Contractor shall not knowingly have a relationship with the following:

 

	
  

	
13.4.1.1

	

An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under Executive Order No. 12549.

 

	
  

	
13.4.1.2

	

An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described in Section 13.4.1.1 of this Contract.  The relationship is defined as follows:

 

	
  

	
13.4.1.2.1

	
A director, officer, or partner of the Contractor;

 

	
  

	
13.4.1.2.2

	
A person with beneficial ownership of five percent of more of the Contractor’s equity; or

 

	
  

	
13.4.1.2.3

	
A person with an employment, consulting or other arrangement with the Contractor for the provision of items or services that are significant and material the Contractor’s obligations under this Contract.

 

	
13.5

	
Reporting and Investigations

	
  

	
13.5.1

	
On a quarterly basis, the Contractor shall submit to ASES a report with the results of the investigations, using the format and data elements prescribed by ASES.

 

	
  

	
13.5.1.1

	
At a minimum, the Contractor shall include in each report, with respect to individual investigations of Fraud, Waste or Abuse:

 

	
  

	
13.5.1.1.1

	
Enrollee name and ID number;

 

	
  

	
13.5.1.1.2

	
Provider name and NPI;

 

	
  

	
13.5.1.1.3

	
Source of complaint;

 

	
  

	
13.5.1.1.4

	
Type of provider;

 

  

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13.5.1.1.5

	
Nature of complaint, including alleged persons or entities involved, category of services, factual explanation of the allegation, and dates of the conduct;

 

	
  

	
13.5.1.1.6

	
Together with each individual investigation report the Contractor will make available to ASES a copy of the investigation file with all the documents that support its findings of Medicaid Fraud, Waste or Abuse, including but not limited to all communication between the Contractor and the Provider about the complaint;

 

	
  

	
13.5.1.1.7

	
Date of the complaint;

 

	
  

	
13.5.1.1.8

	
Approximate dollars involved or amount paid to the Provider during the past three years, whichever is greater;

 

	
  

	
13.5.1.1.9

	
Disciplinary measures imposed, if any;

 

	
  

	
13.5.1.1.10

	
Contact information for a Contractor staff person with relevant knowledge of the matter; and

 

	
  

	
13.5.1.1.11

	
Legal and administrative disposition of the case.

 

	
  

	
13.5.1.2

	
The Contractor shall also include in the report a summary (not specific to an individual case) of

 

	
  

	
13.5.1.2.1

	
Investigative activities, corrective actions, prevention efforts, and results; and

 

	
  

	
13.5.1.2.2

	
Trending and analysis of Utilization Management and Provider payment management.

 

	
  

	
13.5.2

	
The Contractor shall report to ASES any case of Medicaid, Fraud, Waste or Abuse referred to the Office of the Inspector General.

 

	
  

	
13.5.3

	
The Contractor shall report to ASES, within (1) one Business Day of obtaining knowledge with respect to the identity of any Provider or other person who, in violation of 42 CFR 438.610 (a) and (b), is debarred, suspended, or otherwise prohibited from participating in procurement activities.  ASES shall promptly notify the Secretary of HHS of the noncompliance, as required by 42 CFR 438.610(c).

 

  

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13.5.4

	
The Contractor and all Subcontractors shall cooperate fully with federal and Puerto Rico agencies in Fraud, Waste and Abuse investigations and subsequent legal actions.  Such cooperation shall include providing, upon request, information, access to records, and access to interview employees and consultants, including but not limited to those with expertise in the administration of the program and/or medical or pharmaceutical questions or in any matter related to an investigation.

 

	
  

	
13.5.5

	
In accordance with Section 6402 of the PPACA, the Contractor must have a mechanism in place to identify and suspend payments to any provider or other subcontractor when there is a pending investigation of a credible allegation of fraud under the Medicaid program.

 

	
13.6

	
Stark Law Compliance

The Contractor shall have mechanisms in place to ensure that payments are not made to in violation of Section 1903(s) of the Social Security Act with respect to certain physician referrals as defined in Section 1877 of the Social Security Act. The Contractor shall require Providers and suppliers to self-report and return overpayments by the later of: (1) the date which is sixty (60) Calendar Days after the date on which the overpayment was identified; or (2) the date any corresponding cost report is due, if applicable. The Contractor shall ensure that disclosing parties provide a financial analysis that includes the total amount actually or potentially due and owing as a result of the disclosed violation, a description of the methodology used to determine the amount due and owing, the total amount of remuneration involved physicians (or an immediate family member of such physicians) received as a result of an actual or potential violation, and a summary of Audit activity and documents used in the Audit. In accordance with Section 6409 of the PPACA, the Contractor shall encourage Provider use of the self-referral disclosure protocol, under which Providers of services and suppliers may self-disclose actual or potential violations of the physicians self-referral statute (Section 1877 of the Social Security Act).

	
ARTICLE 14

	
GRIEVANCE SYSTEM

 

	
14.1

	
General Requirements

	
  

	
14.1.1

	
The Contractor shall have a Grievance System in place to address Enrollee concerns and Appeals of service decisions.  The Grievance System shall consist of the following four (4) components:  1) Complaint process, 2) Grievance process, 3) Appeal process, and 4) access to the Administrative Law Hearing process.

 

  

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14.1.2

	
The Contractor shall designate, in writing, an officer who shall have primary responsibility for ensuring that Complaints, Grievances, and Appeals are resolved pursuant to this Contract and for signing all Notices of Action.

 

	
  

	
14.1.3

	
The Contractor shall develop written Grievance System policies and procedures that detail the operation of the Grievance System. The Grievance System policies and procedures shall be submitted to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract. In the event that changes are made to the existing approved Grievance System policies and procedures, a copy of the proposed changes shall be made available to ASES for approval according to the timeframe specified in Attachment 12 to this Contract.

 

	
  

	
14.1.4

	
At a minimum, the Contractor’s Grievance System Policies and Procedures shall include the following:

 

	
  

	
14.1.4.1

	
Process for filing a Complaint, Grievance, or Appeal, or seeking an Administrative Law Hearing;

 

	
  

	
14.1.4.2

	
Process for receiving, recording, tracking, reviewing, reporting  and resolving Grievances filed verbally, in writing, or in-person;

 

	
  

	
14.1.4.3

	
Process for receiving, recording, tracking, reviewing, reporting and resolving Appeals filed verbally or in writing;

 

	
  

	
14.1.4.4

	
Process for requesting an expedited review of an Appeal;

 

	
  

	
14.1.4.5

	
Process for notifying Enrollees of their right to file a     Complaint, Grievance or Appeal with the Patient Advocate Office and how to contact the Patient Advocate Office;

 

	
  

	
14.1.4.6

	
Procedures for the exchange of information regarding Complaints, Grievances and Appeals;

 

	
  

	
14.1.4.7

	
Process and timeframes for notifying Enrollees in writing regarding receipt of Complaints, Grievances or Appeals, resolution, action, delay of review, and denial of request for expedited review.

 

	
  

	
14.1.5

	
The Contractor’s Grievance System shall fully comply with the Patient’s Bill of Rights Act and with Act No. 11 of April 11, 2001 (known as the Organic Law of the Office of the Patient Advocate), to the extent that such provisions do not conflict with, or pose an obstacle to, federal regulations.

 

  

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14.1.6

	
For Medicaid and CHIP Eligible Persons, the Contractor’s Grievance System shall be in compliance with federal requirements at 42 CFR 438.400 – 438.424 and 42 CFR 431.200 – 431.250.

 

	
  

	
14.1.7

	
The Contractor shall process each Complaint, Grievance, or Appeal in accordance with applicable Puerto Rico and federal statutory and regulatory requirements, this Contract, and the Contractor’s written policies and procedures.  Pertinent facts from all parties must be collected during the process.

 

	
  

	
14.1.8

	
The Contractor shall include in the Enrollee Handbook educational information regarding the Contractor’s Grievance System which at a minimum includes:

 

	
  

	
14.1.8.1

	
A description of the Contractor’s Grievance System;

 

	
  

	
14.1.8.2

	
Instructions on how to file Complaints, Grievances and Appeals including the timeframes for filing;

 

	
  

	
14.1.8.3

	
The Contractor’s toll-free telephone number and office hours;

 

	
  

	
14.1.8.4

	
Information regarding an Enrollee’s right to file a Complaint, Grievance or Appeal with the Patient Advocate Office and how to file a Complaint, Grievance or Appeal with the Patient Advocate Office;

 

	
  

	
14.1.8.5

	
Information describing the Administrative Law Hearing process and governing rules; and

 

	
  

	
14.1.8.6

	
Timelines and limitations associated with filing Grievances or Appeals.

 

	
  

	
14.1.9

	
The Contractor shall give Enrollees reasonable assistance in completing forms and taking other procedural steps for Complaints, Grievances and Appeals.  This includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TDD and interpreter capability.

 

	
  

	
14.1.10

	
The Contractor shall include information regarding the Grievance System in the Provider guidelines and upon joining the Contractor’s Network, all Providers shall receive education regarding the Contractor’s Grievance System, which includes but is not limited to:

 

  

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14.1.10.1

	
The Enrollee’s right to file Complaints, Grievances and Appeals and the requirements and timeframes for filing;

 

	
  

	
14.1.10.2

	
The Enrollee’s right to file a Complaint, Grievance or Appeal with the Patient Advocate Office;

 

	
  

	
14.1.10.3

	
The Enrollee’s right to an Administrative Law Hearing, how to obtain an Administrative Law Hearing, and representation rules at a Administrative Law Hearing;

 

	
  

	
14.1.10.4

	
The availability of assistance in filing a Complaint, Grievance, or Appeal;

 

	
  

	
14.1.10.5

	
The toll-free numbers to file oral Complaints, Grievances and Appeals;

 

	
  

	
14.1.10.6

	
The Enrollee’s right to request continuation of Benefits during an Appeal, or an Administrative Law Hearing filing, and that if the Contractor’s action is upheld in a Administrative Law Hearing, the Enrollee may be liable for the cost of any continued Benefits; and

 

	
  

	
14.1.10.7

	
Any Puerto Rico-determined Provider Appeal rights to challenge the failure of the Contractor to cover a service.

 

	
  

	
14.1.11

	
The Contractor shall acknowledge receipt of each filed Grievance and Appeal in writing within ten (10) Business Days of receipt.

 

	
  

	
14.1.12

	
The Contractor shall have procedures in place to notify all Enrollees in their primary language of Complaint, Grievance and Appeal dispositions.

 

	
  

	
14.1.13

	
All Complaints, Grievances and Appeals files and forms shall be made available to ASES for auditing. All Complaint, Grievance, and Appeal documents and related information shall be considered as containing protected health information and shall be treated in accordance with HIPAA regulations and other applicable laws of Puerto Rico.

 

  

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14.1.14

	
The Contractor shall develop Grievance System forms to be submitted for approval by ASES according to the timeframe specified in Attachment 12 to this Contract.  The approved forms shall be made available to all Enrollees, shall meet all requirements listed in Sections 6.2 and 6.3 of this Contract for written materials, and shall, at a minimum:

 

	
  

	
14.1.14.1

	
Instruct the Enrollee or Enrollee’s Authorized Representative that documentary evidence should be included, if available; and

 

	
  

	
14.1.14.2

	
Include instructions for completion and submission.

 

	
  

	
14.1.15

	
The Contractor shall ensure that the individuals who make decisions on  Grievances and Appeals were not involved in any previous level of review or decision-making; and are Health Care Professionals who have the appropriate clinical expertise, as determined by ASES, in treating the Enrollee’s condition or disease if deciding any of the following:

 

	
  

	
14.1.15.1

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

 

	
  

	
14.1.15.2

	
A Grievance regarding denial of expedited resolutions of Appeal; and

 

	
  

	
14.1.15.3

	
Any Grievance or Appeal that involves clinical issues.

 

	
  

	
14.1.16

	
The Contractor shall have a system in place to collect, analyze and integrate data regarding Complaints, Grievances and Appeals. At a minimum, the following information shall be recorded:

 

	
  

	
14.1.16.1

	
Date Complaint, Grievance or Appeal was filed;

 

	
  

	
14.1.16.2

	
Enrollee’s name;

 

	
  

	
14.1.16.3

	
Enrollee’s Medicaid ID number, if applicable;

 

	
  

	
14.1.16.4

	
Name of the individual filing the Complaint, Grievance or Appeal on behalf of the Enrollee;

 

	
  

	
14.1.16.5

	
Date acknowledgement of receipt of Grievance/Appeal was mailed to the Enrollee;

 

	
  

	
14.1.16.6

	
Summary of Complaint, Grievance or Appeal;

 

	
  

	
14.1.16.7

	
Date Notice of Disposition or Notice of Adverse Action was mailed to the Enrollee;

 

	
  

	
14.1.16.8

	
Corrective action required; and

 

  

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14.1.16.9

	
Date of resolution.

 

	
14.2

	
Complaint

	
  

	
14.2.1

	
The Complaint process is the procedure for addressing Enrollee Complaints, defined as expressions of dissatisfaction about any matter other than an Action that are resolved at the point of contact rather than through filing a formal Grievance.

 

	
  

	
14.2.2

	
An Enrollee or Enrollee’s Authorized Representative may file a Complaint either orally or in writing.  The Enrollee or Enrollee’s Authorized Representative may follow up an oral request with a written request, however, the timeframe for resolution begins with the date the Contractor receives the oral request.

 

	
  

	
14.2.3

	
An Enrollee or Enrollee’s Authorized Representative shall file a Complaint within fifteen (15) Calendar Days after the date of occurrence that initiated the Complaint.

 

	
  

	
14.2.4

	
The Contractor shall have procedures in place to notify all Enrollees in their primary language of Complaint dispositions.

 

	
  

	
14.2.5

	
The Contractor shall resolve each Complaint within seventy-two (72) hours of the time the Contractor received the initial Complaint, whether orally or in writing.  If the Complaint is not resolved within this timeframe, the Complaint shall be treated as a Grievance.

 

	
  

	
14.2.6

	
The Notice of Disposition shall include the results and date of the resolution of the Complaint and shall include notice of the right to file a Grievance or Appeal and information necessary to allow the Enrollee to request an Administrative Law Hearing, if appropriate, including contact information necessary to pursue an Administrative Law Hearing.

 

	
14.3

	
Grievance Process

 

	
  

	
14.3.1

	
The Grievance process is the procedure for filing an expression of dissatisfaction about any matter other than an Action (see Section 14.4 of this Contract for definition of Action).

	
  

	
14.3.2

	
Any written or verbal communication from an Enrollee or Network Provider, which expresses dissatisfaction about any matter other than an Action shall be promptly and properly handled and resolved by the Contractor.

 

  

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14.3.3

	
An Enrollee or Enrollee’s Authorized Representative may file a Grievance with the Contractor or with the Office of the Patient’s Advocate of Puerto Rico either orally or in writing.  A Provider cannot file a Grievance on behalf of an Enrollee unless written consent is granted by the Enrollee.

 

	
  

	
14.3.4

	
The Contractor shall provide written notice of the disposition of the Grievance as expeditiously as the Enrollee’s health condition requires, but in any event, within ninety (90) Calendar Days of the filing date. The notice shall include the resolution and the basis for the resolution. However, if the Contractor resolved the Grievance and verbally informed the Enrollee of the resolution within five (5) Business Days of receipt of the Grievance, the Contractor shall not be required to provide written notice of resolution, but the Grievance shall be included in the Contractor’s Grievance and Appeals report as described in Section 14.8 of this Contract.

 

	
  

	
14.3.5

	
The Contractor may extend the timeframe for disposition of a Grievance for up to fourteen (14) Calendar Days if the Enrollee requests the extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is a need for additional information and how the delay is in the Enrollee’s interest.  If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee, give the Enrollee written notice of the reason for the delay prior to the delay.

 

	
14.4

	
Action

	
  

	
14.4.1

	
As defined in 42 CFR §438.400(b), an Action means:

 

	
  

	
14.4.1.1

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

 

	
  

	
14.4.1.2

	
The reduction, suspension, or termination of a previously authorized service;

 

	
  

	
14.4.1.3

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

 

	
  

	
14.4.1.4

	
The failure to provide services in a timely manner, as defined by this Contract;

 

	
  

	
14.4.1.5

	
The failure of the Contractor to act within the timeframes provided in 42 CFR 438.408(b); or

 

	
  

	
14.4.1.6

	
For a resident of a rural area, the denial of an Enrollee's request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the General Network.

 

  

Page 203 of 327

  

 

	
  

	
14.4.2

	
In the event of an Action, the Contractor shall notify the Enrollee in writing.  The Contractor shall also provide written notice of an Action to the Provider.  This notice shall meet the language and format requirements in accordance with Sections 6.2 and 6.3 of this Contract and be sent in accordance with the timeframes described in Section 14.4.4 of this Contract.

 

	
  

	
14.4.3

	
The Notice of Action shall contain the following:

 

	
  

	
14.4.3.1

	
The Action the Contractor has taken or intends to take;

 

	
  

	
14.4.3.2

	
The reasons for the Action;

 

	
  

	
14.4.3.3

	
The Enrollee’s right to file an Appeal through the Contractor’s internal Grievance System and the procedure for filing an Appeal;

 

	
  

	
14.4.3.3.1

	
The Provider’s right to dispute an ASES determination as described in Section 16.11 of this Contract;

 

	
  

	
14.4.3.4

	
The Enrollee’s right to request an Administrative  Law Hearing;

 

	
  

	
14.4.3.5

	
The Enrollee’s right to allow a Provider to act on behalf of the Enrollee, upon written consent;

 

	
  

	
14.4.3.6

	
The circumstances under which expedited review is available and how to request it; and

 

	
  

	
14.4.3.7

	
The Enrollee’s right to have Benefits continue pending resolution of the Appeal with the Contractor or during the Administrative Law Hearing, how to request that Benefits be continued, and the circumstances under which the Enrollee may be required to pay the costs of these services.

 

	
  

	
14.4.4

	
The Contractor shall mail the Notice of Action within the following timeframes:

 

	
  

	
14.4.4.1

	
For termination, suspension, or reduction of previously authorized Covered Services at least ten (10) Calendar Days before the date of Action or not later than the date of Action in the event of one of the following exceptions:

 

  

Page 204 of 327

  

 

	
  

	
14.4.4.1.1

	
The Contractor has factual information confirming the death of an Enrollee.

 

	
  

	
14.4.4.1.2

	
The Contractor receives a clear written statement signed by the Enrollee that he or she no longer wishes services or gives information that requires termination or reduction of services and indicates that he or she understands that this must be the result of supplying that information.

 

	
  

	
14.4.4.1.3

	
The Enrollee’s whereabouts are unknown and the post office returns Contractor mail directed to the Enrollee indicating no forwarding address (refer to 42 CFR 431.231(d) for procedures if the Enrollee’s whereabouts become known).

 

	
  

	
14.4.4.1.4

	
The Enrollee’s Provider prescribes a change in the level of medical care.

 

	
  

	
14.4.4.1.5

	
The date of action will occur in less than ten (10) Calendar Days in accordance with 42 CFR 483.12(a)(5)(ii).

 

	
  

	
14.4.4.1.6

	
The Contractor may shorten the period of advance notice to five (5) Calendar Days before the date of Action if the Contractor has facts indicating that Action should be taken because of probable Enrollee Fraud and the facts have been verified, if possible, through secondary sources.

 

	
  

	
14.4.4.2

	
For denial of payment, at the time of any Action affecting the Claim.

 

	
  

	
14.4.4.3

	
For standard authorization decisions that deny or limit Covered Services, within the timeframes required in Section 11.3 of this Contract.

 

	
  

	
14.4.4.4

	
If the Contractor extends the timeframe for the authorization decision and issuance of Notice of Action according to Section 14.4.3 of this Contract, the Contractor shall give the Enrollee written notice of the reasons for the decision to extend if he or she did not request the extension. The Contractor shall issue and carry out its determination as expeditiously as the Enrollee’s health requires and no later than the date the extension expires.

 

  

Page 205 of 327

  

 

	
  

	
14.4.4.5

	
For authorization decisions not reached within the timeframes required in Section 11.3.4 of this Contract for either standard or expedited authorizations, the Notice of Action shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus an Action.

 

	
14.5

	
Appeal Process

	
  

	
14.5.1

	
An Appeal is the request for review of an “Action.”  It is a formal petition by an Enrollee, an Enrollee’s Authorized Representative, or the Enrollee’s Provider, acting on behalf of the Enrollee with the Enrollee’s written consent, to reconsider a decision where the Enrollee or Provider does not agree with an Action taken.

 

	
  

	
14.5.2

	
The Enrollee, the Enrollee’s Authorized Representative, or the Provider may file an Appeal either orally or in writing.  Unless the Enrollee requests expedited review, the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, must follow an oral filing with a written, signed, request for Appeal.

 

	
  

	
14.5.3

	
Oral inquiries seeking to Appeal an action are treated as Appeals (to establish the earliest possible filing date for the Appeal), but Enrollees must confirm oral requests for Appeals in writing, unless the Enrollee requests expedited resolution.

 

	
  

	
14.5.4

	
The requirements of the Appeal process shall be binding for all types of Appeals, including expedited Appeals, unless otherwise established for expedited Appeals.

 

	
  

	
14.5.5

	
The Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, may file an Appeal to the Contractor during a period no less than twenty (20) Calendar Days and not to exceed ninety (90) Calendar Days from the date on the Contractor’s Notice of Action or Notice of Adverse Action.

 

	
  

	
14.5.6

	
Appeals shall be filed directly with the Contractor, or its delegated representatives.  The Contractor may delegate this authority to an Appeal committee, but the delegation shall be in writing.

 

  

Page 206 of 327

  

 

	
  

	
14.5.7

	
The Appeals process shall provide the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, a reasonable opportunity to present evidence and allegations of fact or law, in person, as well as in writing.  The Contractor shall inform the Enrollee of the limited time available to provide this in case of expedited review.

 

	
  

	
14.5.8

	
The Appeals process shall provide the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, opportunity, before and during the Appeals process, to examine the Enrollee’s case file, including Medical Records, and any other documents and records considered during the Appeals process.

 

	
  

	
14.5.9

	
The Appeals process shall include as parties to the Appeal the Enrollee, the Enrollee’s Authorized Representative, the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, or the legal representative of a deceased Enrollee’s estate.

 

	
  

	
14.5.10

	
The Contractor shall establish and maintain an expedited review process for Appeals when the Contractor determines (based on a request from the Enrollee) or the Provider indicates (in making the request on the Enrollee’s behalf) that taking the time for a standard resolution could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function.  The Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, may file an expedited Appeal either orally or in writing.  The Contractor shall ensure that punitive action is not taken against either a Provider who requests an expedited resolution, or a Provider that supports an Enrollee’s Appeal.

 

	
  

	
14.5.11

	
The Contractor shall resolve each expedited Appeal and provide a notice of disposition, as expeditiously as the Enrollee’s health condition requires, within the Government-established timeframes not to exceed three (3) Business Days after the Contractor receives the Appeal.

 

	
  

	
14.5.12

	
The Contractor shall resolve each Appeal and provide written notice of the disposition, as expeditiously as the Enrollee’s health condition requires but shall not exceed forty-five (45) Calendar Days from the date the Contractor receives the Appeal.  For expedited reviews of an Appeal and notice to affected parties, the Contractor has no longer than seventy-two (72) hours or as expeditiously as the Enrollee’s physical or mental health condition requires. If the Contractor denies an Enrollee’s request for expedited review, it shall transfer the Appeal to the timeframe for standard appeal specified herein and shall make reasonable efforts to give the Enrollee prompt oral notice of the denial, and follow up within two (2) Calendar Days with a written notice. The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an Appeal.

 

  

Page 207 of 327

  

 

	
  

	
14.5.13

	
The Contractor may extend the timeframe for standard or expedited resolution of the Appeal by up to fourteen (14) Calendar Days if the Enrollee, Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, requests the extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is need for additional information and how the delay is in the Enrollee’s interest.  If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee, give the Enrollee written notice of the reason for the delay.  The Contractor shall inform the Enrollee of the right to file a grievance if the Enrollee disagrees with the decision to extend the timeframe.

 

	
  

	
14.5.14

	
The Contractor shall provide written notice of disposition.  The written notice shall include:

 

	
  

	
14.5.14.1

	
The results of the Appeal resolution; and

 

	
  

	
14.5.14.2

	
For decisions not wholly in the Enrollee’s favor:

 

	
  

	
14.5.14.2.1

	
The right to request an Administrative Law Hearing;

 

	
  

	
14.5.14.2.2

	
How to request an Administrative Law Hearing;

 

	
  

	
14.5.14.2.3

	
The right to continue to receive benefits pending an Administrative Law Hearing;

 

	
  

	
14.5.14.2.4

	
How to request the continuation of Benefits; and

 

	
  

	
14.5.14.2.5

	
Notification that if the Contractor’s action is upheld in a hearing, the Enrollee may liable for the cost of any continued benefits.

 

  

Page 208 of 327

  

 

	
14.6

	
Administrative Law Hearing

	
  

	
14.6.1

	
The Contractor is responsible for explaining the Enrollee’s right to and the procedures for an Administrative Law Hearing.

 

	
  

	
14.6.2

	
The parties to the Administrative Law Hearing include ASES, the Contractor as well as the Enrollee or his or her representative, or the representative of a deceased Enrollee’s estate.

 

	
  

	
14.6.3

	
If the Contractor takes an Action and the Enrollee requests an Administrative Law Hearing, ASES shall grant the Enrollee such hearing.  The right to such fair hearing, how to obtain it, and the rules concerning who may represent the Enrollee at such hearing shall be explained to the Enrollee and by the Contractor.

 

	
  

	
14.6.4

	
ASES shall permit the Enrollee to request an Administrative Law Hearing before it within a reasonable time period, as follows:

 

	
  

	
14.6.4.1

	
In the event that the Enrollee first files an appeal with the Contractor, per Section 14.5 of this Contract, not less than twenty (20) Calendar Days or more than ninety (90) Calendar Days from receipt of Contractor’s Notice of Action; or

 

	
  

	
14.6.4.2

	
In the event that the Enrollee seeks an Administrative Law Hearing without recourse to the Contractor’s appeal process, as expeditiously as the Enrollee’s health condition requires; but no later than three (3) Business Days after ASES receives, directly from the Enrollee, a hearing request on a decision to deny a service, when ASES determines that taking the time for a standard resolution could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function.

 

	
  

	
14.6.5

	
The Contractor shall make available any records and any witnesses at its own expense in conjunction with a request pursuant to an Administrative Law Hearing.

 

	
  

	
14.6.6

	
The decision issued as a result of the Administrative Law Hearing is subject to review before the Court of Appeals of the Commonwealth of Puerto Rico.

 

	
14.7

	
Continuation of Benefits while the Contractor Appeal and Administrative Law Hearing are Pending

	
  

	
14.7.1

	
As used in this Section, “timely” filing means filing on or before the later of the following:

 

  

Page 209 of 327

  

 

	
  

	
14.7.1.1

	
Within ten (10) Calendar Days of the Contractor mailing the Notice of Adverse Action; or

 

	
  

	
14.7.1.2

	
The intended effective date of the Contractor’s Action.

 

	
  

	
14.7.2

	
The Contractor shall continue the Enrollee’s Benefits if the Enrollee or the Enrollee’s Authorized Representative files the Appeal timely; the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; the services were ordered by a Provider; the period covered by the original authorization has not expired; and the Enrollee requests extension of the Benefits.

 

	
  

	
14.7.3

	
If, at the Enrollee’s request, the Contractor continues or reinstates the Enrollee’s Benefits while the Appeal or Administrative Law Hearing is pending, the Benefits shall be continued until one of the following occurs:

 

	
  

	
14.7.3.1

	
The Enrollee withdraws the Appeal or request for the Administrative Law Hearing.

 

	
  

	
14.7.3.2

	
Ten (10) Calendar Day pass after the Contractor mails the Notice of Adverse Action, unless the Enrollee, within the ten (10) Calendar Day timeframe, has requested an Administrative Law Hearing with continuation of Benefits until an Administrative Law Hearing decision is reached.

 

	
  

	
14.7.3.3

	
An Administrative Law Judge issues an Administrative Law Hearing decision adverse to the Enrollee.

 

	
  

	
14.7.3.4

	
The time period or service limits of a previously authorized service has been met.

 

	
  

	
14.7.4

	
If the final resolution of Appeal or Administrative Law Hearing is adverse to the Enrollee, that is, upholds the Contractor action, the Contractor (on behalf of ASES) may recover from the Enrollee the cost of the services furnished to the Enrollee while the Appeal / Administrative Law Hearing was pending, to the extent that they were furnished solely because of the requirements of this Section.  After recoupment of the cost of the service from the Enrollee (either in full or in part), the Contractor shall submit such funds to ASES.

 

	
  

	
14.7.5

	
If the Contractor or ASES reverses a decision to deny, limit, or delay services that were not furnished while the Appeal / Administrative Law Hearing was pending, the Contractor shall authorize or provide this disputed services promptly and as expeditiously as the Enrollee’s health condition requires.

 

  

Page 210 of 327

  

 

	
  

	
14.7.6

	
If the Contractor or ASES reverses a decision to deny authorization of services, and the Enrollee received the disputed services while the Appeal / Administrative Law Hearing was pending, those services shall be paid for in accordance with Article 16 this Contract.

 

	
14.8

	
Reporting Requirements

	
  

	
14.8.1

	
The Contractor shall log and track all Complaints, Grievances, Notices of Action, Appeals and Administrative Law Hearing requests (see Section 14.1.16 of this Contract for details regarding information collected).

 

	
  

	
14.8.2

	
ASES may publicly disclose summary information regarding the nature of Complaints, Grievances and Appeals and related dispositions or resolutions in consumer information materials.

 

	
  

	
14.8.3

	
The Contractor shall submit quarterly Grievance System Reports to ASES using a format prescribed by ASES.

 

	
14.9

	
Remedy for Contractor Non-Compliance with Advance Directive Requirements.

 

In addition to the Complaint, Grievance, and Appeal rights described in this Article, an Enrollee may lodge with ASES a complaint concerning the Contractor’s non-compliance with the Advance Directive requirements stated in Section 7.10 of this Contract.

 

	
ARTICLE 15

	
ADMINISTRATION AND MANAGEMENT

 

	
15.1

	
General Provisions

	
  

	
15.1.1

	
The Contractor shall be responsible for the administration and management of all requirements of this Contract, and consistent with the Medicaid managed care regulations at 42 CFR Part 438.

 

	
  

	
15.1.2

	
All costs and expenses related to the administration and management of this Contract shall be the responsibility of the Contractor.

 

	
15.2

	
Place of Business and Hours of Operation

	
  

	
15.2.1

	
Given that Enrollment occurs chiefly on site in the Contractor’s administrative offices, the Contractor shall ensure that its administrative offices are physically accessible to all Enrollees and fully equipped to perform all functions related to carrying out this Contract.

 

  

Page 211 of 327

  

 

	
  

	
15.2.2

	
The Contractor shall maintain administrative offices in each Service Region.

 

	
  

	
15.2.3

	
The Contractor shall accommodate any request by ASES to visit the Contractor’s administrative offices to ensure that the offices are compliant with Americans with Disabilities Act (“ADA”) requirements for public buildings, and with all other applicable federal and Puerto Rico rules and regulations.

 

	
  

	
15.2.4

	
The Contractor must maintain one (1) central administrative office and an additional administrative office in each Service Region covered under this Contract.

 

	
  

	
15.2.5

	
The Contractor’s office shall be centrally located and in a location accessible by foot and vehicle traffic.  The Contractor may establish more than one (1) administrative office within each of its Service Regions, but must designate one (1) of the offices as the central administrative office.

 

	
  

	
15.2.6

	
All of the Contractor’s written communications to Enrollees must contain the address of the location identified as the legal, duly licensed, central administrative office.  This administrative office must be open at least between the hours of 9:00 a.m. and 5:00 p.m. Puerto Rico Time, Monday through Friday; in addition, pursuant to the Contractor’s Enrollment Outreach Plan (see Section 6.12.2 of this Contract), the Contractor’s administrative office must have extended opening hours (until 7:00 p.m.) one Business Day per week; and must be open (to the extent necessary to permit Enrollment activities) one Saturday per month, from 9:00 a.m. to 5:00 p.m.

 

	
  

	
15.2.7

	
The Contractor shall ensure that the office(s) are adequately staffed, throughout the Term of this Contract, to ensure that Enrollees may visit the office to enroll at any time during Contractor’s hours of operation; and to ensure that Enrollees and Providers receive prompt and accurate responses to inquiries.

 

	
  

	
15.2.8

	
The Contractor shall provide access to information to Enrollees through Tele MI Salud, during the hours provided in Section 6.8.3 of this Contract.

 

	
  

	
15.2.9

	
The Contractor shall provide access twenty-four (24) hours a day, seven (7) days per week to its Web site.

 

  

Page 212 of 327

  

	
15.3

	
Training and Staffing

 

	
  

	

15.3.1

	

The Contractor shall conduct ongoing training for all of its staff involved in Contractor’s performance of its obligations under this Contract, in all departments, to ensure appropriate functioning in all such areas and to ensure that such staff:

 

	
  

	
15.3.1.1

	
Understand the MI Salud program and the Medicaid managed care requirements;

 

	
  

	
15.3.1.2

	
Are aware of all programmatic changes; and

 

	
  

	
15.3.1.3

	
Are trained in the Contractor’s Cultural Competency Plan

 

	
  

	
15.3.2

	
The Contractor shall submit a Staff Training Plan and a current organizational chart to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to the Staff Training Plan must be previously approved in writing by ASES.

 

	
15.4

	
Data Certification

	
  

	
15.4.1

	
The Contractor shall certify all data that (i) is the basis of ASES payments under this Contract pursuant to 42 CFR 438.604 and 42 CFR 438.606 or (ii) that is otherwise required to be certified by ASES. The data that must be certified include, but are not limited to, Enrollment information, Encounter Data, Claims Reports, reconciliation reports and other information reasonably required on a timely basis by ASES as a basis for payment. The data must be certified by the Authorized Signatory. The certification must attest, based on best knowledge, information, and belief, as follows:

 

	
  

	
15.4.1.1

	
To the accuracy, completeness and truthfulness of the data; and

 

	
  

	
15.4.1.2

	
To the accuracy, completeness, and truthfulness of the documents specified by ASES.

 

	
  

	
15.4.1.3

	
The Contractor shall submit the certification concurrently with the certified data.

 

	
15.5

	
Implementation Plan and Submission of Initial Deliverables

	
  

	
15.5.1

	
The Contractor shall develop an Implementation Plan that verifies that the Contractor will submit the Deliverables listed in the chart in Attachment 12 to this Contract, and that details any additional procedures and activities that will be accomplished during the period between the Effective Date of this Contract and the Implementation Date of this Contract.  The Implementation Plan shall include coordination and cooperation with ASES and its representatives during all phases.  The continued effectiveness of this Contract shall be contingent upon the Contractor’s submission and ASES’s approval of any Deliverables that, as provided in Attachment 12, were due before the Implementation Date of this Contract, and provided that ASES’s approval shall not be unreasonably withheld, conditioned or delayed.

 

  

Page 213 of 327

  

 

	
  

	
15.5.2

	
The Contractor shall submit its Implementation Plan to ASES for ASES’s review and approval according to the timeframe specified in Attachment 12 to this Contract.  Implementation of the Contract shall not commence prior to ASES approval.

 

	
  

	
15.5.2.1

	
The Contractor will not receive any additional payment to cover start up or implementation costs.

 

	
ARTICLE 16

	
PROVIDER PAYMENT MANAGEMENT

 

	
16.1

	
General Provisions

	
  

	
16.1.1

	
ASES expressly guarantees payment for all Medically Necessary Covered Services rendered to Enrollees by any Network Providers and all Providers. So long as ASES is making the Claims Payments, the Contractor shall pay Claims to Providers in the manner described in this Contract, and shall monitor the implemented compensation systems to prevent the compromise of access to services or their quality.  The Contractor shall administer an effective, accurate and efficient Provider payment management function that (a) under this Contract’s arrangement adjudicates and settles Provider Claims for Covered Services that are filed within the timeframes specified by this Article and in compliance with all applicable Puerto Rico and federal laws, rules, and regulations; (b) processes Claims Payments to applicable Providers within the timeframes specified by this Article; and (c) performs third-party administration functions.

 

	
  

	
16.1.2

	
The Contractor shall maintain a Claims management system that can identify the date of receipt (the date the Contractor receives the Claim as indicated by the date-stamp), real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied, suspended, appealed, etc.), and the date of payment (the date of the check or other form of payment).

 

  

Page 214 of 327

  

 

	
  

	
16.1.3

	
To the extent feasible, the Contractor shall implement an Automated Clearinghouse (“ACH”) mechanism that allows Providers to request and receive electronic funds transfer (“EFT”) of Claims payments.  The Contractor shall encourage its Providers, as an alternative to the filing of paper-based Claims, to submit and receive Claims information through electronic data interchange (“EDI”), i.e., electronic Claims.  Electronic Claims must be processed in adherence to information exchange and data management requirements specified in Article 17.  As part of this Electronic Claims Management (“ECM”) function, the Contractor shall also provide on-line and phone-based capabilities to obtain Claims processing status information.

 

	
  

	
16.1.4

	
If the Contractor does not make payments through an ACH system, the Contractor shall either provide a central address to which Providers must submit Claims; or provide to each Network Provider a complete list, including names, addresses, and phone number, of entities to which the Providers must submit Claims.

 

	
  

	
16.1.5

	
The Contractor shall notify Providers in writing of any changes in the Claims filing list at least thirty (30) Calendar Days before the effective date of the change.  If the Contractor is unable to provide 30 Calendar Days of notice, it must (i) give Providers a thirty- (30) Calendar Day extension on their Claims filing deadline to ensure Claims are routed to the correct processing center and (ii) provide written notification to ASES within one (1) Business Day.

 

	
  

	
16.1.6

	
All Claims submitted for payment, in order to be processed, shall comply with the Clean Claim standards as established by federal regulation (42 CFR 447.45), and as described in Section 16.10.2 of this Contract.

 

	
  

	
16.1.7

	
The Contractor shall generate explanations of benefits and remittance advices in accordance with ASES standards for formatting, content, and timeliness.

 

	
  

	
16.1.8

	
The Contractor shall not pay any Claim submitted by a Provider who is excluded or suspended from the Medicare, Medicaid or CHIP programs for Fraud, Abuse or waste or otherwise included on HHS Office of the Inspector General exclusions list, or employs someone on this list.  The Contractor shall not pay any Claim submitted by a Provider that is on payment hold under the authority of ASES (see Section 10.5.4 of this Contract).  The Contractor shall only pay Claims that have been submitted by the Provider within ninety (90) Calendar Days of providing such service.

 

	
16.2

	
[Intentionally left blank].

	
16.3

	
[Intentionally left blank].

 

  

Page 215 of 327

  

 

	
16.4

	
[Intentionally left blank].

	
16.5

	
Payment Schedule

	
  

	
16.5.1

	
At a minimum, the Contractor shall run two (two) Provider payment cycles per month, on the same day each week, as determined by the Contractor.  The Contractor shall develop a payment schedule to be submitted to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.

 

	
  

	
16.5.2

	
Other than for cause explicitly stated in the Provider Contract, payment to Providers made in the form of a Capitation payment shall be issued no later than the fifteenth (15th) Calendar Day of the month in which ASES issues its Claims Payment to the Contractor.  Any Provider Capitation payment retained by the Contractor past this date in a given month shall accrue interest at the prevailing legal interest rate for personal loans as such rate is determined by the Board of the Office of the Commissioner of Financial Institutions, and interest shall be paid along with the Capitation payment to the Provider for that month.

 

	
16.6

	
Contractor Administration Responsibilities –for Vieques and Guaynabo.

	
  

	
16.6.1

	
ASES will set up a separate account from which the Contractor shall draw the necessary funding to process payments for services rendered in the Centro de Diagnostico y Tratamiento de Vieques (“Vieques CDT”); these draws shall be in accordance with ASES specifications.  All draws against this account shall be substantiated through the submission of Encounter Data as prescribed in 16.8.1 and reconciled to these data on a monthly basis on a schedule to be agreed upon between ASES and the Contractor.

 

	
  

	
16.6.2

	
The Contractor shall coordinate with the applicable appropriate personnel of the Vieques CDT and the Grupo Medico de Guaynabo to ensure proper incorporation of the service management and reimbursement terms associated with such Provider into the Contractor’s business operations and information systems.

 

	
16.7

	
Required Claims Processing Reports

	
  

	
16.7.1

	
The Contractor shall provide to ASES each fifteenth (15th) and (30th) day of each calendar month  a Claims Payment Report listing all Claims submitted by Providers that are pending and have not been paid.  The Claims Payment Report shall be certified by the Authorized Signatory in accordance with Sections 15.4 and 22 of this Contract.  The report shall include a pre-check register with proposed payments to be made by the Contractor to the Providers.  The Claims Payment Report shall not include requests for the payment of Claims that are determined not to be Medically Necessary.  The format of the report shall be provided by ASES.

 

  

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16.7.2

	
The Contractor shall provide an additional report listing all paid and denied Claims each fifteenth (15th) and (30th) day of each calendar month.  The format of the report shall be provided by ASES and shall detail payments made to all Providers.

 

	
  

	
16.7.2.1

	
The report shall list, by Provider, Claims from the preceding month that were paid, and those that have not been made by reason of administrative delay or the Contractor’s decision to deny the Claim.

 

	
  

	
16.7.3

	
In the event that Providers associated with a PMG consent to the disbursement of payment directly to the PMG, the Contractor shall so specify in its report.

 

	
  

	
16.7.4

	
The Contractor shall provide to ASES, each fifteenth (15th) and (30th) day of each calendar month, records or financial data related to Claims submitted but not paid by reason of accounting or by reason of Contractor decision to deny the Claim.  Such data shall be submitted in a format acceptable to ASES.

 

	
  

	
16.7.5

	
The Contractor shall provide to PMGs, on a monthly basis, and through an electronic or machine readable media format, a detailed report classified by Enrollee, by Provider, by diagnosis, by procedure, by date of service and by real cost, of all payments made by the Contractor to the PMG. The Contractor shall provide this report to ASES at the same time the report is provided to the PMGs.

 

	
16.8

	
Submission of Encounter Data

	
  

	
16.8.1

	
The Contractor shall establish an efficient information system to maintain all data pertaining to Enrollee Encounters, Claims processing and rapid transmission of all the information required by ASES.

 

	
  

	
16.8.2

	
The PMGs must report on a quarterly basis each Encounter to the Contractor, classified by each participating Provider within the PMG, as well as the health services of each Encounter. The data shall be submitted regardless of the payment arrangement, Capitated or otherwise, agreed upon between the Contractor and the Provider.  The Contractor must submit to ASES the Capitation distribution, if applicable, within each PMG as established in the formats required by ASES actuarial reports.

 

  

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16.8.3

	
To assure that all Enrollees Encounters are registered and recorded, the Contractor shall conduct audits of Encounter data submitted by Providers.  Any violations with respect to Encounter reporting shall be subject to corrective measures.  The Contractor shall provide quarterly reports to ASES of all the findings and corrective measures taken with respect to the Encounter Data reporting requirements.

 

	
  

	
16.8.4

	
Providers shall furnish complete Encounter Data to the Contractor on a monthly basis.

 

	
16.9

	
Relationship With Pharmacy Benefit Manager (PBM)

	
  

	
16.9.1

	
The Contractor shall work with the PBM selected by ASES to facilitate the processing of Pharmacy Services Claims submitted by the PBM, as provided in Section 7.5.12.11 of this Contract.  ASES is responsible for the funding of pharmacy claims, and the Contractor is responsible to execute the payment of the Claims to be paid to the PBMs on behalf of the network of pharmacies in accordance with the PBM contract.

 

	
  

	
16.9.2

	
The Contractor acknowledges its obligation with respect to the validation and payment of Pharmacy Claims, and timely notification, and certification to ASES with respect to the process and payment of those Claims.  The Contractor shall submit Pharmacy Services Claims reports in accordance with Section 18.2 of this Contract in a format approved by ASES.

 

	
  

	
16.9.3

	
PBMs’ switching and transaction fees are to be paid by ASES with corresponding validation by the Contractor.

 

	
  

	
16.9.4

	
ASES acknowledges that the Contractor is undertaking the process of validation and payment of those claims on behalf of ASES and the Contractor is not responsible in any manner for the liability and/or risk of pharmacy coverage within the Contractor responsibilities, other than for reasons solely attributable to Contractor, its employees and agents.

 

	
  

	
16.9.5

	
In order to facilitate Claims processing, the Contractor shall send to the PBM, on a daily basis, the Enrollee data described in Section 5.2.9 of this Contract.

 

	
16.10

	
Timely Payment of Claims

	
  

	
16.10.1

	
The Contractor shall comply with the timely processing of claims standards contained  in section 1902(a)(37) of the Social Security Act, Section 5001(f)(2) of the American Recovery and Reinvestment Act of 2009 (ARRA) and in implementing Federal Medicaid regulations at 42 CFR 447.45(d).

 

  

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16.10.2

	
Provider Contracts shall include the following provisions for timely payment of Clean Claims.

 

	
  

	
16.10.2.1

	
A Clean Claim, as defined in 42 CFR 447.45, is a Claim received by the Contractor for adjudication, which can be processed without obtaining additional information from the Provider of the service or from a Third Party, as provided in Section 23.4.5.1 of this Contract.  It includes a Claim with errors originating in the Contractor’s claims system.  It does not include a Claim from a Provider who is under investigation for Fraud or Abuse, or a Claim under review for Medical Necessity.

 

	
  

	
16.10.2.2

	
Provider Contracts shall provide that ninety-five percent (95%) of all Clean Claims must be paid by the Contractor not later than thirty (30) Calendar Days from the date of receipt of the Claim (including Claims billed by paper and electronically), and one hundred percent (100%) of all Clean Claims must be paid by the Contractor not later than fifty (50) Calendar Days from the date of receipt of the Claim.

 

	
  

	
16.10.2.3

	
Any Clean Claim not paid within thirty (30) Calendar Days shall bear interest in favor of Provider on the total unpaid amount of such Claim, according to the prevailing legal interest rate fixed by the Puerto Rico Commissioner of Financial Institutions.  Such interest shall be considered payable on the day following the terms of this Section 16.10, and interest shall be paid together with the Claim.  If the delay in payment to a Provider is the result of the actions or omissions by the Contractor, the Contractor shall be responsible (i) for payment of any interest due to the Provider under this Section and (ii) compliance with the applicable requirements of the PR Prompt Payment Law. If the delay in payment to a Provider is the result of ASES’s failure to make timely and complete Claims Payments to the Contractor when due, ASES (and not the Contractor) shall be responsible to (i) pay any such interest due to the Provider and (ii) compliance with the applicable requirements of the PR Prompt Payment Law.

 

  

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16.10.3

	
An Unclean Claim is any Claim that falls outside the definition of Clean Claim in Section 16.10.2.1 of this Contract.  The Contractor shall include the following provisions in its Provider Contracts for timely resolution of Unclean Claims.

 

	
  

	
16.10.3.1

	
Ninety percent (90%) of Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than thirty (30) Calendar Days from the date of initial receipt of the Claim.  This includes Claims billed on paper or electronically.

 

	
  

	
16.10.3.2

	
Of the remaining ten percent (10%) of total Unclean Claims that may remain outstanding after thirty (30) Calendar Days.

 

	
  

	
16.10.3.2.1

	
Nine percent (9%) of the Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than ninety (90) Calendar Days from the date of initial receipt (including Claims billed on paper and those billed electronically); and

 

	
  

	
16.10.3.2.2

	
One percent (1%) of the Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than one year (12 months) from the date of initial receipt of the Claim (including Claims billed on paper and those billed electronically).

 

	
  

	
16.10.3.2.3

	
The Contractor shall submit an Unclean Claims Report each fifteenth (15th) and (30th) day of each calendar month in a format to be provided by ASES.  The Contractor shall continue to submit an Unclean Claims Report until all such Claims have been resolved or through the Runoff Period, whichever is longer.

 

	
  

	
16.10.4

	
The Contractor shall not establish any administrative procedures, such as administrative audits, authorization number, or other formalities under the control of the Contractor, which could prevent the Provider from submitting a Clean Claim. 

 

  

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16.10.5

	
The foregoing timely payment standards are more stringent than those required in the federal regulations, at 42 CFR 447.45(d).  The Contractor shall include the foregoing standards in each Provider Contract and ASES will submit proof of this alternative payment agreement to CMS.

 

	
  

	
16.10.6

	
The Contractor shall deliver to Providers, within fifteen (15) Calendar Days of award of the Provider Contract (along with the Provider guidelines described in Section 10.2.1 of this Contract), Claims coding and processing guidelines for the applicable Provider type, and the definition of a Clean Claim to be applied.

 

	
  

	
16.10.7

	
The Contractor shall give Providers ninety (90) Calendar Days notice in advance of the effective date of any change in Claims coding and processing deadlines.

 

	
16.11

	
Contractor Denial of Claims and Resolution of Contractual and Claims Disputes

	
  

	
16.11.1

	
Not later than the fifth (5th) Business Day after the receipt of a Provider Claim that the Contractor has deemed not to meet the Clean Claim requirements, the Contractor shall suspend the Claim and request in writing (notification via e-mail, the Contractor’s Web site, or an interim remittance advice satisfies this requirement) all outstanding information such that the Claim can be deemed clean.  Upon receipt of all the requested information from the Provider, the Contractor shall complete processing of the Claim in accordance with the standards outlined in Section 16.10 of this Contract.

 

	
  

	
16.11.2

	
Claims suspended for additional information must be closed (paid or denied) such that compliance with the timely payment rules outlined in Section 16.10 of this Contract is achieved.

 

	
  

	
16.11.3

	
The Contractor must process, and finalize, all appealed Claims to a paid or denied status within thirty (30) Calendar Days of receipt of the Appealed Claim; for Claims for which the Contractor has requested further information, per Section 16.11.1 of this Contract, the Contractor shall pay or deny the Claim within thirty (30) Calendar Days of receipt of the requested information.

 

	
  

	
16.11.4

	
The Contractor shall send Providers written notice (notification via e-mail, surface mail, the Contractor’s Web site, or a remittance advice satisfies this requirement) for each Claim that is denied, including the reason(s) for the denial, the date the Contractor received the Claim, and a reiteration of the outstanding information required from the Provider to adjudicate the Claim.

 

  

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16.11.5

	
In situations in which the Contractor denies a Provider’s Claim for services, and the Provider disputes the denial, as provided in Section 16.11.6 of this Contract, the Contractor shall not Withhold payment pending final resolution of the dispute, but instead shall pay the Claim within thirty (30) Calendar Days of the Contractor’s receipt of the Provider’s written complaint and request for mediation (see Section 16.11.6.2.1 of this Contract).  The Contractor shall seek recoupment of the paid Claim only in the event that the dispute is resolved, at the level of the mediation described in Section 16.11.6.2.1 of this Contract, in the Contractor’s favor.

 

	
  

	
16.11.6

	
Provider Dispute Resolution System

 

	
  

	
16.11.6.1

	
The Contractor shall establish and use a procedure to resolve billing, payment, and other administrative disputes between Providers and the Contractor arising under Provider Contracts including:

 

	
  

	
16.11.6.1.1

	
A mediation system for resolution of Provider disputes of denied Claims; and

 

	
  

	
16.11.6.1.2

	
A Provider complaint resolution process implemented by the Contractor to address, among others, lost or incomplete Claims forms or electronic submissions; Contractor requests for additional explanation as to services or treatment rendered by a Provider; and inappropriate or unapproved Referrals issued by Providers.

 

	
  

	
16.11.6.1.3

	
This dispute resolution system shall exclude Grievances filed by Providers on behalf of Enrollees pursuant to Section 14.3 of this Contract.

 

  

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16.11.6.2

	
Provider Complaints Concerning Denied Claims

 

	
  

	
16.11.6.2.1

	
If there is no agreement between the Contractor and the Provider on a denied Claim, a third party, external to the Contractor and the Provider and chosen by mutual agreement, shall be appointed to adjudicate the denial, upon the Provider’s submission of a written complaint and request for mediation.  The third party shall render his or her decision no more than thirty (30) Calendar Days from the date of the Provider’s request for third-party mediation.  If there is no agreement on the third party’s selection, he or she shall be appointed by ASES, and, subject to the appeal rights described in this Section, the parties will comply with the third party’s decision.  The party adversely affected shall pay for the third party’s service fees.  If both the Provider and the Contractor have caused an error, the third party shall determine the percentage attributable to each party, and payment to the third party shall be in accordance with percentage of responsibility.

 

	
  

	
16.11.6.2.2

	
The party adversely affected by the mediator’s decision may pursue an Administrative Law Hearing.  The parties to the Administrative Law Hearing shall be the Contractor and the Provider.  ASES shall grant a Provider or Contractor request for an Administrative Law Hearing, provided that the Provider or Contractor, as the case may be, submits a written appeal, accompanied by supporting documentation, not more than thirty (30) Calendar Days following the Provider’s or Contractor’s receipt of the mediator’s written decision.  ASES, at its sole expense, shall contract with an independent party to serve as the examining officer in any such Administrative Law Hearing.

 

  

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16.11.6.3

	
Other Disputes Arising Under the Provider Contract

 

	
  

	
16.11.6.3.1

	
For any dispute between the Provider and Contractor arising under the Provider Contract, other than a disputed denial of a Claim, the Contractor shall implement an internal dispute resolution system, which shall include the opportunity for an aggrieved Provider to submit a timely written complaint to the Contractor.  The Contractor shall issue a written decision on the Provider’s complaint within fifteen (15) Calendar Days of receipt of the Provider’s written complaint.  A Contractor written decision that is in any way adverse to the Provider shall include an explanation of the grounds for the decision and a notice of the Provider’s right to and procedures for an Administrative Law Hearing within ASES.

 

	
  

	
16.11.6.3.2

	
If the Provider is not satisfied with the decision on its complaint within the Contractor’s dispute resolution system, the Provider may pursue an Administrative Law Hearing.  The parties to the Administrative Law Hearing shall be the Contractor and the Provider.  ASES shall grant a Provider request for an Administrative Law Hearing, provided that the Provider submits a written appeal, accompanied by supporting documentation, not more than thirty (30) Calendar Days following the Provider’s receipt of the Contractor’s written decision.  ASES, at its sole expense, shall contract with an independent party to serve as the examining officer in any such Administrative Law Hearing.

 

	
  

	
16.11.6.4

	
Judicial Review.  A decision issued as a result of the Administrative Law Hearing provided for in Section 16.11.6.2.2 or 16.11.6.3.2 of this Contract shall be subject to review before the Court of Appeals of the Commonwealth of Puerto Rico.

 

	
  

	
16.11.7

	
[Intentionally left blank].

 

  

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16.11.8

	
ASES Guarantee of Payment

 

	
  

	
16.11.8.1

	
ASES expressly guarantees payment for all Covered Services and Benefits rendered to Enrollees by any Provider pursuant to the terms of this Contract. Subject to Section 16.11.8.10 of this Contract, the Contractor shall use such ASES Claims Payments to compensate Providers for all Covered Services and Benefits, and its compensation systems will not compromise access to services or their quality.

 

	
  

	
16.11.8.2

	
The insolvency, liquidation, bankruptcy or breach of contract by ASES, the Contractor, a PMG or Provider shall not release said party from its corresponding obligation to pay for Covered Services rendered as authorized herein.

 

	
  

	
16.11.8.3

	
ASES’s obligation to guarantee payment to all PMGs, Providers or Subcontractors for services rendered by them in connection with this Contract is subject to compliance with established claim proceedings and requisites set forth in this Contract.

 

	
  

	
16.11.8.4

	
If Providers or Subcontractors claim direct substitute payments due from the Contractor or PMG to ASES in accordance with this Section, then ASES shall deduct any amounts payable to Providers or Subcontractors from amounts due to a PMG as Claims Payments.

 

	
  

	
16.11.8.5

	
ASES agrees to pay direct substitute payments to the PMGs and/or Providers according to the payment schedule agreed in their respective contracts.

 

	
  

	
16.11.8.6

	
ASES shall Immediately notify the Contractor in writing in the event sufficient funds are not available to satisfy ASES’s payment obligations under this Contract when due.

 

	
  

	
16.11.8.7

	
[Intentionally left blank].

 

	
  

	
16.11.8.8

	
[Intentionally left blank].

 

	
  

	
16.11.8.9

	
[Intentionally left blank].

 

	
  

	
16.11.8.10

	
The Contractor shall have no obligation to pay Claims to Providers for Covered Services to the extent that ASES has failed to make timely and complete payments of the Claims Payment as required under Section 22 of this Contract and shall not be subject to any prompt payment law penalties (including the PR Prompt Payment Law) for such non-payment or any interest to Providers.  ASES agrees to guaranty any interest due to the Providers and penalties under any prompt payment laws (including the PR Prompt Payment Law) as a result of such non-payment.

 

  

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16.12

	
Contractor Recovery from Providers

	
  

	
16.12.1

	
When ASES or the Contractor determines after the fact that it has paid a Claim incorrectly, or when ASES or the Contractor, per Section 16.11.5 of this Contract, is entitled to seek recoupment after a mediation concerning a denied Claim has been resolved in the Contractor’s favor, ASES or the Contractor (on behalf of ASES) may request applicable reimbursement from the Provider through written notice, stating the basis for the request.  The notice shall list the Claims and the amounts to be recovered.

 

	
  

	
16.12.2

	
The Provider will have a period of ninety (90) Calendar Days to make the requested payment, to agree to ASES or the Contractor’s retention of said payment (on behalf of ASES), or to dispute the recovery action following the process described in Section 16.11 of this Contract.  To the extent the Provider requests additional time to make the requested payment, the Contractor may agree to a payment plan; however, the Contractor shall not accept any payment plan in excess of one (1) year, unless the Contractor receives advance written authorization from ASES.

 

	
  

	
16.12.3

	
To the extent the Contractor recoups amounts on behalf of ASES, the Contractor shall remit such amounts to ASES within fourteen (14) Business Days.  The Contractor shall not be authorized to reduce any amount, unless the Contractor receives advance written authorization from ASES. For the avoidance of doubt, the Contractor shall not retain any amount of the recouped funds for such administrative service.

 

	
ARTICLE 17

	
INFORMATION MANAGEMENT AND SYSTEMS

 

	
17.1

	
General Provisions

	
  

	
17.1.1

	
The Contractor shall have Information management processes and Information Systems (hereafter referred to as the “Systems”) that enable it to meet MI Salud requirements, ASES and federal reporting requirements, all other Contract requirements, and any other applicable Puerto Rico and federal laws, rules and regulations, including but not limited to the standards and operating rules in Section 1104 of the PPACA and associated regulations, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and associated regulations and 42 CFR 438.242.

 

  

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17.1.1.1

	
The Contractor shall file a statement of certification with the U.S. Department of Health and Human Services (HHS) no later than December 31, 2013 certifying that the Contractor’s Data and Systems are in compliance with the standards and operating rules for EFT, eligibility, claim status and health care payment/remittance advice transactions, in accordance with Section 1104 of the PPACA and associated regulations.

 

	
  

	
17.1.2

	
The Contractor’s Systems shall possess capacity sufficient to handle the workload projected for the start of the program and will be scalable and flexible so they can be adapted as needed, within negotiated timeframes, in response to program or Enrollment changes.

 

	
  

	
17.1.3

	
The Contractor’s Systems shall have the capability of adapting to any future changes necessary as a result of modifications to the service delivery system and its requirements, including data collection, records and reporting based upon unique Enrollee and Provider identifiers to track services and expenditures across funding streams.  The Systems shall be scalable and flexible so they can be adapted as needed, within negotiated timeframes, in response to changes in Contract requirements, increases in enrollment estimates, etc.  The System architecture shall facilitate rapid application of the more common changes that can occur in the Contractor’s operation, including but not limited to:

 

	
  

	
17.1.3.1

	
Changes in pricing methodology;

 

	
  

	
17.1.3.2

	
Rate changes;

 

	
  

	
17.1.3.3

	
Changes in utilization management criteria;

 

	
  

	
17.1.3.4

	
Additions and deletions of Provider types; and

 

	
  

	
17.1.3.5

	
Additions and deletions of procedure, diagnosis and other service codes.

 

	
  

	
17.1.4

	
The Contractor shall provide secure, online access to select system functionality to at least three (3) ASES personnel to facilitate resolution of Enrollee inquiries and to research Enrollee-related issues as needed.

 

  

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17.1.5

	
The Contractor shall participate in Systems Work Groups organized by ASES.  The Systems Work Groups will meet on a designated schedule as agreed to by ASES and the MI Salud Plans and the MBHO.

 

	
  

	
17.1.6

	
The Contractor shall provide a continuously available electronic mail communication link (E-mail system) with ASES.  This system shall be:

 

	
  

	
17.1.6.1

	
Available from the workstations of the designated Contractor contacts; and

 

	
  

	
17.1.6.2

	
Capable of attaching and sending documents created using software products other than Contractor systems, including the Commonwealth’s currently installed version of Microsoft Office and any subsequent upgrades as adopted.

 

	
17.2

	
Global System Architecture and Design Requirements

	
  

	
17.2.1

	
The Contractor shall comply with federal and Puerto Rico policies, standards and regulations in the design, development and/or modification of the Systems it will employ to meet the aforementioned requirements and in the management of Information contained in those Systems.  Additionally, the Contractor shall adhere to ASES and Puerto Rico-specific system and data architecture standards and/or guidelines.

 

	
  

	
17.2.2

	
The Contractor’s Systems shall:

 

	
  

	
17.2.2.1

	
Be (i) SQL and ODBC compliant and/or have the connectivity required to for proper system communication with ASES’s system, and (ii) capable of storing in relational databases all Enrollee-related information as required by ASES;

 

	
  

	
17.2.2.2

	
Adhere to Internet Engineering Task Force/Internet Engineering Standards Group standards for data communications, including TCP and IP for data transport;

 

	
  

	
17.2.2.3

	
Conform to HIPAA standards for data and document management and in total compliance with HIPAA Security Rule;

 

	
  

	
17.2.2.4

	
Contain controls to maintain information integrity.  These controls shall be in place at all appropriate points of processing.  The controls shall be tested in periodic and spot audits following a methodology to be developed jointly by and mutually agreed upon by the Contractor and ASES; and

 

  

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17.2.2.5

	
Partner with ASES in the development of transaction/event code set, data exchange and reporting standards not specific to HIPAA or other federal effort and will conform to such standards as stipulated in the plan to implement the standards.

 

	
  

	
17.2.3

	
Where Web services are used in the engineering of applications, the Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards such as XML, UDDI, WSDL and SOAP so as to facilitate integration of these Systems with ASES and other State systems that adhere to a service-oriented architecture.

 

	
  

	
17.2.4

	
Audit trails shall be incorporated into all Systems to allow information on source data files and documents to be traced through the processing stages to the point where the Information is finally recorded.  The audit trails shall:

 

	
  

	
17.2.4.1

	
Contain a unique log-on or terminal ID, the date, and time of any create/modify/delete action and, if applicable, the ID of the system job that effected the action;

 

	
  

	
17.2.4.2

	
Have the date and identification “stamp” displayed on any on-line inquiry;

 

	
  

	
17.2.4.3

	
Have the ability to trace data from the final place of recording back to its source data file and/or document shall also exist;

 

	
  

	
17.2.4.4

	
Be supported by listings, transaction Reports, update Reports, transaction logs, or error logs;

 

	
  

	
17.2.4.5

	
Facilitate auditing of individual Claim records as well as batch audits; and

 

	
  

	
17.2.4.6

	
Be maintained for seven (7) years in either live and/or archival systems.  The duration of the retention period may be extended at the discretion of and as indicated to the Contractor by ASES as needed for ongoing audits or other purposes, subject to and in accordance with Section 33 of this Contract.

 

	
  

	
17.2.5

	
The Contractor shall house indexed images of documents used by Enrollees and Providers to transact with the Contractor in the appropriate database(s) and document management systems so as to maintain the logical relationships between certain documents and certain data.  The Contractor shall follow all applicable requirements for the management of data in the management of documents.

 

  

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17.2.6

	
The Contractor shall institute processes to insure the validity and completeness of the data it submits to ASES.  At its discretion, ASES will conduct general data validity and completeness audits using industry-accepted statistical sampling methods.  Data elements that will be audited include but are not limited to: Enrollee ID, date of service, Provider ID, category and sub category (if applicable) of service, diagnosis codes, procedure codes, revenue codes, date of Claim processing, and date of Claim payment.

 

	
  

	
17.2.7

	
Where a System is herein required to, or otherwise supports, the applicable batch or on-line transaction type, the system shall comply with HIPAA-standard transaction code sets.

 

	
  

	
17.2.8

	
The Contractor shall assure that all Contractor staff is trained in all HIPAA requirements, as applicable.

 

	
  

	
17.2.9

	
The layout and other applicable characteristics of the pages of Contractor Web sites shall be compliant with Federal “section 508 standards” and Web Content Accessibility Guidelines developed and published by the Web Accessibility Initiative.

 

	
17.3

	
System and Data Integration Requirements

	
  

	
17.3.1

	
The Contractor’s applications shall be able to interface with ASES’s systems for purposes of data exchange and will conform to standards and specifications set by ASES.  These standards and specifications are detailed in Attachment 9.

 

	
  

	
17.3.2

	
The Contractor’s System(s) shall be able to transmit and receive transaction data to and from ASES’s systems as required for the appropriate processing of Claims.

 

	
  

	
17.3.3

	
Each month the Contractor shall generate Encounter Data files from its claims management system(s) and/or other sources.  The files will contain settled Claims and Claim adjustments and Encounter Data from Providers for the most recent month for which all such transactions were completed.  The Contractor shall provide these files electronically to ASES and/or its Agent in adherence to the procedure, content standards and format indicated in Attachment 9.  The Contractor shall make changes or corrections to any systems, processes or data transmission formats as needed to comply with Encounter Data quality standards as originally defined or subsequently amended.

 

  

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17.3.4

	
The Contractor’s System(s) shall be capable of generating files in the prescribed formats for upload into ASES Systems used specifically for program integrity and compliance purposes.

 

	
  

	
17.3.5

	
The Contractor’s System(s) shall possess mailing address standardization functionality in accordance with US Postal Service conventions.

 

	
17.4

	
System Access Management and Information Accessibility Requirements

	
  

	
17.4.1

	
The Contractor’s System shall employ an access management function that restricts access to varying hierarchical levels of system functionality and Information. The access management function shall:

 

	
  

	
17.4.1.1

	
Restrict access to Information on a “need to know" basis, e.g. users permitted inquiry privileges only will not be permitted to modify information;

 

	
  

	
17.4.1.2

	
Restrict access to specific system functions and information based on an individual user profile, including inquiry only capabilities; global access to all functions will be restricted to specified staff jointly agreed to by ASES and the Contractor; and

 

	
  

	
17.4.1.3

	
Restrict attempts to access system functions to three (3), with a system function that automatically prevents further access attempts and records these occurrences.

 

	
  

	
17.4.2

	
The Contractor shall make System Information available to duly Authorized Representatives of ASES and other Puerto Rico and federal agencies to evaluate, through inspections or other means, the quality, appropriateness and timeliness of services performed.

 

	
  

	
17.4.3

	
The Contractor shall have procedures to provide for prompt transfer of System Information upon request to other Network or Out-of-Network Providers for the medical management of the Enrollee in adherence to HIPAA and other applicable requirements.

 

	
  

	
17.4.4

	
All Information, whether data or documents, and reports that contain or make references to said Information, involving or arising out of this Contract are owned by ASES except as provided in Section 28.1.2 of this Contract.  The Contractor is expressly prohibited from sharing or publishing ASES Data without the prior written consent of ASES.  In the event of a dispute regarding the sharing or publishing of ASES Data, ASES’s decision on the matter shall be final and not subject to appeal.

 

  

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17.5

	
Systems Availability and Performance Requirements

	
  

	
17.5.1

	
The Contractor shall ensure that Enrollee and Provider portal and/or phone-based functions and information, such as confirmation of Contractor Enrollment (CCE) and electronic claims management (ECM), Enrollee services and Provider services, are available to the applicable System users twenty-four (24) hours a day, seven (7) Days a week, except during periods of scheduled System Unavailability agreed upon by ASES and the Contractor.  Unavailability caused by events outside of a Contractor’s Span of Control is outside of the scope of this requirement.

 

	
  

	
17.5.2

	
The Contractor shall ensure that at a minimum all other System functions and Information are available to the applicable system users between the hours of 7:00 a.m. and 7:00 p.m. Monday through Friday.

 

	
  

	
17.5.3

	
The Contractor shall develop an automated method of monitoring the CCE and ECM functions on at least a thirty (30) minute basis twenty-four (24) hours a day, seven (7) days per week.

 

	
  

	
17.5.4

	
Upon discovery of any problem within its Span of Control that may jeopardize System availability and performance as defined in this Section of the Contract, the Contractor shall notify the applicable ASES staff in person, via phone, electronic mail and/or surface mail.

 

	
  

	
17.5.5

	
The Contractor shall deliver notification as soon as possible but no later than 7:00 pm if the problem occurs during the business day and no later than 9:00 am the following business day if the problem occurs after 7:00 pm.

 

	
  

	
17.5.6

	
Where the operational problem results in delays in report distribution or problems in on-line access during the business day, the Contractor shall notify the applicable ASES staff within fifteen (15) minutes of discovery of the problem, in order for the applicable work activities to be rescheduled or be handled based on System Unavailability protocols.

 

	
  

	
17.5.7

	
The Contractor shall provide to appropriate ASES staff information on System Unavailability events, as well as status updates on problem resolution.  These up-dates shall be provided on an hourly basis and made available via electronic mail, telephone and, if applicable, the Contractor’s Web site.

 

  

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17.5.8

	
The following rules govern Unscheduled System Unavailability for CCE functions, ECM functions, and all other functions.

 

	
  

	
17.5.8.1

	
CCE Functions

 

	
  

	
17.5.8.1.1

	
Unscheduled System Unavailability of CCE functions caused by the failure of systems and telecommunications technologies within the Contractor’s Span of Control will be resolved, and the restoration of services implemented, within thirty (30) minutes of the official declaration of System Unavailability.

 

	
  

	
17.5.8.1.2

	
From the Effective Date of the Contract through December 31, 2011, Unscheduled System Unavailability for CCE functions shall be remedied within sixty (60) minutes of the official declaration of System Unavailability, if unavailability occurs during normal business hours; or within sixty (60) minutes of the start of the next Business Day, if unavailability occurs outside business hours.

 

	
  

	
17.5.8.1.3

	
Throughout the Contract Term, the Contractor shall have in place a method to validate eligibility manually twenty-four (24) hours per day, seven (7) days a week as a contingency to any Unscheduled Systems Unavailability for CCE functions.

 

	
  

	
17.5.8.2

	
ECM Functions.  Unscheduled System Unavailability of ECM functions caused by the failure of systems and technologies within the Contractor’s Span of Control will be resolved, and the restoration of services implemented, within sixty (60) minutes of the official declaration of System Unavailability, if unavailability occurs during normal business hours; or within sixty (60) minutes of the start of the next Business Day, if unavailability occurs outside business hours.

 

  

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17.5.8.3

	
All Other Contractor System Functions.  Unscheduled System Unavailability of all other Contractor System functions caused by systems and telecommunications technologies within the Contractor’s Span of Control shall be resolved, and the restoration of services implemented,

 

	
  

	
17.5.8.3.1

	
Within four (4) hours of the official declaration of Unscheduled System Unavailability, when unavailability occurs during business hours, and

 

	
  

	
17.5.8.3.2

	
Within two (2) hours of the start of the next Business Day, when unavailability occurs during non-business hours.

 

	
  

	
17.5.9

	
[Intentionally left blank].

 

	
  

	
17.5.10

	
Cumulative System Unavailability caused by systems and telecommunications technologies within the Contractor’s Span of Control shall not exceed one (1) hour during any continuous five (5) day period for functions that affect MI Salud Enrollees and services.  For functions that do not affect MI Salud Enrollees, Cumulative System Unavailability caused by systems and telecommunications technologies within the Contractor’s Span of Control shall not exceed four (4) hours during any continuous five (5) Business Day period.

 

	
  

	
17.5.11

	
The Contractor shall not be responsible for the availability and performance of systems and telecommunications technologies outside of the Contractor’s Span of Control.

 

	
  

	
17.5.12

	
Full written documentation that includes a Corrective Action Plan, describing how the problem will be prevented from occurring again, shall be delivered within five (5) Business Days of the problem’s occurrence.

 

	
  

	
17.5.13

	
Regardless of the architecture of its Systems, the Contractor shall develop and be continually ready to invoke a Business Continuity and Disaster Recovery (BC-DR) plan that at a minimum addresses the following scenarios: (a) the central computer installation and resident software are destroyed or damaged, (b) System interruption or failure resulting from network, operating hardware, software, or operational errors that compromises the integrity of transactions that are active in a live system at the time of the outage, (c) System interruption or failure resulting from network, operating hardware, software or operational errors that compromises the integrity of data maintained in a live or archival system, (d) System interruption or failure resulting from network, operating hardware, software or operational errors that does not compromise the integrity of transactions or data maintained in a live or archival system but does prevent access to the System, i.e. causes unscheduled System Unavailability.

 

  

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17.5.14

	
The Contractor shall on an annual basis test its BC-DR plan through simulated disasters and lower level failures in order to demonstrate to ASES that it can restore System functions per the standards outlined elsewhere in this Section 17.5 of the Contract.  The results of these tests shall be reported to ASES within thirty (30) Calendar Days of completion of said tests.

 

	
  

	
17.5.15

	
In the event that the Contractor fails to demonstrate in the tests of its BC-DR plan that it can restore system functions per the standards outlined in this Contract, the Contractor shall be required to submit to ASES a Corrective Action Plan that describes how the failure will be resolved.  The Corrective Action Plan will be delivered within five (5) Business Days of the conclusion of the test.

 

	
  

	
17.5.16

	
The Contractor shall submit a monthly Systems Availability and Performance Report to ASES.

 

	
17.6

	
System Testing and Change Management Requirements

	
  

	
17.6.1

	
The Contractor shall absorb the cost of routine maintenance, inclusive of defect correction, System changes required to effect changes in Puerto Rico and federal statute and regulations, and production control activities, of all Systems within its Span of control.

 

	
  

	
17.6.2

	
The Contractor shall respond to ASES reports of System problems not resulting in System Unavailability according to the following timeframes:

 

	
  

	
17.6.2.1

	
Within five (5) Calendar Days of receipt the Contractor shall respond in writing to notices of system problems.

 

	
  

	
17.6.2.2

	
Within fifteen (15) Calendar Days, the correction will be made or a Requirements Analysis and Specifications document will be due.

 

	
  

	
17.6.3

	
The Contractor shall correct the deficiency by an effective date to be determined by ASES.

 

  

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17.6.4

	
Contractor systems will have a system-inherent mechanism for recording any change to a software module or subsystem.

 

	
  

	
17.6.5

	
The Contractor shall put in place procedures and measures for safeguarding ASES from unauthorized modifications to Contractor Systems.

 

	
  

	
17.6.6

	
Unless otherwise agreed to in advance by ASES, scheduled System Unavailability to perform System maintenance, repair and/or upgrade activities to Contractor’s CCE systems shall take place between 11 p.m. on a Saturday and 6 a.m. on the following Sunday.

 

	
  

	
17.6.7

	
The Contractor shall work with ASES pertaining to any testing initiative as required by ASES.

 

	
  

	
17.6.8

	
The Contractor shall provide sufficient system access to allow verification of system functionality, availability and performance by ASES during the times required by ASES prior to the Implementation Date and as subsequently required during the term of the Contract.

 

	
17.7

	
System Security and Information Confidentiality and Privacy Requirement

 

	
  

	

17.7.1

	
The Contractor shall provide for the physical safeguarding of its data processing facilities and the systems and information housed therein. The Contractor shall provide ASES with access to data facilities upon ASES’s request.  The physical security provisions shall be in effect for the life of this Contract.

 

	
  

	

17.7.2

	
The Contractor shall restrict perimeter access to equipment sites, processing areas, and storage areas through a card key or other comparable system, as well as provide accountability control to record access attempts, including attempts of unauthorized access.

 

	
  

	

17.7.3

	
The Contractor shall include physical security features designed to safeguard processor site(s) through required provision of fire retardant capabilities, as well as smoke and electrical alarms, monitored by security personnel.

 

	
  

	

17.7.4

	
The Contractor shall ensure that the operation of all of its Systems is performed in accordance with Puerto Rico and federal regulations and guidelines related to security and confidentiality of the protected information managed by Contractor and strictly comply with HIPAA Privacy and Security Rule, as amended, and with Breach Notification Rules under HITECH Act.

 

  

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17.7.5

	
The Contractor will put in place procedures, measures and technical security to prohibit unauthorized access to the regions of the data communications network inside of a Contractor’s Span of Control.

 

	
  

	
17.7.6

	
The Contractor shall ensure compliance with:

 

	
  

	
17.7.6.1

	
42 CFR Part 431 Subpart F (confidentiality of information concerning applicants and Enrollees of public medical assistance programs);

 

	
  

	
17.7.6.2

	
42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and

 

	
  

	
17.7.6.3

	
Special confidentiality provisions in Puerto Rico or federal law related to people with HIV/AIDS and mental illness.

 

	
  

	
17.7.6.4

	
Section 105 of Title I of GINA, and the new privacy protections for genetic information, 78 Federal Register 5658-5659.

 

	
  

	
17.7.7

	
The Contractor shall provide its Enrollees with a privacy notice as required by HIPAA.  The Contractor shall provide ASES with a copy of its Privacy Notice for its filing.

 

	
17.8

	
Information Management Process and Information Systems Documentation Requirements

	
  

	
17.8.1

	
The Contractor shall ensure that written System Process and Procedure Manuals document and describe all manual and automated system procedures for its information management processes and information systems.

 

	
  

	
17.8.2

	
The System User Manuals shall contain information about, and instructions for, using applicable System functions and accessing applicable system data.

 

	
  

	
17.8.3

	
When a System change that would alter the conditions and services agreed upon in this Contract is subject to ASES sign off, the Contractor shall draft revisions to the appropriate manuals prior to ASES sign off of the change.

 

	
  

	
17.8.4

	
Updates to the electronic version of these manuals shall occur in real time; updates to the printed version of these manuals shall occur within ten (10) Business Days of the update taking effect.

 

	
  

	
17.8.5

	
ASES reserves the right to Audit the Contractor’s Policies and Procedures Manuals/ Protocols compliance related to their Information Management Systems upon five (5) days prior notice to Triple S.

 

  

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17.9

	
Reporting Functionality Requirements

	
  

	
17.9.1

	
The Contractor’s Systems shall have the capability of producing a wide variety of reports that support program management, policymaking, quality improvement, program evaluation, analysis of fund sources and uses, funding decisions and assessment of compliance with federal and Puerto Rico requirements.

 

	
  

	
17.9.2

	
The Contractor shall support a mechanism for obtaining service and expenditure reports by funding source, Provider, Provider Type or other characteristic; and Enrollee, Enrollee Group/Category or other characteristic.

 

	
  

	
17.9.3

	
The Contractor shall extend access to this mechanism to select ASES personnel in a secure manner to access data, including program and fiscal information regarding Enrollees served, services rendered, etc. and the ability for said personnel to develop and/or retrieve reports.  This requirement could be met by the provision of access to a decision support system/data warehouse.  The Contractor shall provide training in and documentation on the use of this mechanism.

 

	
17.10

	
Disaster Recovery, Disaster Declaration, Data Content Delivery to ASES

	
  

	
17.10.1

	
Contractor shall maintain a disaster recovery and business recovery plan in effect throughout the term of the Contract.  The disaster recovery plan shall be subject to ASES review upon reasonable notice to Contractor.  Contractor shall maintain reasonable safeguards against the destruction, loss, intrusion and unauthorized alteration of printed materials and data in its possession.  At a minimum, Contractor shall perform (i) incremental daily back-ups, (ii) weekly full backups, and (iii) such additional back-ups as Contractor may determine to be necessary to maintain such reasonable safeguards.

 

	
  

	
17.10.2

	
Both Parties recognize that a failure by the Contractor’s Network may adversely impact ASES business and operations, as the responsible party for MI Salud Health Service Program.  Therefore, in the event that the Contractor’s Network designed to deliver the Administrative Services herein contemplated becomes unable, or is anticipated to become unable, to deliver such Administration Services on a timely basis, Contractor shall Immediately notify ASES by telephone, and shall work closely with ASES to fix the problem.  In the event that Contractor fails to provide such required notice to ASES and such delay in the notification has a material and adverse effect upon ASES and/or MI Salud Enrollees, ASES may terminate this Contract for cause as provided in Article 35 of this Contract.

 

  

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17.10.3

	
Within five (5) Calendar Days upon ASES request, Contractor will deliver a copy of the then current ASES’s Data Content to ASES in a mutually acceptable form and format which is useable and readable and understandable by ASES.

 

	
17.11

	
Health Information Organization and Health Information Exchange (HIE) Requirements

	
  

	
17.11.1

	
The Contractor shall initiate the active participation in any Health Information Organization that offers Health Information Exchange services, in order to integrate the Enrollees’ Personal Health Information, facilitate access to and retrieval of their clinical data to provide safer and more timely, efficient, effective, and equitable patient-centered care. The HIO participation is also required to support the analysis of the health of the population.  At the time  ASES may require, the Contractor shall be active in a HIO and cooperate with this effort.

 

	
  

	
17.11.2

	
ASES shall retain the right to request from Contractor the active participation in the Puerto Rico Health Information Exchange Corporation (PRHIEC), the Puerto Rico HIO State Designated Entity, in order to achieve the effective alignment of activities across Medicaid and state public health programs, to avoid duplicate efforts and to ensure integration and support of a unified approach to information exchange for the MI Salud Enrollees Program.

 

	
  

	
17.11.3

	
The Contractor shall verify that the HIO complies with all IT standards and requirements for interoperability and security capabilities dictated by ONCHIT, as other federal and Puerto Rico regulations.

 

	
  

	
17.11.4

	
The Contractor shall work with Network Providers and staff to encourage an active participation in an HIO, as specified in the Strategic Plan found in Attachment 22.

 

	
ARTICLE 18

	
REPORTING

 

	
18.1

	
General Requirements

	
  

	
18.1.1

	
The Contractor shall comply with all the reporting requirements established by ASES in this Article 18. ASES has provided the Contractor with the appropriate reporting formats, data elements, instructions, and/or submission timetables in this Article 18. The Parties may upon mutual agreement, change the content, format or frequency of such reports.

 

  

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18.1.2

	
ASES may, at its discretion, require the Contractor to submit additional reports not otherwise included in Section 18.2 of this Contract, both ad hoc and recurring (collectively, the “Additional Reports”). If ASES requests any revisions or corrections to the reports already submitted, the Contractor shall make the changes and re-submit the reports, according to the time period and format specified by ASES in Section 18.1.4 below.

 

	
  

	
18.1.3

	
All reports containing information about a Provider must include the Provider’s NPI, if applicable.

 

	
  

	
18.1.4

	
The Contractor shall submit all reports to ASES, unless indicated otherwise in this Contract, according to the schedule below:

 

	
DELIVERABLES

	  	
DUE DATE

	
Weekly Reports

	  	
Friday of the following week

	
Each fifteenth (15th) and (30th) day of each calendar month Reports

	  	
The fifteenth (15th) and (30th) day of each calendar month

	
Monthly Reports

	  	
5th Calendar Day of the following month

	
Quarterly Reports

	  	
30th Calendar Day of the following month

	
Annual Reports

	  	
Ninety (90) Calendar Days after the end of the calendar year

	
Additional Reports

	  	
Within ten (10) Business Days of the date of the request (or such shorter period if circumstances so require subject to agreement by the Parties)

 

	
  

	
18.1.5

	
The Contractor shall submit all reports to ASES in the manner and format prescribed by ASES.  On or before September 30, 2013 ASES will submit to the Contractor the proposed templates for the submission of reports under this Contract.  Review and comments to the proposed templates will be completed in forty five (45) days maximum. The Contractor will have forty five (45) days from the end of the review and comments period to make any programming changes to its information system to comply with the reporting requirements under this Contract.  The reporting requirements will be effective on the earlier of the following dates: (i) at the end of the submission, review and programming period described above; or (ii) January 1, 2014,

 

	
  

	
18.1.6

	
The Contractor shall transmit to and receive from ASES all transactions and code sets in the appropriate standard formats as specified under HIPAA and as directed by ASES, so long as ASES’s direction does not conflict with federal law.

 

  

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18.1.7

	
At all times, the Contractor shall have the following Data available and ready to be delivered to ASES within twenty-four (24) hours of receipt of the request for new contracted providers and within five (5) days of the receipt of the request for any other provider, in addition to the provider Master File requirements stated in Attachment 5:

 

	
  

	
18.1.7.1

	
Physicians:

 

	
  

	
18.1.7.1.1

	
Front Cover Sheet (Valid Template de MI Salud reference)

 

	
  

	
18.1.7.1.2

	
Validation of provider Signature in the agreement

 

	
  

	
18.1.7.1.3

	
Reforma Rider Model and signature

 

	
  

	
18.1.7.1.4

	
Type of Specialty

 

	
  

	
18.1.7.1.5

	
Fee-Schedule (According to locator included in Attachment 23)

 

	
  

	
18.1.7.2

	
Other facilities:

 

	
  

	
18.1.7.2.1

	
Front Cover Sheet (Valid Template de MI Salud reference)

 

	
  

	
18.1.7.2.2

	
Validation of provider Signature in the agreement

 

	
  

	
18.1.7.2.3

	
Type of Specialty

 

	
  

	
18.1.7.2.4

	
Fee-Schedule (According to locator included in Attachment 23)

 

	
  

	
18.1.7.3

	
Allied professionals:

 

	
  

	
18.1.7.3.1

	
Front Cover Sheet (Valid Template of MI Salud reference)

 

	
  

	
18.1.7.3.2

	
Validation of provider Signature in the agreement

 

	
  

	
18.1.7.3.3

	
Type of Specialty

 

	
  

	
18.1.7.3.4

	
Fee-Schedule (According to locator included in Attachment 23)

 

  

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18.1.8

	
Attachment 24 will contain reporting templates and instructions that the Contractor shall use to submit for the following reports. ASES will periodically add reports to this list and will update the Contractor as necessary.

 

	
  

	
18.1.9

	
All quantitative reports shall include a summary table that presents Data over time including monthly, quarterly and/or year-to-date summaries as directed by ASES.

 

	
  

	
18.1.10

	
Each report must include an analysis, which shall include, at a minimum: (i) identification of any changes compared to previous reporting periods as well as trending over time; (ii) an explanation of said changes (positive or negative); (iii) an action plan or performance improvement activities addressing any negative changes; and (iv) any other additional information pertinent to the reporting period. ASES may assess liquidated damages for failure to address any of these requirements.

 

	
  

	
18.1.11

	
If a report is rejected for any reason, the Contractor shall resubmit the report within ten (10) Business Days from notification of the rejection or as directed by ASES.

 

	
  

	
18.1.12

	
The Contractor shall submit all reports electronically to ASES unless directed otherwise in writing by ASES.

 

	
18.2

	
Specific Requirements

The following is an overview of the Contract reporting requirements.  This list constitutes all reports required for the Contractor (collectively, the “Reports”).  ASES has the discretion to add Additional Reports pursuant to Section 18.1.2 of this Contract as deemed appropriate.

	
CONTRACT

ARTICLE

	
FREQUENCY

	
GENERAL DESCRIPTION

OF REQUIREMENTS

	
Contractor

Responsibilities –

Enrollment (Article 5)

	
Daily

 

Within One Business Day of change

 

	
Report on new Enrollments

 

Enrollment Database: notify ASES when Database is updated to reflect a change in the place of residence of an Enrollee

 

	 	   Quarterly	
Member Enrollment Materials Report

 

	 	   Bi-Annually	
Report on Contractor’s utilization of the Administrative Fee to perform the different administrative services.

 

  

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CONTRACT

ARTICLE

	    FREQUENCY	
GENERAL DESCRIPTION

OF REQUIREMENTS

	
Covered Services 

(Article 7)

 

	
Quarterly

 

Quarterly

 

Quarterly

 

Quarterly

 

 

Quarterly

 

 

Quarterly

	
Report  on EPSDT screening

 

Executive Director’s Report

 

Executive Director’s Pharmacy Report

 

Report on the case management services received by Enrollees with specific chronic conditions and associated outcomes

 

Report on number of Enrollees  diagnosed with predicate conditions for disease management services

 

Report on the Maternal and Pre-Natal Wellness Plan

	
Provider Network

(Article 9)

	
Monthly

	
Report on Credentialing and re credentialing status of Providers

	
Provider Contracting

(Article 10)

	
Quarterly

	
Reconciliation report of advance payments made to State Health Facilities

	 	
Quarterly

	
Report on Physician Incentive Plan

 

	
Utilization Management

(Article 11)Quality

Improvement (Article

12)

	
Monthly

 

Quarterly

	
Health Care Data Reports

 

Reports on:

 

Network and Out-of Network Providers

 

Ratio of Enrollees to PCPs

 

Utilization of Diabetes

 

  

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CONTRACT

ARTICLE

	    FREQUENCY	
GENERAL DESCRIPTION

OF REQUIREMENTS

	 	 	
Disease Management

 

Utilization of Asthma Disease Management

 

Utilization of Hypertension Disease Management

 

EPSDT Utilization

 

Call Center Report

 

MI SaludPreventive Services Utilization

 

Pharmacy Services Utilization

 

Dental Services Utilization

 

ER Utilization by Region and by PMG

 

Prenatal Care Utilization

 

Covered Population by Municipality, Group, Age, and Gender

	
Quality Improvement

(Article 12)

	
Quarterly

	
Various HEDIS medical care and Access measures listed in Section 12.5.3 of this Contract; Preventive Clinical Programs; Emergency Room Use Indicators

	 	 	 
	 	    Annually 	
Report on HEDIS Measures in the areas of Prevention and Screening, Respiratory Conditions, Cardiovascular Conditions, and Access / Availability of Care

	
Fraud, Waste and Abuse

(Article 13)

	
Quarterly

 

 

	
Employee and Contractor Suspension/Disbarment Report

 

Provider Suspensions and Terminations Report

 

  

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CONTRACT

ARTICLE

	     FREQUENCY	
GENERAL DESCRIPTION

OF REQUIREMENTS

	 	
 

 

 

Within one

Business Day of obtaining knowledge

	
 

Fraud, Waste and Abuse Report

 

Disclosure of persons debarred, suspended, or excluded from participation in the Medicaid, Medicare or CHIP Programs

	
Grievance System

(Article 14)

	
Quarterly

	
Grievance and Appeals Report

	
Provider Payment

Management (Article 16)

	
Each fifteenth (15th) and (30th) day

of each calendar month

	    Claims Payment Report
	 	 	 
	 	
Each fifteenth (15th) and (30th) day of each calendar month

	
Report listing all paid and denied Claims

	 	 	 
	 	
Monthly

	
Encounter Data

	 	 	 
	 	
Quarterly

	
Findings and corrective measures taken with respect to encounter registration and reporting

	 	 	 
	 	
Each fifteenth (15th) and (30th) day of each calendar month

	
Pharmacy Claims report

	 	 	 
	 	
Each fifteenth (15th) and (30th) day of each calendar month

	
Unclean Claims Report

	
Information Systems

(Article 17)

	
Monthly

	
Systems Availability and Performance Report

 

 

  

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CONTRACT

ARTICLE

	     FREQUENCY	
GENERAL DESCRIPTION

OF REQUIREMENTS

	 	
Quarterly

 

Quarterly

	
Website Report

 

Privacy and Security Incident Report

	
Payment for Services

(Article 22)

	
Quarterly

 

Monthly

 

Monthly

 

Quarterly

	
Actuarial Report

 

IBNR report

 

Administrative Fee Disbursement Report

 

PMG IBNR report

	
Financial Management

(Article 23)

	
Quarterly

 

 

Quarterly

 

 

Monthly

	
Contractor’s findings regarding routine audits of Providers to evaluate cost-avoidance performance

 

Contractor’s unaudited quarterly financial statement

 

 

Report listing Enrollees who have new health insurance coverage, casualty insurance coverage, or a change in health or casualty insurance coverage

	 	 	 
	 	    Monthly	
Report on Provider stop loss limits

	 	 	 
	 	    Annually	
Audited financial statement

	 	 	 
	 	
Annually

	
Report to the Puerto Rico Insurance Commissioner’s Office

	 	 	 
	 	
Annually

	
Corporate annual report

	 	 	 
	 	
Annually

	
Report on Controls Placed in Operation and Tests of Operating Effectiveness

	 	 	 
	 	
Annually

	
Disclosure of Information on Annual Business Transactions

 

  

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CONTRACT

ARTICLE

	     FREQUENCY	
GENERAL DESCRIPTION

OF REQUIREMENTS

	
Termination of Contract

(Article 35)

	
Upon reasonable request during the Transition Period

 

	
Any Transition Report (not otherwise listed above)

	
Transition of Contract

(Article 36)

	
Once, on the Termination Date

	
Final Report

	
18.3

	
Summarized Statistical Data

	
  

	
18.3.1

	
The Contractor shall produce and deliver to ASES, a summary record of Covered Services provided to Beneficiaries on a monthly basis. The Records will classify Covered Services provided, including but not limited to:

 

	
  

	
18.3.1.1

	
Region

 

	
  

	
18.3.1.2

	
Age of Beneficiary

 

	
  

	
18.3.1.3

	
Sex of Beneficiary

 

	
  

	
18.3.1.4

	
Federal/State Medicaid

 

	
  

	
18.3.1.5

	
Coverage Code

 

	
  

	
18.3.1.6

	
Diagnosis

 

	
  

	
18.3.1.7

	
DRG’s, if applicable

 

	
  

	
18.3.1.8

	
Procedure

 

	
  

	
18.3.1.9

	
Type of Service

 

	
  

	
18.3.1.10

	
Place of Service

 

	
  

	
18.3.1.11

	
Length of Stay

 

	
  

	
18.3.1.12

	
NDC Name

 

	
  

	
18.3.1.13

	
Cost

 

	
  

	
18.3.1.14

	
Number of Beneficiaries

 

  

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18.3.1.15

	
Other

 

	
  

	
18.3.2

	
During the Contract Term, ASES will provide instructions as to the summary record specifics.

 

	
  

	
18.3.3

	
The Records produced must include all Data on Covered Services given by the Provider Network including those paid under a capitation arrangement.

 

	
18.4

	
At any time after the Effective Date of this Contract, ASES may redefine the mechanisms for transmission of Data between ASES and the Contractor. The Contractor commits to applying the required changes in their systems and operational processes to support these modifications.

	
ARTICLE 19

	
ENFORCEMENT INTERMEDIATE SANCTIONS

 

	
19.1

	
General Provisions

	
  

	
19.1.1

	
In the event the Contractor is in default as to any applicable term, condition, or requirement of this Contract, and in accordance with any applicable provision of 42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any time on or after one hundred twenty (120) Calendar Days following the Effective Date, the Contractor agrees that, in addition to the terms of Section 35.1.1 of this Contract, ASES may impose intermediate sanctions against the Contractor for any such default in accordance with this Article 19; provided, however, that ASES may not impose intermediate sanctions with respect to any specific event of default of Contractor for which liquidated damages are sought to be imposed or are imposed against the Contractor in accordance with Article 20; provided, however, that the assessment of intermediate sanctions under this Contract shall not limit the authority of ASES to impose any other fines, civil money penalties, sanctions or other remedies pursuant to the laws or regulations of the Commonwealth of Puerto Rico or the United States of America.

 

	
  

	
19.1.2

	
Notwithstanding any intermediate sanctions imposed upon the Contractor under this Article 19, other than Contract termination, the Contractor shall continue to provide Administrative Services and make available through its Network Providers all Covered Services and other Benefits under this Contract.

 

	
  

	
19.1.3

	
Except where a particular provision of this Contract or any law or regulation of Puerto Rico or the United States expressly provides for the imposition of civil monetary penalties on the basis of individual Enrollees, no intermediate sanction under this Article 19 shall be determined on such basis.

 

  

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19.2

	
ASES may impose the following intermediate sanctions:

 

	
  

	
19.2.1

	
Civil Money Penalty – ASES may impose a civil money penalty for the following categories of events.

 

	
  

	
19.2.1.1

	
Category 1 - A civil money penalty in accordance with any applicable provision of 42 CFR 438.700 of $100,000 per determination shall be imposed for this category.  The following constitute Category 1 events:

 

	
  

	
19.2.1.1.1

	
Acts by the Contractor that discriminate among Enrollees on the basis of their health status or need for health care services. This includes termination of enrollment or refusal to reenroll a beneficiary, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by beneficiaries whose medical condition or history indicates probable need for substantial future medical services.  Notwithstanding the foregoing, ASES may impose a civil money penalty in the amount of $15,000 per each beneficiary that was not enrolled because of discriminatory practices as described above, subject to the overall limit of $100,000 per each determination.

 

	
  

	
19.2.1.1.2

	
The misrepresentation or falsification by the Contractor of information it submits to ASES and/or CMS.

 

	
  

	
19.2.1.2

	
Category 2 - A civil money penalty in accordance with any applicable provision of 42 CFR 438.700 of $25,000 per determination shall be imposed for this category.  The following constitute Category 2 events:

 

  

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19.2.1.2.1

	
Failure by the Contractor to substantially provide medically necessary services that the Contractor is required to provide, under applicable law or under this Contract, to an Enrollee covered by this Contract.

 

	
  

	
19.2.1.2.2

	
Misrepresentation or falsification by the Contractor of information that it furnishes to an enrollee, potential enrollee, or health care provider.

 

	
  

	
19.2.1.2.3

	
Failure by the Contractor to comply with the requirements for physician incentive plans, as set forth in 42 CFR 422.208 and 422.210.

 

	
  

	
19.2.1.2.4

	
The distribution by the Contractor, directly or indirectly through any agent or independent contractor, of marketing materials that have not been approved by ASES or that contain false or materially misleading information.

 

	
  

	
19.2.1.3

	
Category 3 – Pursuant to 42 CFR 438.704 (c), ASES may impose a civil money penalty for the Contractor’s imposition of premiums or charges in excess of the amounts permitted under the Medicaid program.  The maximum amount of the penalty is $25,000 or double the amount of the excess charges, whichever is greater. ASES will deduct from the penalty the amount of overcharge and return it to the affected enrollees.

 

	
  

	
19.2.2

	
Temporary Management - ASES may appoint temporary management for the Contractor’s MI Salud operations, as provided in 42 C.F.R. 438.702 and 42 C.F.R. 438.706, until the Contractor’s orderly termination or reorganization, or as a result of Contractor’s:

 

  

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19.2.2.1

	
Continued egregious behavior including but not limited to behavior described in Categories 1 thru 3 of this Article 19;

 

	
  

	
19.2.2.2

	
Behavior that is contrary to, or is non-compliant with, Sections 1903(m) or 1932 of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and 1396u-2;

 

	
  

	
19.2.2.3

	
Actions which have caused substantial risk to enrollee’s health; or

 

	
  

	
19.2.2.4

	
Behavior which has led ASES to determine that temporary management is necessary to ensure the health of Contractor’s enrollees while improvements to remedy Category 1 through 3 violations are being made.

 

	
  

	
19.2.2.5

	
If temporary management is appointed for any reason specified in Sections 19.1.4.2.1 – 19.1.4.2.4 above, such temporary management will cease once ASES has determined that the sanctioned behavior will not recur.

 

	
  

	
19.2.3

	
Enrollment Termination – ASES may grant Enrollees the right to terminate enrollment without cause, and notify the affected Enrollees of their right to disenroll when:

 

	
  

	
19.2.3.1

	
The Contractor has engaged in continued egregious behavior, including but not limited to behavior described in Categories 1 thru 3 of this Article 19;

 

	
  

	
19.2.3.2

	
The Contractor has engaged in behavior that is contrary to, or is non-compliant with, Sections 1903(m) or 1932 of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and 1396u-2;

 

	
  

	
19.2.3.3

	
The Contractor has taken actions that have caused substantial risk to Enrollees’ health;

 

	
  

	
19.2.3.4

	
ASES determines that temporary management is necessary to ensure the health of the Contractor’s enrollees; or

 

	
  

	
19.2.3.5

	
ASES determines that such enrollment termination is necessary to remedy Category 1 thru 3 violations.

 

  

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19.2.4

	
Enrollment Suspension – ASES may suspend all new enrollments, including default enrollment, after the effective date of the intermediate sanction and until the intermediate sanction is no longer in effect.

 

	
  

	
19.2.5

	
Payment Suspension – ASES may suspend payment of the Administrative Fee for beneficiaries enrolled after the effective date of the intermediate sanction and until the Centers for Medicare and Medicaid (CMS) or ASES is satisfied that the reason for imposition of the intermediate sanction no longer exists and is not likely to recur or upon Contract Termination.

 

	
  

	
19.2.6

	
Mandatory Imposition of Certain Intermediate Sanctions – ASES shall impose the temporary management and enrollment suspension intermediate sanctions described in Sections 19.1.4.2 and 19.1.4.3 above, if ASES finds that the Contractor has repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932 of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and 1396u-2.

 

	
  

	
19.2.7

	
Subject to Article 35 of this Contract, in lieu of imposing a sanction allowed under this Article 19, ASES may terminate this Contract, without any liability whatsoever (but subject to making any payments due under this Contract through any such date of termination), if the terms of a Corrective Action Plan implemented pursuant to this Article 19 to address a failure specified in Category 1 or Category 2 of this Article 19 are not implemented to ASES’s reasonable satisfaction or if such failure continues or is not corrected, to ASES’s sole reasonable satisfaction.

 

	
19.3

	
Notice of Administrative Inquiry

	
  

	
19.3.1

	
Prior to the imposition of an intermediate sanction under this Article 19, ASES shall issue a notice of administrative inquiry to be delivered personally to the Contractor or through the United States Postal Service Certified Mail that will inform the Contractor about ASES’s compliance, monitoring and auditing activities regarding potential non-compliance as described in this Article 19.  This notice of administrative inquiry shall include the following:

 

	
  

	
19.3.1.1

	
A brief description of the facts;

 

  

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19.3.1.2

	
Applicable Puerto Rico and federal laws and regulations, or Contract provisions;

 

	
  

	
19.3.1.3

	
The Contractor’s potential non-compliance with Puerto Rico and federal laws and regulations as referenced in the Contract;

 

	
  

	
19.3.1.4

	
The Contractor’s potential breach of applicable Contract provisions and event categories that could result in intermediate sanctions pursuant to this Article 19;

 

	
  

	
19.3.1.5

	
ASES’s authority to determine and impose intermediate sanctions under this Article 19;

 

	
  

	
19.3.1.6

	
The amount of Contractor’s potential exposure to intermediate sanctions, and how they were computed; and

 

	
  

	
19.3.1.7

	
A statement describing the Contractor’s right to submit a Corrective Action Plan within thirty (30) days of receipt of the notice of administrative inquiry under this Article 19.

 

	
  

	
19.3.2

	
The Contractor shall have the right to submit a Corrective Action Plan within thirty (30) days of receipt of the notice of administrative inquiry issued pursuant to this Article 19.  If the Contractor submits a Corrective Action Plan to ASES on a timely basis, ASES shall not impose intermediate sanctions with respect to the facts described in its notice of administrative inquiry.

 

	
  

	
19.3.3

	
A notice of administrative inquiry shall not constitute ASES’s final or partial determination of intermediate sanctions; thus, any administrative inquiries issued by ASES are not subject to administrative review under Section 19.4, and would be considered premature, rendering any administrative examiner without jurisdiction to review the matter.

 

	
  

	
19.3.4

	
If the Contractor fails to comply with any material provision under a  Corrective Action Plan submitted to ASES pursuant to Section 19.3.2 above, ASES may, in accordance with Section 19.4, impose:

 

	
  

	
19.3.4.1

	
A daily $5,000 civil money penalty, up to maximum of $100,000, for Contractor’s ongoing failure to comply with any material provision of the  Corrective Action Plan; or

 

  

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19.3.4.2

	
The applicable intermediate sanction for any or all behavior that resulted in the Contractor’s submission of the Corrective Action Plan pursuant to Section 19.3.2 above.

 

	
19.4

	
Notice of Imposition of Intermediate Sanctions

	
  

	
19.4.1

	
Prior to the imposition of intermediate sanctions, ASES will issue a notification to the Contractor, to be delivered personally or through the United States of America Postal Service Certified Mail that includes the following:

 

	
  

	
19.4.1.1

	
A brief description of the facts;

 

	
  

	
19.4.1.2

	
Applicable Puerto Rico and federal laws and regulations, or Contract provision;

 

	
  

	
19.4.1.3

	
The Contractor’s non-compliance with Puerto Rico and federal laws and regulations as referenced in the Contract;

 

	
  

	
19.4.1.4

	
The Contractor’s breach of applicable Contract provisions;

 

	
  

	
19.4.1.5

	
ASES’s determination to impose intermediate sanctions;

 

	
  

	
19.4.1.6

	
Intermediate sanctions imposed and their effective date;

 

	
  

	
19.4.1.7

	
Methodology for the determination and calculation of the intermediate sanctions including, to the extent imposed, the any civil monetary penalty; and

 

	
  

	
19.4.1.8

	
In ASES’s discretion, a statement describing the Contractor’s option to submit a Corrective Action Plan within thirty (30) days following receipt of the notice of imposition of intermediate sanctions or, in lieu thereof, seek administrative review of the imposed intermediate sanctions pursuant to Section 19.5.

 

	
  

	
19.4.2

	
In ASES’s discretion, the Contractor shall have the option to submit a Corrective Action Plan to ASES within thirty (30) days of receipt of the notice of intermediate sanctions. If the Contractor submits a Corrective Action Plan under this section, ASES may only recover 10% of the civil money penalty, if any, imposed under the notice of intermediate sanctions, and/or discontinue the imposition of the intermediate sanction.  Alternatively, the Contractor may seek administrative review of the imposition of intermediate sanctions pursuant to Section 19.5.

 

  

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19.4.3

	
ASES shall notify CMS in writing of the imposition of intermediate sanctions within thirty (30) days of imposing the intermediate sanctions, and concurrently provide the Contractor with a copy of such notice.

 

	
19.5

	
Administrative Review

	
  

	
19.5.1

	
Contractor has the right to seek administrative review of the imposition of intermediate sanctions, including but not limited to civil money penalties, by ASES, pursuant to the following procedure:

	
  

	
19.5.1.1

	
The Contractor has the right within thirty (30) days following receipt of the notice of imposition of intermediate sanctions to seek administrative review in writing of ASES’s determination and any such intermediate sanctions, pursuant to Act 72, Act No. 170 of August 12, 1988, as amended, 42 CFR Part 438 and any other applicable law or regulation.

 

	
  

	
19.5.1.2

	
As part of the administrative review, the Parties shall cooperate with the examining officer, and follow all applicable procedures for the administrative review.

 

	
  

	
19.5.1.3

	
Upon completion of the administrative review, the examining officer may recommend to:

 

	
  

	
19.5.1.3.1

	
Confirm the intermediate sanctions;

 

	
  

	
19.5.1.3.2

	
Modify or amend the intermediate sanctions pursuant to applicable law or regulation; or

 

	
  

	
19.5.1.3.3

	
Eliminate the imposed intermediate sanctions.

 

	
  

	
19.5.1.4

	
In addition to the actions described under Section 19.4.3, the examining officer may recommend the institution of a Corrective Action Plan with respect to Contractor’s alleged noncompliance set forth in ASES’s notice of intermediate sanctions.

 

  

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19.5.2

	
ASES shall notify CMS in writing of any modification in the imposition of intermediate sanctions through the administrative review process within thirty (30) days of receipt of the ASES’s final determination, and concurrently provide the Contractor with a copy of such notice.

 

	
19.6

	
Judicial Review

To the extent administrative review is sought by the Contractor pursuant to Section 19.5, the Contractor has the right to seek judicial review of ASES’s actions by the Puerto Rico Court of Appeals, San Juan Panel, within thirty (30) days of the notice of final determination issued by ASES.

	
ARTICLE 20

	
ENFORCEMENT - LIQUIDATED DAMAGES AND OTHER REMEDIES

 

	
20.1

	
General Provisions

	
  

	
20.1.1

	
In the event the Contractor is in default as to any applicable term, condition, or requirement of this Contract, and in accordance with any applicable provision of 42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any time on or after one hundred twenty (120) Calendar Days following the Effective Date, the Contractor agrees that, in addition to the terms of Section 35.1.1 of this Contract, ASES may assess liquidated damages against the Contractor for any such default, in accordance with this Article 20; provided, however, that ASES may not impose liquidated damages with respect to a specific event of default of Contractor if ASES has not complied with its obligations with respect to, or giving rise to, the same event. Furthermore, ASES may not impose liquidated damages with respect to a specific event of default of Contractor for which intermediate sanctions, including but not limited to civil monetary penalties, sought to be imposed or are imposed against the Contractor in accordance to Article 19. The Parties further acknowledge and agree that the specified liquidated damages are reasonable and the result of a good faith effort by the Parties to estimate the anticipated or actual harm caused by the Contractor’s breach and are in lieu of any other financial remedies to which ASES may otherwise have been entitled. The Contractor shall not be subject to the assessment of liquidated damages under more than one category of this Article 20 for the same event, or arising from the same occurrence of non-compliance with this Contract.

 

  

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20.1.2

	
Notwithstanding any sanction, including liquidated damages, imposed upon the Contractor under this Article 20, other than Contract termination, the Contractor shall continue to provide Administrative Services and make available through its Network Providers all Covered Services and other Benefits under this Contract.

 

	
  

	
20.1.3

	
Except where a particular provision of this Contract or any law or regulation of Puerto Rico or the United States expressly provides for liquidated damages on the basis of individual Enrollees, no liquidated damages under this Article 20 shall be determined on such basis.

 

	
20.2

	
The Parties have determined that Contractor’s breach or failure to comply with the terms and conditions of this Contract for which liquated damages may be assessed under this Article 20 shall be divided into four (4) categories of events:

 

	
  

	
20.2.1

	
Category 1 - Liquidated damages in accordance with any applicable provision of this Contract of up to $100,000 per violation, incident or occurrence shall be imposed for Category 1 events. The following constitute Category 1 events:

 

	
  

	
20.2.1.1

	
Material non-compliance with an ASES or CMS directive, determination or notice to cease and desist not otherwise described in Article 19 or other provision of this Article 20, provided that the Contractor has received prior written notice with respect to such specific material non-compliance.

 

	
  

	
20.2.2

	
Category 2- Liquidated damages in accordance with any applicable provision of this Contract of up to $25,000 per violation, incident or occurrence shall be imposed for Category 2 events.  The following constitute Category 2 events:

	
  

	
20.2.2.1

	
Subject to ASES compliance with its obligations under Article 22 of this Contract, repeated noncompliance by the Contractor with any material obligation that adversely affects the services that the Contractor is required to provide under Article 7 of this Contract;

 

	
  

	
20.2.2.2

	
Failure of the Contractor to assume its material duties under this Contract in accordance with the transition timeframes specified herein;

 

	
  

	
20.2.2.3

	
Failure of the Contractor to terminate a Provider that imposes Co-Payments or other cost-sharing on Enrollees that are in excess of the fees permitted by ASES, as listed on Attachment 8 (ASES will deduct the amount of the overcharge and return it to the affected Enrollees);

 

  

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20.2.2.4

	
Failure of the Contractor to address Enrollees’ Complaints, Appeals, and Grievances, and Provider disputes, within the timeframes specified in this Contract;

 

	
  

	
20.2.2.5

	
Failure of the Contractor to comply with the confidentiality provisions in accordance with 45 CFR 160 and 164; and

 

	
  

	
20.2.2.6

	
Violation of the Contractor to comply with a subcontracting requirement in the Contract.

 

	
  

	
20.2.3

	
Category 3 - Liquidated damages in accordance with any applicable provision this Contract of $5,000 per day shall be imposed for Category 3 events.  The following constitute Category 3 events:

	
  

	
20.2.3.1

	
Failure to submit required Reports in the timeframes prescribed in Article 18;

 

	
  

	
20.2.3.2

	
Submission of incorrect or deficient Deliverables or Reports in accordance with Article 18 of this Contract;

 

	
  

	
20.2.3.3

	
Failure to comply with the Claims processing standards as follows:

 

	
  

	
20.2.3.3.1

	
Failure to process and finalize to a paid or denied status ninety-five percent (95%) of all Clean Claims within thirty (30) Calendar Days of receipt;

 

	
  

	
20.2.3.3.2

	
Failure to process and finalize to a paid or denied status one hundred percent (100%) of all Clean Claims within fifty (50) Calendar Days of receipt; and

 

	
  

	
20.2.3.3.3

	
Failure to process Unclean Claims as specified in Section 16.10.3 of this Contract;

 

	
  

	
20.2.3.4

	
Failure to pay Providers interest at the rate identified in and otherwise in accordance with Section 16.10.2 of this Contract when a Clean Claim is not adjudicated within the claims processing deadlines;

 

  

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20.2.3.5

	
Failure to comply with the quarterly submission of EPSDT reports to ASES;

 

	
  

	
20.2.3.6

	
Failure to notify PCPs of the Gaps in Care analysis in accordance with the EPSDT guidelines specified in Section 7.9 of this Contract;

 

	
  

	
20.2.3.7

	
Failure to provide the Claims Payment Disbursement Illustration and Actuarial Report information required in Section 22.4.1.2 of this Contract;

 

	
  

	
20.2.3.8

	
Failure to seek, collect and/or report Third Party Liability information as provided in Section 23.4 of this Contract; and

 

	
  

	
20.2.3.9

	
Failure of Contractor to issue written notice to Enrollees upon Provider’s termination of a Provider as described in Section 10.4.3 of this Contract.

 

	
  

	
20.2.4

	
Category 4 - Liquidated damages as specified below shall be imposed for Category 4 events. The following constitute Category 4 events:

	
  

	
20.2.4.1

	
Failure to implement the business continuity-disaster recovery (BC-DR) plan as follows:

 

	
  

	
20.2.4.1.1

	
Implementation of the BC-DR plan exceeds the proposed time by two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day 2;

 

	
  

	
20.2.4.1.2

	
Implementation of the BC-DR plan exceeds the proposed time by more than (2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each day beginning with Day 3 and up to Day 5;

 

	
  

	
20.2.4.1.3

	
Implementation of the BC-DR plan exceeds the proposed time by more than five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars ($25,000) per day beginning with Day 6 and up to Day 10;

 

  

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20.2.4.1.4

	
Implementation of the BC-DR plan exceeds the proposed time by more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning with Day 11;

 

	
  

	
20.2.4.2

	
Unscheduled System Unavailability in violation of Article 17, in ASES’s discretion, two hundred fifty dollars ($250) for each thirty (30) minutes or portions thereof;

 

	
  

	
20.2.4.3

	
Failure to make available to ASES or its Agent, valid extracts of Encounter Information for a specific month within fifteen (15) Calendar Days of the close of the month: five hundred dollars ($500) per day.  After thirty (30) Calendar Days of the close of the month:  two thousand dollars ($2,000) per day;

 

	
  

	
20.2.4.4

	
Failure to correct a system problem not resulting in System Unavailability within the allowed timeframe, where failure to complete was not due to the action or inaction on the part of ASES as documented in writing by the Contractor:

 

	
  

	
20.2.4.4.1

	
One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars ($250) per Calendar Day for Days 1 through 15;

 

	
  

	
20.2.4.4.2

	
Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per Calendar Day for Days 16 through 30; and

 

	
  

	
20.2.4.4.3

	
More than thirty (30) Calendar Days late: one thousand dollars ($1,000) per Calendar Day for Days 31 and beyond; and

 

	
  

	
  20.2.4.5

	
 Failure to meet the Tele MI Salud performance standards:

 

	
  

	
20.2.4.5.1

	
$1,000 for each percentage point that is below the target answer rate of eighty percent (80%) in thirty (30) seconds;

 

  

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20.2.4.5.2

	
$1,000 for each percentage point that is above the target of a three percent (3%) Blocked Call rate; and

 

	
  

	
20.2.4.5.3

	
$1,000 for each percentage point that is above the target of a five percent (5%) Abandoned Call rate.

 

	
20.3

	
Other Remedies

 

	
  

	
20.3.1

	
Subject to Article 35 of this Contract, in lieu of imposing a remedy allowed under this Article 20, ASES may terminate this Contract, without any liability whatsoever (but subject to making any payments due under this Contract through any such date of termination), if the terms of a Corrective Action Plan implemented pursuant to this Article 20 to address a failure specified in Category 1 or Category 2 of this Article 20 are not implemented to ASES’s reasonable satisfaction or if such failure continues or is not corrected, to ASES’s sole reasonable satisfaction.

 

	
  

	
20.3.2

	
In the event of noncompliance by the Contractor with Article 18 or Sections 22.3.2 or 22.3.3 of this Contract, ASES shall have the right to Withhold, with respect to Article 18, a sum not to exceed ten percent (10%) - and with respect to Sections 22.3.2 or 22.3.3 of this Contract, a sum not to exceed thirty percent (30%)—of the Administrative Fee for the following month and for continuous consecutive months thereafter until such noncompliance is cured and corrected, in lieu of imposing any liquidated damages, penalties or sanctions against the Contractor hereunder.  ASES shall release the Withhold of the Administrative Fee to the Contractor within two (2) Business Days after the corresponding event of noncompliance is cured to ASES’s sole but reasonable satisfaction.

 

	
20.4

	
Notice of Administrative Inquiry regarding Liquidated Damages and/or Other Article 20 Remedies

	
  

	
20.4.1

	
Prior to the imposition of any remedies under this Article 20, ASES shall issue a notice of administrative inquiry to be delivered personally to the Contractor or through the United States Postal Service Certified Mail that will inform the Contractor about ASES’s compliance, monitoring and auditing activities regarding potential non-compliance as described in this Article 20.  This notice of administrative inquiry shall include the following:

 

  

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20.4.1.1

	
A brief description of the facts;

 

	
  

	
20.4.1.2

	
Applicable Puerto Rico and federal laws and regulations, or Contract provisions;

 

	
  

	
20.4.1.3

	
The Contractor’s potential non-compliance with Puerto Rico and federal laws and regulations as referenced in the Contract;

 

	
  

	
20.4.1.4

	
The Contractor’s potential breach of applicable Contract provisions and event categories that could result in remedies or liquidated damages pursuant to this Article 20;

 

	
  

	
20.4.1.5

	
ASES’s authority to determine and seek  liquidated damages or other remedies against the Contractor under this Article 20;

 

	
  

	
20.4.1.6

	
The amount of Contractor’s potential exposure to liquidated damages, or other Article 20 remedies, and how they were computed; and

 

	
  

	
20.4.1.7

	
A statement describing the Contractor’s right to submit a Corrective Action Plan within thirty (30) days of receipt of the notice of administrative inquiry under this Article 20.

 

	
  

	
20.4.2

	
The Contractor shall have the right to submit a Corrective Action Plan within thirty (30) days of receipt of the notice of administrative inquiry issued pursuant to this Article 20.  If the Contractor submits a Corrective Action Plan to ASES on a timely basis, ASES shall not impose damages or other remedies under this Article 20 with respect to the facts described in its notice of administrative inquiry.

 

	
  

	
20.4.3

	
A notice of administrative inquiry shall not constitute ASES’s final or partial determination of liquidated damages; thus, any administrative inquiries are not subject to administrative review under Section 20.6; and would be construed to be premature rendering any administrative examiner without jurisdiction to review the matter.

 

  

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20.4.4

	
If the Contractor fails to comply with any material provision under a Corrective Action Plan submitted to ASES pursuant to Section 20.7.2 above, ASES may, in accordance with Section 20.5, impose:

 

	
  

	
20.4.4.1

	
A daily amount of $5,000 in liquidated damages, up to a maximum of $100,000, for the Contractor’s failure to comply with any material provision part or condition of the Corrective Action Plan; and/or

 

	
  

	
20.4.4.2

	
The applicable Article 20 remedy for any or all behavior that resulted in the submission of Corrective Action Plan pursuant to Section 20.4.2 above.

 

	
20.5

	
Notice of Imposition of Liquidated Damages and/or Other Article 20 Remedies

 

	
  

	
20.5.1

	
Prior to the imposition of liquidated damages and/or any other remedies under this Article 20, ASES will issue a notification  to the Contractor to be delivered personally or through the United States of America Postal Service Certified Mail that includes the following:

 

	
  

	
20.5.1.1

	
A brief description of the facts;

 

	
  

	
20.5.1.2

	
Applicable Puerto Rico and federal laws and regulations, or Contract provision;

 

	
  

	
20.5.1.3

	
ASES’s determination to assess and impose liquidated damages or any other Article 20 remedy;

 

	
  

	
20.5.1.4

	
Liquidated damages and/or any other Article 20 remedy imposed and their effective date;

 

	
  

	
20.5.1.5

	
Methodology for the determination and calculation of liquidated damages and/or any other Article 20 remedy; and

 

	
  

	
20.5.1.6

	
In ASES’s discretion, a statement describing the Contractor’s option to submit a Corrective Action Plan within thirty (30) days of receipt of a notice of liquidated damages or other remedies pursuant to this Article 20.  If the Contractor submits a Corrective Action Plan under this section, ASES may only recover 10% of the liquidated damages imposed under such notice of liquidated damages. Alternatively, the Contractor may seek administrative review of the imposition of remedies pursuant to Section 20.7.

 

  

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20.6

	
Administrative Review

	
  

	
20.6.1

	
Contractor has the right to seek administrative review of the imposition of liquidated damages and/or any other remedy under this Article 20, pursuant to the following procedure:

	
  

	
20.6.2

	
The Contractor has the right within thirty (30) days following the receipt of the notice of liquidated damages and/or any other remedy under this Article 20 to seek administrative review in writing of ASES’s determination and any such remedies, pursuant to Act 72, Act No. 170 of August 12, 1988, as amended, and any other applicable law or regulation.

 

	
  

	
20.6.3

	
As part of the administrative review, the Parties shall cooperate with the examining officer, and follow all applicable procedures for the administrative review.

 

	
  

	
20.6.4

	
Upon the completion of the administrative review, the examining officer may recommend to:

 

	
  

	
20.6.4.1

	
Confirm the liquidated damages and/or any other remedy;

 

	
  

	
20.6.4.2

	
Modify or amend the liquidated damages and/or any other remedy; or

 

	
  

	
20.6.4.3

	
Eliminate the imposed liquidated damages and/or any other remedy.

 

	
  

	
20.6.5

	
In addition to the actions described under Section 20.6.4, the examining officer may recommend the institution of a Corrective Action Plan with respect to Contractor’s alleged noncompliance described in ASES’s notice of liquidated damages.

 

  

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20.7

	
Judicial Review

 

To the extent administrative review is sought by the Contractor pursuant to Section 20.9, the Contractor has the right to seek judicial review of ASES’s actions by the Puerto Rico Court of Appeals, San Juan Panel, within thirty (30) days of the notice of final determination issued by ASES.

 

	
ARTICLE 21

	
TERM OF CONTRACT

 

	
21.1

	
Subject to and upon the terms and conditions herein this Contract shall continue in full force and effect for a period of one year commencing on July 1, 2013 (the “Effective Date) and shall terminate on June 30, 2014 (the “Termination Date”).  The foregoing notwithstanding,  ASES reserves the right to amend or partially terminate, with prior written notice of ninety (90) Calendar Days, the Contract at any time to implement a demonstrative plan to  incorporate the new public health policies and/or strategies of the Government of the Commonwealth of Puerto Rico.

	
21.2

	
Except as provided under section 61, hereunder the term of this contract (“Contract Term”) shall begin at 12:01 a.m., Puerto Rico Time, on July 1, 2013 (also referred to as the “Effective Date of the Contract”) and shall continue until June 30, 2014.

	
21.3

	
The provision of Benefits under this Contract shall begin on the Effective Date of the Contract.

	
21.4

	
The Administrative Fee shall be the same during the Contract Term, unless otherwise agreed to by the Parties in writing.  In the event of an amendment or partial termination pursuant to Section 21.1 that results in a significant reduction of covered lives under the Contract, ASES will consider, based upon the needs of the Government of the Commonwealth of Puerto Rico and ASES, evaluating a renegotation of the Administrative Fee with the Contractor.

	
21.5

	
The Contract shall be terminated absolutely at the close of the Contract Term.

 

	
ARTICLE 22

	
PAYMENT FOR SERVICES

 

	
22.1

	
General Provisions

	
  

	
22.1.1

	
ASES’s obligations under this Contract to make Claims Payments and Administrative Fee payments to the Contractor shall commence on the Effective  Date of the Contract.

 

	
  

	
22.1.2

	
The Parties acknowledge and agree that any change in the scope or extent of the services to be performed by the Contractor hereunder that materially affects the basis upon which the Administrative Fee was originally calculated will be grounds for recalculation of the Administrative Fee paid hereunder.

 

  

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22.1.3

	
[Intentionally left blank].

 

	
  

	
22.1.4

	
ASES acknowledges that the Claims Payments agreed to under the terms of this Contract in addition to any applicable cost-sharing as provided in Attachment 8 may not constitute full payment for Covered Services and Benefits under MI Salud.  The Contractor will have no responsibility for payment for Covered Services and Benefits in excess of the Claims Payments unless the Contractor has obtained prior written approval, in the form of a Contract amendment, authorizing an increase in the total payment and the payments for Covered Services are increased by an amount sufficient to cover any such increase by an amount which is actuarially sound, as certified by ASES actuaries.

 

	
  

	
22.1.5

	
The Contractor shall maintain all the utilization and financial data related to this Contract duly segregated from its commercial and Platino business accounting system including, but not limited to, the general ledger.  In addition, the Contractor shall maintain separate utilization and financial data for each Service Region covered under this Contract.

 

	
  

	
22.1.6

	
[Intentionally left blank].

 

	
  

	
22.1.7

	
Fee-for-service amounts paid by the Contractor for Claims, or Capitation payments made by the Contractor derived or otherwise based on Encounter Data submitted by Providers, resulting from services determined not to be Medically Necessary by the Contractor, will not be considered in the MI Salud Program experience for any purposes or for the incentive plans contemplated under this Contract.

 

	
22.2

	
Administrative Fee

	
  

	
22.2.1

	
The Administrative Fee shall be calculated by multiplying the actual number of Enrollees as of the last day of the month preceding the month in which payment is made by the Per Member Per Month Administrative Fee agreed to between the Contractor and ASES for each Service Region covered by this Contract.  The Per Member Per Month Administrative Fee for each Service Region is specified in Attachment 11.

 

	
  

	
22.2.1.1

	
The Administrative Fee shall be due to the Contractor on the last day of the month.

 

  

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22.2.1.2

	
The Administrative Fee payment will be done through Automated Clearinghouse system (ACH).  On or before to the Effective Date, the Contractor shall execute any and all documents required to effectuate the payments of the Administrative Fee by ACH, as provided in Attachment 19.

 

	
  

	
22.2.1.3

	
The Contractor shall electronically transfer to ASES all the adjudicated claims received from the Providers prior to the payment. Electronic transfer of Claims must be processed in adherence to information exchange and data management requirements specified by ASES.

 

	
  

	
22.2.2

	
The Per Member Per Month Administrative Fee shall only be paid for Enrollees for whom ASES has received adequate notification of Enrollment from the Contractor as of the date specified by ASES, under Section 5.2.3 of this Contract; provided, however, that the Contractor shall receive the applicable fee once it cures, to ASES’s reasonable satisfaction, any deficiency in the notification of Enrollment.

 

	
  

	
22.2.3

	
The Per Member Per Month Administrative Fee for Enrollees not enrolled in MI Salud for the entire month shall be determined on a pro rata basis by the following calculation: (i) the Per Member Per Month Administrative Fee shall be divided by the number of days in the month, (ii) such amount shall be multiplied by the number of days in the month the Enrollee was enrolled in MI Salud, including the Effective Date of Enrollment and the period referred to in Section 4.4.1.2 of this Contract.

 

	
  

	
22.2.4

	
Any Administrative Fee invoice to be submitted by the Contractor shall be certified as provided in this Contract and any Federal requirement.  The certification must attest, based on best knowledge, information, and belief, as to the accuracy, completeness and truthfulness of the enrollment data, encounter data, and any other financial data as ASES may reasonably request under the terms of this Contract.  The monthly Administrative Fee invoice that the Contractor must submit to ASES shall include the following certification:

 

“Bajo pena de nulidad absoluta certifico que ningún servidor público de ASES es parte o tiene algún interés en las ganancias o beneficios producto del contrato objeto de esta factura y, de ser parte o tener interés en las ganancias o beneficios productos del contrato, ha mediado una dispensa previa.  La única consideración para suministrar los bienes o servicios objeto del contrato han sido el pago acordado con el representante autorizado de ASES.  El importe de esta factura es justo y correcto.  Los trabajos han sido realizados, los productos y servicios han sido entregados y/o prestados y no han sido pagados.”

 

  

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Under penalty of absolute nullity, I certify that no employee of ASES is a party to or has any interest in the payments or benefits arising from the Contract that underlies this invoice or, alternatively, that if an employee thereof is a party to or has an interest in the payments or benefits arising of said Contract, that the necessary waiver was obtained in connection hereto.  The payment agreed upon with the appropriate, duly authorized representative of ASES constitutes the sole consideration for providing the services called for in the Contract.  The amount billed in this invoice is just and correct.  The services billed for in this invoice have been performed according to the Contract's terms and have not been paid.”

 

	
  

	
22.2.5

	
[Intentionally left blank].

 

	
  

	
22.2.6

	
If ASES makes payment in excess of the Administrative Fee or Claims Payment, ASES may, upon five (5) Business Days prior written notice to the Contractor, Withhold any future payment of the Administrative Fee or Claims Payment, as applicable, to offset any such excess payment.

 

	
  

	
22.2.7

	
Administrative expenses to be included in determining the experience of the MI Salud Program are those related to this Contract in accordance with Section 23.1.8 of this Contract.  Separate allocations of expenses from any other of the Contractor’s business or insurance plans other than expenses under this Contract related to the MI Salud Program, from the Contractor’s subsidiaries or affiliated companies, from the Contractor’s parent company, or from other entities will not be reflected or commingled with the financial data of the MI Salud Program. Any cost-shifting, financial consolidation or the implementation of other combined financial measures is expressly forbidden.

 

	
  

	
22.2.8

	
The Contractor is solely responsible, at its cost and expense, for its web site maintenance, update, and to be in full compliance with all regulations applicable to cyber security.

 

  

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22.3

	
Claims Payment

	
  

	
22.3.1

	
The Claims Payment Report shall be certified as provided in this Contract and any Federal requirement.  The certification must attest, based on best knowledge, information, and belief, as to the accuracy, completeness and truthfulness of the enrollment data, encounter data, and any other data required in this Contract.

 

	
  

	
22.3.2

	
After receipt of the Claims Payment Report, ASES shall have five (5) Business Days to review the Claims Payment Report and transfer funds into a zero-balance account.  To the extent ASES determines that a request for payment of a Claim is unwarranted under the terms of this Contract, ASES shall provide notice to the Contractor of such determination and the corresponding explanation before deducting any such amount(s) from the total amount requested in the Claims Payment Report.  The Contractor shall have two (2) Business Days to remit payment to Providers after such payment by ASES.

 

	
  

	
22.3.3

	
After receipt of the Pharmacy Claims Payment Report, ASES shall have five (5) Business Days to review the Pharmacy Claims Payment Report and transfer funds into a zero-balance account.  In compliance with Section 10.5.8.4 of this Contract after such payment by ASES, the Contractor shall have two (2) Business Days to remit payment into the zero-balance account for the PBM after such payment by ASES.

 

	
  

	
22.3.4

	
ASES shall provide written instructions to the Contractor on or before the Implementation Date with respect to the management and operation of all zero balance accounts to be established under this Contract.

 

	
22.4

	
Claims Incurred But Not Reported

	
  

	
22.4.1

	
As part of its Administrative Services and in accordance with the Insurance Code of Puerto Rico, the Contractor shall perform, on a monthly basis, an actuarially sound process to estimate and track potential liability associated with Claims incurred but not reported (“IBNR”) for each Service Region and for each PMG.  In addition, as part of its Administrative Services, the Contractor shall conduct annual reviews to its IBNR methodology and make adjustments as necessary or otherwise as reasonably required by ASES.

 

	
  

	
22.4.1.1

	
IBNR Claims at the Contractor

 

	
  

	
22.4.1.1.1

	
Every thirty (30) Calendar Days, the Contractor shall submit an estimated amount of Claims incurred but not reported (“IBNR”).

 

  

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22.4.1.2

	
IBNR Claims at the PMG

 

	
  

	
22.4.1.2.1

	
ASES shall establish a reserve fund for IBNR for Capitation payments to PMGs based on actuarial estimates to be provided by the Contractor.  If such reserve fund were to exceed twenty percent (20%) of Per Member Per Month Capitation payments to PMGs for the first Fiscal Year of the Contract (i.e., the period from the Effective Date of the Contract through June 30, 2012); or ten percent (10%) of Per Member Per Month Capitation payments to PMGs for the second Fiscal Year (i.e., the period from July 1, 2012 to June 30, 2013), the Contractor shall inform ASES so that ASES may determine, in its discretion, any change in the reserve fund under this section 22.4.1.2.

 

	
  

	
22.4.1.2.2

	
The reserve shall be reconciled and adjusted every ninety (90) Calendar Days.  The Contractor shall submit quarterly reconciliation reports to ASES.  ASES shall have five (5) Business Days to review the IBNR reconciliation reports and, if necessary, any excess will be liquidated in the following twenty five (25) Business Days.  Once the PMG has the reserve necessary as determined by the Contractor, the monthly retention may not exceed three percent (3%) of Per Member Per Month Capitation payments to PMGs; provided, that if at any time the reserve falls below the amount determined as adequate by the Contractor’s actuaries, the Contractor shall inform ASES so that ASES may determine, in its discretion, any change in the retention amount to ensure the adequacy of the reserve fund.  Any increase must be justified in information from the PMG file.

 

  

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22.4.1.2.3

	
The Contractor shall continue to submit quarterly IBNR reconciliation reports to ASES until three hundred and sixty-five (365) Calendar Days after the end of the Contract Term.  Any remainder of the IBNR funds shall be returned to the PMGs in an unextendable period of sixty (60) Calendar Days from the date that ASES approves in writing the Contractor’s final quarterly reconciliation report.

 

	
22.5

	
  Contractor Objections to Payment

	
  

	
22.5.1

	
If the Contractor wishes to contest the amount of payments (including but not limited to the Administrative Fee) made by ASES in accordance with the terms outlined in this Article for services provided under the terms of this Contract, the Contractor shall submit to ASES all relevant documentation supporting the Contractor’s objection no later than ninety (90) Calendar Days after payment is made.   Once this term has ended, the Contralor forfeits its rights to object payments made by ASES hereunder.

 

	
  

	
22.5.2

	
After the Contractor’s submission of all relevant information, the Contractor and ASES will meet to discuss any objections to payment and the relevant data and information.  If after discussing the matter and analyzing all relevant data it is subsequently determined that an error in payment was made, the Contractor and ASES will develop a plan to remedy the situation, which would include a timeframe for resolution agreed to by both Parties, within a time period mutually agreed upon by both Parties.

 

	
22.6

	
Retention Fund for Quality Incentive Program

ASES will Withhold and release the Retention Fund for the Quality Incentive Program in accordance with Section 12.5 of this Contract.

	
22.7

	
Financial Performance Incentive

	
  

	
22.11.1

	
  A financial performance incentive has been agreed to between ASES and the Contractor.  If the member-weighted average of the cost of actual Claims incurred per member per month for all Service Regions is more than one and a half percent (1.5%) below the member-weighted average of ASES’s projected Claims cost per member per month for all Service Regions, excluding the Virtual Region (the “Threshold Amount”) as per Attachment 10 of this Contract, the Contractor shall be entitled to fifty percent of the difference between the aggregate Threshold Amount and the actual incurred Claims for such regions.  The calculation methodology for the Claims cost is included in Attachment 10A to this Contract.

 

  

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22.11.2

	
Calculation of the actual Claims incurred will be made on June 30, 2015 (after the end of the Runoff Period), following a reconciliation process to be agreed upon by the Parties.  No later than July 31, 2015, the agreed amount of the Contractor’s share of the savings below the Threshold Amount, if any, will be paid to the Contractor.

 

	
ARTICLE 23

	
FINANCIAL MANAGEMENT

 

	
  

	
23.1  General Provisions

 

	
  

	
23.1.1

	
Subject to ASES timely payment of all Claims Payment for each Service Region under the terms of this Contract, the Contractor shall be responsible for the sound financial management of the MI Salud Program.

 

	
  

	
23.1.2

	
The Contractor shall notify ASES of any loans or other special financial arrangements made between the Contractor and any PMG or other Network Provider.  Any such loans shall strictly conform to the legal requirements of federal and Puerto Rico anti-fraud and anti-kickback laws and regulations.

 

	
  

	
23.1.3

	
The Contractor shall provide ASES with copies of its audited financial statements following Generally Accepted Accounting Principles (“GAAP”) in the United States, at its own cost and charge, for the duration of the Contract, and as of the end of each the Contractor’s fiscal year during the Contract Term, regarding the financial operations related to the MI Salud Program.  The statements shall provide (1) a separate accounting of activities relating to each Service Region, and (2) a consolidated section accounting for all MI Salud Program activities.  These reports shall be submitted to ASES no later than ninety (90) days after the close of each Fiscal Year during the term of this Contract.

 

	
  

	
23.1.4

	
The Contractor shall provide to ASES a copy of its Annual Report to the Office of the Insurance Commissioner, as applicable, in the format agreed upon by the National Association of Insurance Commissioners (NAIC), for the year ended on December 31, 2010, and subsequently thereafter, if the Contract is renewed, not later than March 31 of each year.

 

  

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23.1.5

	
The Contractor shall provide to ASES unaudited financial statements for each quarter during the Contract Term, not later thirty (30) Calendar Days after the closing of each quarter.  The Contractor shall submit (1) a separate accounting of activities relating to each Service Region, and (2) a consolidated section accounting for all MI Salud Program activities.

 

	
  

	
23.1.6

	
The Contractor shall provide to ASES a copy of its annual corporate report at the close of the calendar year.

 

	
  

	
23.1.7

	
The Contractor shall maintain adequate procedures and controls to ensure that any payments pursuant to this Contract are properly made.  The Contractor shall submit such proposed procedures and controls to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.  Any subsequent changes to these procedures and controls must be previously approved in writing by ASES.  In establishing and maintaining such procedures, the Contractor will provide for separation of the functions of certification and disbursement.

 

	
  

	
23.1.8

	
The Contractor acknowledges, and shall incorporate in contracts with Providers, Subcontractors, and other persons engaged by the Contractor in connection with this Contract, that the MI Salud Program is a government-funded program.  As such, administrative costs shall be in accordance with cost principles permissible, and with applicable federal and Puerto Rico guidelines, including applicable Office of Management and Budget Circulars, primarily recognizing that: (1) a cost shall be reasonable if it is of the type generally recognized as ordinary and necessary, and if in its nature and amount, and taking into consideration the purpose for which it was disbursed, it does not exceed that which would be incurred by a prudent person in the ordinary course of business under the circumstances prevailing at the time the decision was made to incur the cost; and (2) a cost shall be reasonable if it is allocable to or related to the cost objective that compels cost association.

 

	
  

	
23.1.9

	
The Contractor shall maintain an accounting system for MI Salud separate from the rest of its commercial activities. This system will only include only MI Salud data.  The data contained in any report required to be provided by the Contractor to ASES hereunder will be provided by Service Region unless otherwise agreed to in writing by the Parties.

 

  

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23.1.10

	
The Contractor shall provide, throughout the Contract Term, any other necessary and related information that is deemed necessary by ASES in order to evaluate the Contractor’s financial capacity and stability.

 

	
23.2

	
Solvency and Financial Requirements

 

	
  

	
23.2.1

	
The Contractor shall establish and maintain adequate net worth, working capital, and financial reserves to carry out its obligations under this Contract.

 

	
  

	
23.2.2

	
The Contractor shall comply with the Puerto Rico Insurance Code with respect to insolvency protection.

 

 

	
23.3

	
Reinsurance and Stop Loss

 

	
  

	
23.3.1

	
ASES may enter, in its discretion, into a Reinsurance program at any time.  The Contractor shall provide any information requested by ASES in a timely manner as may be required for ASES to enter into a Reinsurance program.

 

	
  

	
23.3.2

	
ASES shall establish a stop-loss limit of ten thousand dollars ($10,000) per Enrollee for Primary Medical Groups.  Stop-loss coverage shall comply with the limits specified in 42 CFR 422.208(f).  The limit shall be activated when the expense of providing Covered Services to an Enrollee, including all outpatient and inpatient expenses, reaches this sum.  The Contractor shall have mechanisms in place to identify the stop loss once it is reached for an Enrollee, and shall establish monthly reports to inform ASES and the PMGs of Enrollees who have reached the stop-loss limit.  ASES shall assume all losses exceeding the limit.

 

	
  

	
23.3.3

	
The stop-loss responsibility shall not be transferred to a PMG unless the PMG and the Contractor expressly agree to the PMG’s assuming this risk and the associated risk distribution arrangement has been previously approved in writing by ASES.

 

 

	
23.4

	
Third Party Liability and Cost Avoidance

 

	
  

	
23.4.1

	
General Provisions

 

	
  

	
23.4.1.1

	
The MI Salud program shall be the payer of last resort for all Covered Services rendered on behalf of Medicaid and CHIP Enrollees in accordance with federal regulations; ASES intends to enforce this rule with respect to all MI Salud Enrollees. ASES and the Contractor shall agree to develop protocols and procedures for the coordination of benefits in the event any other source of payment or health insurance with respect to the Covered Services.

 

  

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23.4.1.2

	
The Contractor shall exercise full assignment rights as applicable and shall be responsible for making every reasonable effort to determine the legal liability of Third Parties to pay for services rendered to Enrollees under this Contract and to cost avoid or recover any such liability from the Third Party.  “Third Party,” for purposes of this Section, shall mean any person or entity that is or may be liable to pay for the care and services rendered to a MI Salud Enrollee.  Examples of a Third Party include an Enrollee’s health insurer, casualty insurer, a managed care organization, and Medicare.

 

	
  

	
23.4.1.3

	
The Contractor hereby agrees to utilize, and cause its Providers to utilize, available public or private sources of payment for services rendered to Enrollees in the MI Salud Plan for claims cost avoidance purposes, within thirty (30) Calendar Days of becoming aware of such sources. If Third Party Liability (TPL) exists for part or all of the Covered Services provided directly by the Contractor to an Enrollee, the Contractor shall make Reasonable Efforts to recover from TPL sources the value of Covered Services rendered.  If TPL exists for part or all of the Covered Services provided to an Enrollee by a Subcontractor or a Provider, and the Third Party will make payment within a reasonable time, the Contractor may pay the Subcontractor or Provider only the amount, if any, by which the Subcontractor’s or Provider’s allowable claim exceeds the amount of TPL.

 

	
  

	
23.4.1.4

	
The Contractor shall deny payment on a Claim that has been denied by a Third Party payer when the reason for denial is the Provider’s  failure to follow prescribed procedures, including, but not limited to, failure to obtain Prior Authorization, failure to file Claims timely, etc.

 

	
  

	
23.4.1.5

	
The Contractor shall, within five (5) Business Days of issuing a denial of any claim based on TPL, provide TPL data to the Provider.

 

  

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23.4.1.6

	
The Contractor shall treat funds recovered from Third Parties as offsets to Claims payments. The Contractor shall report all cost avoidance values to ASES in accordance with federal guidelines and as described subsequently in this Section.

 

	
  

	
23.4.1.7

	
The Contractor shall post all Third Party payments or recoveries to Claim-level detail by Enrollee.

 

	
  

	
23.4.1.8

	
If the Contractor operates or administers a non-MI Salud health plan, the Contractor shall, to the extent permitted by law, assist ASES with the identification of Enrollees with access to other insurance to coordinate benefits for such Enrollees.

 

	
  

	
23.4.1.9

	
The Contractor shall audit and review its Providers’ claims, using monthly the reports submitted pursuant to Section 16.7 of this Contract or other pertinent data, to ensure that Providers are not receiving duplicate payment for services billable to third parties, in particular the Medicare program.  The Contractor shall report to ASES on a quarterly basis its findings regarding claims, invoices, or duplicate or inappropriate payments.  According to the timeframe specified in Attachment 12 to this Contract, the Contractor shall submit to ASES for its review and approval a plan for such routine audits.  Any subsequent changes to the plan for routine audits must be previously approved in writing by ASES.

 

	
  

	
23.4.1.10

	
The Contractor shall make a reasonable effort (in accordance with reasonable industry standards and practices), including through collaboration with Providers, to collect and report Third Party recoveries.  Third Party recoveries shall be remitted to ASES promptly upon receipt by the Contractor.

 

	
  

	
23.4.1.11

	
The Contractor shall comply with the applicable provisions of 42 CFR 433 Subpart D – Third Party Liability and 42 CFR 447.20 Provider Restrictions: State Plan Requirements, or work cooperatively with ASES to assure compliance with the requirements therein, as it relates to the Medicaid and CHIP populations served by the MI Salud Plan and its Third Party Liability and cost avoidance responsibilities.

 

  

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23.4.2

	
Legal Causes of Action for Damages.  ASES (or another agency of the Commonwealth) will have the sole and exclusive right to pursue and collect payments made by the Contractor when a legal cause of action for damages is instituted on behalf of a MI Salud Enrollee against a Third Party, or when ASES receives notices that legal counsel has been retained by or on behalf of any Enrollee.  The Contractor shall cooperate with ASES in all collection efforts, and shall also direct its Providers to cooperate with ASES in these efforts.

 

	
  

	
23.4.3

	
Estate Recoveries.  ASES (or another agency of the Commonwealth) will have the sole and exclusive right to pursue and recover correctly paid benefits from the estate of a deceased MI Salud Enrollee who was Medicaid Eligible in accordance with federal and Puerto Rico law.   Such recoveries will be retained by ASES.

 

	
  

	
23.4.4

	
Subrogation

 

	
  

	
23.4.4.1

	
Third Party resources shall include subrogation recoveries. The Contractor shall be required to seek subrogation amounts regardless of the amount believed to be available as required by federal Medicaid guidelines and Puerto Rico law.

 

	
  

	
23.4.4.2

	
The amount of any subrogation recoveries collected by the Contractor outside of the Claims processing system shall be treated by the Contractor as offsets to medical expenses for the purposes of reporting.

 

	
  

	
23.4.4.3

	
The Contractor shall conduct diagnosis and trauma code editing to identify potential subrogation claims. This editing should, at minimum, identify claims with a diagnosis of 900.00 through 999.99 (excluding 994.6) or claims submitted with an accident trauma indicator of ‘Y.’

 

	
  

	
23.4.5

	
Cost Avoidance

 

	
  

	
23.4.5.1

	
When the Contractor is aware of health or casualty insurance coverage before paying for a Covered Service, the Contractor shall avoid payment by promptly (within fifteen (15) Business Days of receipt) rejecting the Provider’s claim and directing that the Claim be submitted first to the appropriate Third Party.

 

  

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23.4.5.2

	
Exceptions to the Cost-Avoidance Rule. In the following situations, the Contractor shall first pay its Providers and then coordinate with the liable Third Party, unless prior approval to take other action is obtained from ASES:

 

	
  

	
23.4.5.2.1

	
The coverage is derived from a parent whose obligation to pay support is being enforced by a government agency.

 

	
  

	
23.4.5.2.2

	
The claim is for Maternal and Prenatal Services to a pregnant woman or for EPSDT services that are covered by the Medicaid program.

 

	
  

	
23.4.5.2.3

	
The claim is for labor, delivery, and post-partum care and does not involve hospital costs associated with an inpatient stay.

 

	
  

	
23.4.5.2.4

	
The claim is for a child who is in the custody of ADFAN.

 

	
  

	
23.4.5.2.5

	
The claim involves coverage or services mentioned in this subsection in combination with another service.

 

	
  

	
23.4.5.3

	
If the Contractor knows that the Third Party will neither pay for nor provide the Covered Service, and the service is Medically Necessary, the Contractor shall neither deny payment for the service nor require a written denial from the Third Party.

 

	
  

	
23.4.5.4

	
If the Contractor does not know whether a particular service is covered by the Third Party, and the service is Medically Necessary, the Contractor shall promptly (within ten (10) Business Days of receipt of the Claim) contact the Third Party and determine whether or not such service is covered rather than requiring the Enrollee to do so.  Further, the Contractor shall require the Provider to bill the Third Party if coverage is available.

 

	
  

	
23.4.6

	
Sharing of TPL Information by ASES

 

	
  

	
23.4.6.1

	
By the fifth (5th) Calendar Day after the close of the month during which ASES learns of such information, ASES will provide the Contractor with a list of all known health insurance information on Enrollees for the purpose of updating the Contractor’s files.

 

  

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23.4.6.2

	
Additionally, by the fifteenth (15th) Calendar Day after the close of the calendar quarter, ASES will provide to the Contractor a copy of a document containing all of the health insurers licensed by the Commonwealth as of the close of the previous quarter, and any other related information that is needed in order to file TPL claims.

 

	
  

	
23.4.7

	
Sharing of TPL Information by the Contractor

 

	
  

	
23.4.7.1

	
The Contractor shall submit a monthly report to ASES (following ASES file content, format and transmission specifications) by the fifth (5th) Calendar Day after the close of the month during which the Contractor learns that an Enrollee has new health insurance coverage, or casualty insurance coverage, or of any change in an Enrollee’s health insurance coverage. The Contractor shall impose a corresponding requirement on its Providers to notify the Contractor of any newly discovered coverage.

 

	
  

	
23.4.7.2

	
When the Contractor becomes aware that an Enrollee has retained counsel, who either may institute or has instituted a legal cause of action for damages against a Third Party, the Contractor shall notify ASES in writing, including the Enrollee’s name and MI Salud Enrollee Identification number, the date of the accident / incident, the nature of the injury, the name and address of Enrollee’s legal representative, copies of the pleadings, and any other documents related to the action in the Contractor’s possession or control.  This shall include, but not be limited to, the name of the Provider, the Enrollee’s diagnosis, the Covered Service provided to the Enrollee, and the amount paid to the Provider for each service.

 

	
  

	
23.4.7.3

	
The Contractor shall notify ASES within thirty (30) Calendar Days of the date it becomes aware of the death of one of its Medicaid Eligible Enrollees age fifty-five (55) or older, giving the Enrollee’s full name, Social Security number, and date of death.  ASES will then determine whether it can recover correctly paid Medicaid benefits from the Enrollee’s estate.

  

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23.4.7.4

	
The Contractor agrees to share with ASES instances of Enrollee non-cooperation with the Contractor’s and with Network Providers’ efforts to determine sources of Third Party Liability.

 

	
  

	
23.4.8

	
Historic cost avoidance due to the existence of liable Third Parties is embedded in the cost of health services delivery and is reflected in the rates upon which ASES will base Claims Payments to the Contractor.  The Claims Payment does not include any reductions due to tort recoveries.

 

	
23.5

	
MI Salud as Secondary Payer to Medicare

 

	
  

	
23.5.1

	
In general, as provided in Section 7.12 of this Contract, save for services offered by Medicare Platino plans which operate independently of this Contract, MI Salud does not duplicate coverage provided by Medicare to Dual Eligible Beneficiaries and the Contractor shall not be a secondary payer for services for which Medicare is liable.

 

	
  

	
23.5.1.1

	
However, in a situation in which a Covered Service is covered in whole or part by both Medicare and MI Salud (for example, hospitalization services for a Dual Eligible Beneficiary who is enrolled in Medicare Part A only and whose hospitalization costs exceed the Medicare limit, per Section 7.12.1.1.1 of this Contract), the Contractor shall determine liability as a secondary payer as follows:

 

	
  

	
23.5.1.1.1

	
If the total amount of Medicare’s established liability for the services (Medicare paid amount) is equal to or greater than the negotiated contract rate between the Contractor and the Provider for the services, minus any MI Salud cost-sharing requirements, then the Provider is not entitled to, and the Contractor shall not pay, any additional amounts for the services.

 

	
  

	
23.5.1.1.2

	
If the total amount of Medicare’s established liability (Medicare paid amount) is less than the negotiated contract rate between the Contractor and the Provider for the services, minus any MI Salud cost-sharing requirements, the Provider is entitled to, and the Contractor shall pay, the lesser of:

 

  

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23.5.1.1.2.1

	
The Medicaid cost-sharing (deductibles and coinsurance) payment amount for which the Dual Eligible Beneficiary is responsible under Medicare, and

 

	
  

	
23.5.1.1.2.2

	
An amount which represents the difference between (1) the negotiated contract rate between the Contractor and the Provider for the service minus any MI Salud cost-sharing requirements, and (2) the established Medicare liability for the services.

 

	
  

	
23.5.2

	
Enrollment Exclusions and Contractor Liability for the Cost of Care.  Any Dual Eligible Beneficiary who is already enrolled in a Medicare Platino Plan may not be enrolled by the Contractor. However, if the Contractor operates its own Medicare Platino Plan, the Contractor may enroll a Dual Eligible Beneficiary in the Platino Plan, which furnishes MI Salud benefits, per separate contract with ASES.

 

	
  

	
23.5.3

	
Protections for Medicaid Enrollees

 

	
  

	
23.5.3.1

	
The Contractor shall neither impose, nor allow Network Providers to impose, any cost-sharing charges of any kind upon Medicaid Eligible Persons enrolled in MI Salud, other than as authorized in this Contract.

 

	
  

	
23.5.3.2

	
Unless otherwise permitted by federal or Puerto Rico law, Covered Services may not be denied to a Medicaid Enrollee because of a Third Party’s potential liability to pay for the services, and the Contractor shall ensure that its cost avoidance efforts do not prevent Enrollees from receiving Medically Necessary services.

 

	
23.6

	
[Intentionally left blank].

 

	
23.7

	
Reporting Requirements

 

	
  

	
23.7.1

	
The Contractor shall submit to ASES all of the reports as indicated in Section 18.2 of this Contract.

 

  

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23.7.2

	
Failure to submit the reports within the established timeframes, or failure to submit complete, accurate reports, may result in the imposition of liquidated damages pursuant to Article 19 of this Contract or Withhold of the Administrative Fee as outlined in Section 19.6.3 of this Contract.

 

	
  

	
23.7.3

	
The Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by ASES) of each year a “Report on Controls Placed in Operation and Tests of Operating Effectiveness,” meeting all standards and requirements of the AICPA’s SAS 70, for the Contractor’s operations performed for ASES under the MI Salud Contract.

 

	
  

	
23.7.3.1

	
The audit shall be conducted by an independent auditing firm, which has prior SAS 70 audit experience.  The auditor must meet all AICPA standards for independence.  The selection of, and contract with the independent auditor shall be subject to the prior written approval of ASES.  ASES reserves the right to, at the Contractor’s expense, designate other auditors or reviewers to examine the Contractor’s operations and records for monitoring and/or stewardship purposes.

 

	
  

	
23.7.3.2

	
The independent auditing firm shall simultaneously deliver identical reports of its findings and recommendations to the Contractor and ASES within forty-five (45) Calendar Days after the close of each review period.  The audit shall be conducted and the report shall be prepared in accordance with generally accepted auditing standards for such audits as defined in the publications of the AICPA, entitled “Statements on Auditing Standards” (SAS).  In particular, both the “Statements on Auditing Standards Number 70-Reports on the Processing of Transactions by Service Organizations” and the AICPA Audit Guide, “Audit Guide of Service-Center-Produced Records” are to be used.

 

	
  

	
23.7.3.3

	
The Contractor shall respond to the audit findings and recommendations within thirty (30) Calendar Days of receipt of the audit and shall submit an acceptable proposed corrective action to ASES.  The Contractor shall implement the Corrective Action Plan within forty (40) Calendar Days of its approval by ASES.

 

  

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23.7.4

	
The Contractor shall submit to ASES a “Disclosure of Information on Annual Business Transactions.”  This Report must include:

 

	
  

	
23.7.4.1

	
Definition of A Party in Interest – As defined in Section 1318(b) of the Public Health Service Act, a party in interest is:

 

	
  

	
23.7.4.1.1

	
Any director, officer, partner, or employee responsible for management or administration of the Contractor; any person who is directly or indirectly the beneficial owner of more than five percent (5%) of the equity of the Contractor; any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than five percent (5%) of the Contractor; or, in the case of a Contractor organized as a nonprofit corporation, an incorporator or Enrollee of such corporation under applicable State corporation law;

 

	
  

	
23.7.4.1.2

	
Any organization in which a person described in Section 23.7.4.1.1 above is director, officer or partner; has directly or indirectly a beneficial interest of more than five percent (5%) of the equity of the Contractor; or has a mortgage, deed of trust, note, or other interest valuing more than five percent (5%) of the assets of the Contractor;

 

	
  

	
23.7.4.1.3

	
Any person directly or indirectly controlling, controlled by, or under common control with the Contractor; or

 

	
  

	
23.7.4.1.4

	
Any spouse, child, or parent of an individual described in Sections 23.7.4.1.1-23.7.4.1.3 of this Contract.

 

	
  

	
23.7.4.2

	
Types of Transactions Which Must Be Disclosed.  Business transactions which must be disclosed include:

 

  

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23.7.4.2.1

	
Any sale, exchange or lease of any property between the Contractor and a party in interest;

 

	
  

	
23.7.4.2.2

	
Any lending of money or other extension of credit between the Contractor and a party in interest; and

 

	
  

	
23.7.4.2.3

	
Any furnishing for consideration of goods, services (including management services) or facilities between the Contractor and the party in interest.  This does not include salaries paid to employees for services provided in the normal course of their employment.

 

	
  

	
23.7.4.3

	
The information which must be disclosed in the transactions listed in this Section 23.7.4 between the Contractor and a party of interest includes:

 

	
  

	
23.7.4.3.1

	
The name of the party in interest for each transaction;

 

	
  

	
23.7.4.3.2

	
A description of each transaction and the quantity or units involved;

 

	
  

	
23.7.4.3.3

	
The accrued dollar value of each transaction during the Fiscal Year; and

 

	
  

	
23.7.4.3.4

	
Justification of the reasonableness of each transaction.

 

	
ARTICLE 24

	
PAYMENT OF TAXES

 

	
24.1

	
The Contractor certifies and guarantees that at the time of execution of this Contract:

 

	
  

	
24.1.1

	
It is a corporation duly authorized to conduct business in Puerto Rico and has filed income tax returns for the previous five (5) years;

 

	
  

	
24.1.2

	
It complied with and paid unemployment insurance tax, disability insurance tax (Law 139), social security for drivers (“seguro social choferil”), if applicable;

 

	
  

	
24.1.3

	
It filed any required corporation reports with the State Department for the five (5) previous years; and

 

  

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24.1.4

	
It does not owe any kind of taxes to the Commonwealth of Puerto Rico, its instrumentalities, dependencies, corporations or municipalities.

 

	
24.2

	
The Contractor will forthwith pay all taxes lawfully imposed upon it with   respect to this Contract or any product delivered in accordance herewith. ASES makes no representation whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by any governmental entity.

 

	
24.3

	
Notwithstanding the above, if, as a result of the enactment of any state, local or municipal legal provision, administrative regulation or government directive, Contractor is burdened with a requirement to pay a fee, tax, imposition, levy, or duty with regards to any of the proceeds of this Agreement, including but not limited to the imposition of any fees pertaining to the existence of any government contracts, or any added value tax (IVU, for its Spanish acronym), the parties will renegotiate, in good faith, an adjustment to the Administrative Fee.

 

	
ARTICLE 25

	
RELATIONSHIP OF PARTIES

 

	
25.1

	
Neither Party is an agent, employee, or servant of the other.  It is expressly agreed that the Contractor and any Subcontractors and agents, officers, and employees of the Contractor or any Subcontractor in the performance of this Contract shall act as independent contractors and not as officers or employees of ASES.  The Parties acknowledge, and agree, that the Contractor, its agent, employees, and servants shall in no way hold themselves out as Agent, employees, or servants of ASES.  It is further expressly agreed that this Contract shall not be construed as a partnership or joint venture between the Contractor or any Subcontractor and ASES.

 

	
ARTICLE 26

	
INSPECTION OF WORK

 

	
26.1

	
ASES, the Puerto Rico Medicaid Program, other agencies of the Commonwealth, the Department of Health and Human Services, the General Accounting Office, the Comptroller General of the United States, the Comptroller General of the Commonwealth, if applicable, or their Authorized Representatives, shall have the right to enter into the premises of the Contractor or all Subcontractors, or such other places where duties under this Contract are being performed for ASES, to inspect, monitor or otherwise evaluate the services or any work performed pursuant to this Contract.  All inspections and evaluations of work being performed shall be conducted with reasonable prior notice and during normal business hours.  All inspections and evaluations shall be performed in such a manner as will not unduly impact or delay the Contractor’s business operations.

 

	
ARTICLE 27

	
GOVERNMENT PROPERTY

 

	
27.1

	
The Contractor agrees that any papers, materials and other documents that are produced or that result, directly or indirectly, from or in connection with the Contractor’s provision of the services under this Contract shall be the property of ASES upon creation of such documents, for whatever use that ASES deems appropriate, and the Contractor further agrees to prepare any and all documents, including the Deliverables listed in Attachment 12 to this Contract, or to take any additional actions that may be necessary in the future to effectuate this provision fully.  In particular, if the work product or services include the taking of photographs or videotapes of individuals, the Contractor shall obtain the consent from such individuals authorizing the use by ASES of such photographs, videotapes, and names in conjunction with such use.  Contractor shall also obtain necessary releases from such individuals, releasing ASES from any and all claims or demands arising from such use.

 

  

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27.2

	
The Contractor shall be responsible for the proper custody and care of any ASES-owned property furnished for the Contractor’s use in connection with the performance of this Contract.  The Contractor will reimburse ASES for its loss or damage, normal wear and tear excepted, while such property is in the Contractor’s custody or use.

 

	
ARTICLE 28

	
OWNERSHIP AND USE OF DATA AND SOFTWARE

 

	
28.1

	
Ownership and Use of Data

 

	
  

	
28.1.1

	
ASES holds the total ownership of all Information created from Data, documents, and messages (verbal or electronic), reports, or meetings involving or arising out of or in connection with this Contract (the information will be hereinafter referred to as “ASES Data”).  The Contractor shall make all ASES Information and or Data available to ASES, which will also provide such ASES Data to CMS or other pertinent government agencies and authorities upon request.  The Contractor is expressly prohibited from sharing or publishing ASES Data without the prior written consent of ASES, except as required by law.  .

 

	
  

	
28.1.2

	
ASES acknowledges that before executing this Contract and in contemplation of the same, the Contractor has developed and designed certain programs and systems such as standard operating procedures, programs, business plans, policies and procedures, which ASES acknowledges are the exclusive property of the Contractor (the “Contractor Proprietary Information”).  Nevertheless, in case of default by the Contractor or termination pursuant to the terms of this Contract, ASES is hereby authorized to use to the extent allowable by any applicable commercial software and hardware licensing that exists at that moment or with which agreement can be reached at that moment with the vendor to modify such licensing to permit its use by ASES, at no cost to ASES, such Contractor properties for a period of one hundred and twenty (120) Calendar Days to effect an orderly transition to any new contractor or service provider for the Service Regions.  In any cases where the use of such systems from an operational perspective would also impact other lines of Contractor’s business or where licensing restrictions cannot be remedied, Contractor shall operate such systems on behalf of ASES.  Such operation by Contractor on behalf of ASES can occur at ASES’ reasonable discretion under the full supervision of their employees or appointed third party personnel.  Under such a scenario, ASES’ access to data will be restricted through the most efficient means possible.

 

  

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28.1.3

	
Contractor shall not deny ASES access to ASES’s Data in any case, nor will Contractor retain ASES’s Data or, deny ASES access to ASES’s Data, while controversies that exist between ASES and the Contractor are being resolved and finally adjudicated.

 

	
28.2

	
Responsibility for Information Technology Investments

 

The Parties understand and agree that the cost of any newly acquired or developed software programs or upgrades or enhancements to existing software programs, hardware, or other related information technology equipment or infrastructure component, made in order to comply with the requirements of this Contract shall be borne in its entirety by the Contractor.

	
ARTICLE 29

	
CRIMINAL BACKGROUND CHECKS

 

	
29.1

	
ASES is prohibited by law from entering into contracts with any entity that has been, or whose president, vice president, director, executive director, member of the board of directors or a person performing equivalent functions been convicted of, or entered a guilty plea, in Puerto Rico, the United States of America, or any other jurisdiction, for any crime involving corruption, fraud, embezzlement, or unlawful appropriation of public funds, pursuant to Act 458, as amended, and Act 84 of 2002.

 

	
29.2

	
Before the Implementation Date of this Contract, and  as a condition for the continued effectiveness of the Contract, the Contractor shall provide to ASES a certification that neither the Contractor nor the persons listed in Section 29.1 of this Contract, fall under the prohibition stated in Section 29.1 of this Contract.  As an essential and indispensable condition for the execution and delivery of this Contract, the Contractor must deliver concurrently with the execution of the Contract, the sworn statements required to comply with Act 458 of December 29, 2000, as amended.  The certification should be included in Attachment 12.

 

	
29.3

	
ASES may terminate this Contract if ASES determines that the Contractor, or any of the natural persons listed in Section 29.1 of this Contract, falls within the prohibition stated in Section 29.1 of this Contract, or failed to provide an accurate certification as required in Section 29.2 of this Contract.  In addition, the Contractor shall terminate a Provider Contract if it learns that a Provider, or any of the natural persons listed in Section 29.1 of this Contract related to the Provider, falls within the prohibition stated in Section 29.1 of this Contract.

 

  

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29.4

	
During the Contract Term, the Contractor shall promptly (within twenty (20) Business Days of the date it receives the information) provide to ASES any material information it obtains regarding any of the claims referred to in Section 29.1 and attributed to the persons listed in Section 29.1.

 

	
29.5

	
In cases in which none of the events listed in Section 29.1 of this Contract has occurred, but statements or admissions of crimes have been made by or against the Contractor, or one of its shareholders, partners, officers, principals, subsidiaries, or parent companies, ASES shall provide all pertinent information about the matter, within twenty (20) Business Days from the date it receives the information, to the Secretary of Justice of Puerto Rico, who will make the pertinent findings and recommendations concerning the Contract.

 

	
29.6

	
In addition, as provided in 42 CFR 455.106(c), ASES may refuse to enter into or renew an agreement with any entity if any person who has an ownership or control interest in the entity, or is an agent or managing employee of the entity, has been convicted of a criminal offense related to the person’s involvement in any program established under Medicare, Medicaid, or the Title XX services programs.  Before the Implementation Date of this Contract, pursuant to 42 CFR 455.106(a), the Contractor shall disclose to ASES the identity of any person who has an ownership or control interest in the Contractor, or is an agent or managing employee of the such entity who has been convicted of a criminal offense related to the Medicare, Medicaid, or Title XX services programs.  The Contractor shall collect the same information on criminal conviction for Providers during the Credentialing process, as provided in Section 9.4.3.21 of this Contract, and shall, immediately upon receipt of such information relating to a Provider, disclose the information to ASES.  ASES will notify the HHS Inspector General of any disclosures related to criminal convictions within twenty (20) Business Days from the date that ASES receives the information, as required by 42 CFR 455.106.

 

	
ARTICLE 30

	
SUBCONTRACTS

 

	
30.1

	
Use of Subcontractors

 

	
  

	
30.1.1

	
The Contractor shall not subcontract or permit anyone other than Contractor personnel to perform any of the work, services, or other performances required of the Contractor under this Contract relating to the Administrative Services associated with the provision of Covered Services and Benefits to Enrollees or assign any of its rights or obligations hereunder, without the prior written consent of ASES.  Prior to hiring or entering into an agreement with any Subcontractor, any and all Subcontractors shall be approved by ASES; provided, that such approval shall not be unreasonably withheld, conditioned or delayed; and further provided, that the subcontracts included in Attachment 17 to this Contract are expressly approved by ASES as of the Effective Date of this Contract.  ASES reserves the right to inspect all subcontract agreements at any time during the Contract period.  Upon request from ASES the Contractor shall provide in writing the names of all proposed or actual Subcontractors.  The Contractor is solely accountable for all functions and responsibilities contemplated and required by this Contract, whether the Contractor performs the work directly or through a Subcontractor.

 

  

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30.1.2

	
All contracts between the Contractor and Subcontractors must be in writing and must specify the activities and responsibilities delegated to the Subcontractor containing terms and conditions consistent with this Contract.  The contracts must also include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate.

 

	
  

	
30.1.3

	
All contracts must ensure that the Contractor evaluates the prospective Subcontractor’s ability to perform the activities to be delegated; monitors the Subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by ASES and consistent with industry standards or Puerto Rico laws and regulations; and identifies deficiencies or areas for improvement, ensuring that corrective action is taken as appropriate.

 

	
  

	
30.1.4

	
The Contractor shall give ASES prompt notice in writing by registered mail or certified mail of any action or suit filed by any Subcontractor and prompt notice of any Claim made against the Contractor by any Subcontractor or vendor that, in the opinion of Contractor, may result in litigation related in any way to this Contract.

 

	
  

	
30.1.5

	
All Subcontractors must fulfill the requirements of applicable law, including 42 CFR 438 as appropriate.

 

	
  

	
30.1.6

	
All Provider Contracts shall be in compliance with the requirements and provisions as set forth in Section 10.3 of this Contract.

 

	
  

	
30.1.7

	
The Contractor shall be held directly accountable and liable for all of the contractual provisions in this Contract regardless of whether the Contractor chooses to subcontract their responsibilities to a third party.  No subcontract shall operate to terminate the legal responsibility of the Contractor to assure that all activities carried out by the subcontractor conform to the provisions of the Contract.  Subcontracts shall not terminate the legal liability of the Contractor under this Contract.

 

  

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30.1.8

	
Notwithstanding Section 30.2.1 of this Contract, ASES agrees that the Contractor will be allowed to assign or subcontract all or part of its obligations under the Contract to its sister company Triple-C, Inc., provided that notwithstanding such assignment or subcontract the Contractor shall remain obligated to ASES under the terms of this Contract.

 

	
30.2

	
Cost or Pricing by Subcontractors

	
  

	
30.2.1

	
The Contractor shall submit, and shall require any Subcontractors hereunder to submit, cost or pricing data for any subcontract to this Contract prior to award.  The Contractor shall also certify that the information submitted by the Subcontractor is, to the best of the Contractor’s knowledge and belief, accurate, complete and current as of the date of agreement, or the date of the negotiated price of the subcontract or amendment to the Contract.  The Contractor shall insert the substance of this Section in each subcontract hereunder.

 

	
  

	
30.2.2

	
If ASES determines that any price, including profit or fee negotiated in connection with this Contract, or any cost reimbursable under this Contract was increased by any significant sum because of the inaccurate cost or pricing data, then such price and cost shall be reduced accordingly and this Contract and the subcontract shall be modified in writing to reflect such reduction.

 

	
ARTICLE 31

	
REQUIREMENT OF INSURANCE LICENSE

 

	
31.1

	
In order for this Contract to take effect, the Contractor must be licensed to underwrite health insurance by the Puerto Rico Insurance Commissioner.  The Contractor must submit a copy of its insurance license according to the timeframe specified in Attachment 12 to this Contract.

 

	
31.2

	
The Contractor shall renew the license as required, and shall submit evidence of the renewal to ASES within thirty (30) Calendar Days of the expiration date of the license.

 

	
ARTICLE 32

	
CERTIFICATIONS

 

	
32.1

	
As essential and indispensable condition for the execution and delivery of the Contract, the Contractor must deliver concurrently with the execution of the Contract the sworn statement required by Article 29 of the Contract to comply with act 458 of December 29, 2000, as amended.

 

	
32.2

	
The Contractor shall provide to ASES within fifteen (15) Calendar Days of the execution of this Contract, and thereafter by January 10 of each calendar year, the certifications and other documents set forth below, according to the timeframe specified below.  If any certification, document, acknowledgment, or other representation or assurance on the Contractor’s part under this Article, or elsewhere in this Contract, is determined to be false or misleading, ASES shall have cause for termination of this Contract pursuant to Article 35 of this Contract.  In the event that the Contract is terminated based upon this Article, the Contractor shall reimburse ASES all Administrative Fees received by the Contractor under the Contract.

 

  

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32.3

	
The Contractor shall submit the following certifications:

 

	
  

	
32.3.1

	
Certification issued by the Treasury Department of Puerto Rico (Model SC-2888) evidencing that Contractor has filed income tax returns in the past five years, or evidence of Contractor’s non-profit status;

 

	
  

	
32.3.2

	
Certification from the Treasury Department of Puerto Rico that Contractor has no outstanding debt with the Department or, if such a debt exists, it is subject to a payment plan or pending administrative review under applicable law or regulation (Model SC-3537);

 

	
  

	
32.3.3

	
Certification from the Center for the Collection of Municipal Revenues (“CRIM”,  its Spanish acronym) certifying  that there is no outstanding debt or, if a debt exists, that such debt is subject to payment plan or pending administrative review under applicable law or regulations;

 

	
  

	
32.3.4

	
Certification from the Department of Labor and Human Resources certifying  compliance with unemployment insurance, temporary disability insurance and/or chauffeur’s social security, if applicable;

 

	
  

	
32.3.5

	
Evidence of Incorporation and of Good Standing issued by the Department of State of Puerto Rico;

 

	
  

	
32.3.6

	
Certification of current municipal license tax (“Patentes Municipales”), if applicable; and

 

	
  

	
32.3.7

	
Certification issued by the Minor Children Support Administration (“ASUME”, by its Spanish acronym) of no outstanding alimony or child support debts, if applicable.

 

	
32.4

	
The Contractor shall, in addition, provide the following documents:

 

	
  

	
32.4.1

	
A list of all contracts Contractor has with government agencies, public corporations or municipalities, including those contracts in the process of being executed;

 

	
  

	
32.4.2

	
A letter indicating if any of its directors serves as member of any governmental board of directors or commission;

 

  

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32.4.3

	
A certificate of the Corporate Resolution authorizing the person signing this Contract to appear on behalf of the Contractor;

 

	
  

	
32.4.4

	
Evidence of compliance with the Compensation System for Work-Related Accidents Act (“Fondo del Seguro del Estado de Puerto Rico”); and

 

	
  

	
32.4.5

	
A copy of the Insurance Coverage Certificate as required in Article 37.

 

	
  

	
32.4.6

	
A sworn statement certifying that it has no debt with the government of the Commonwealth of Puerto Rico, or with any state agencies, corporations or instrumentalities that provide or are related to the provision of health services.

 

	
32.5

	
If the Contractor fails to meet the obligations of Sections 32.2 and 32.3 of this Contract within the required timeframe, ASES shall cease payment to the Contractor until the documents have been delivered to the ASES’s satisfaction, or adequate evidence is provided to ASES that reasonable efforts have been made to obtain the documents.

 

	
ARTICLE 33

	
RECORDS REQUIREMENTS

 

	
33.1

	
General Provisions

 

	
  

	
33.1.1

	
The Contractor shall preserve and make available all of its records pertaining to the performance under this Contract for inspection or audit, as provided below, throughout the Term of this Contract, for a period of seven (7) years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other Section of this Contract.  If the Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for period of seven (7) years from the date of termination or of any resulting final settlement.  The Contractor is responsible to preserve all Records pertaining to the performance under this Contract, and have it available and accessible in a timely manner in a reasonable format that assures the integrity of it.   Records that relate to Appeals, litigation, or the settlements of Claims arising out of the performance of this Contract, or costs and expenses of any such agreements as to which exception has been taken by the  Contractor or any of its duly Authorized Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or exceptions have been disposed of.

 

  

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33.2

	
Records Retention and Audit Requirements

 

	
  

	
33.2.1

	
Since funds from the Puerto Rico Plans under Title XIX and Title XXI of the Social Security Act Medical Assistance Programs (Medicaid and CHIP) are used to finance this project in part, the Contractor shall agree to comply with the requirements and conditions of the Centers for Medicare and Medicaid Services (CMS), the Comptroller General of the United States, the Comptroller of Puerto Rico and ASES, as to the maintenance of records related to this Contract.

 

	
  

	
33.2.2

	
Puerto Rico and federal standards for audits of ASES agents, contractors, and programs are applicable to this Section and are incorporated by reference into this Contract as though fully set out herein.

 

	
  

	
33.2.3

	
Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.40, the Contractor shall make all of its books, documents, papers, Provider records, Medical Records, financial records, data, surveys and computer databases available for examination and audit by ASES, HSS and its sub-agencies, the Comptroller of Puerto Rico, the Comptroller General of the United States of America and/or their authorized representatives.  Any records requested hereunder shall be produced for on-site review by ASES or sent to the requesting authority by mail within fourteen (14) Calendar Days following a request.  All records shall be provided at the sole cost and expense of the Contractor.  ASES shall have unlimited rights to use, disclose, and duplicate all information and data in any way relating to this Contract in accordance with applicable Puerto Rico and federal laws and regulations but subject to any proprietary rights of the Contractor over such information and data.

 

	
  

	
33.2.4

	
In certain circumstances, as follows, the authorities listed in Section 33.2.3 of this Contract shall have the right to inspect and audit records in a timeframe that exceeds the timeframe set forth in Section 33.1.1 of this Contract.

 

	
  

	
33.2.4.1

	
ASES determines that there is a special need to retain a particular record or group of records for a longer period and notifies the Contractor at least thirty (30) Calendar Days before the expiration of the timeframe set forth in Section 33.1.1 of this Contract.

 

	
  

	
33.2.4.2

	
There has been a Contract termination, dispute, Fraud, or similar fault by the Contractor, resulting in a final judgment or settlement against the Contractor, in which case the retention may be extended to three (3) years from the date of the final judgment or settlement.

 

  

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33.2.4.3

	
ASES determines that there is a reasonable possibility of Fraud, and gives the Contractor notice, before the expiration of the timeframe set forth in Section 33.1.1 of this Contract, that it wishes to extend the time period for retention of records.

 

	
  

	
33.2.4.4

	
There has been, during the time period set forth in Section 33.1.1, an audit initiated by CMS, the Comptroller of Puerto Rico, the Comptroller General of the United States, or ASES, in which case the timeframe for retention of records shall extend until the conclusion of the audit and publication of the final report.

 

	
  

	
33.2.5

	
All records retention requirements set forth in this Article or in any other Article shall be subject at all times and to the extent mandated by law and regulation, to the HIPAA regulations described elsewhere in this Contract.

 

	
  

	
33.2.6

	
Subject to Article 53 of this Contract, the Contractor shall be subject to Claims audits once every six months commencing on the Implementation Date.  The Contractor shall maintain accurate records at all times.  Upon five (5) Business Days notice, the Contractor shall provide ASES reasonable access to Claims’ records to verify conformance with the terms of the Contract.  If any such audit is an on-site audit, it shall be conducted during the Contractor’s normal business hours, and shall not be disruptive to the normal operations of the Contractor.  ASES shall be permitted to conduct audits in accordance with this Section with any or all of its own internal resources or by securing the services of a third party accounting or auditing firm, solely at ASES’s election and expense.

 

	
  

	
33.2.7

	
Every six months commencing on the Implementation Date, ASES shall have the right to perform MIS audits.

 

	
33.3

	
Medical Record Requests

 

	
  

	
33.3.1

	
The Contractor shall require that the Network Providers agree that a copy of each Enrollee’s Medical Record, in hard copy or electronic format, be made available, without charge, upon the written request of the Enrollee or Authorized Representative within fourteen (14) Calendar Days of the receipt of the written request.

 

  

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33.3.2

	
The Contractor shall require that the Network Providers agree that Medical Records be furnished at no cost to a new PCP, a PMG, an Out-of-Network Provider or other specialist, upon the Enrollee’s written request, no later than fourteen (14) Calendar Days following the written request.

 

	
  

	
33.3.3

	
Notwithstanding the foregoing, the Contractor must comply with the Puerto Rico Patient Bill of Rights which states that every provider, medical-hospital institution, and every insurer shall provide every patient a speedy access to their files and records.  A patient is entitled to receive a copy of his/her medical record within a term which shall not exceed five (5) Calendar Days.

 

	
ARTICLE 34

	
CONFIDENTIALITY

 

	
34.1

	
General Confidentiality Requirements

 

	
  

	
34.1.1

	
The Contractor shall treat all information, including Medical Records and any other health and Enrollment information that identifies a particular Enrollee or that is obtained or viewed by it or through its staff and Subcontractors’ performance under this Contract as confidential information, consistent with the confidentiality requirements of 45 CFR parts 160 and 164 and the terms of that certain Business Associate Agreement dated as of September 19, 2011 by and between the Contractor and ASES (the “Business Associate Agreement”).  The Contractor shall not use or disclose any information so obtained in any manner, except as may be necessary for the proper discharge of its obligations under this Contract and permitted under the Business Associate Agreement.

 

	
  

	
34.1.2

	
Employees or authorized Subcontractors of the Contractor who have a reasonable need to know such Enrollee information for purposes of performing their duties under this Contract shall use personal or patient information, provided such employees or Subcontractors are covered by a non-disclosure agreement that has been approved by ASES; provided, however, that the Business Associate Agreement shall be considered pre-approved by ASES.  The Contractor shall remove any person from performance of services hereunder upon notice that ASES reasonably believes that such person has failed to comply with the confidentiality obligations of this Contract.  The Contractor shall replace such removed personnel in accordance with the staffing requirements of this Contract.

 

	
  

	
34.1.3

	
ASES, the Commonwealth, federal officials as authorized by federal law or regulations, or the Authorized Representatives of these parties shall have access to all confidential information in accordance with the requirements of Puerto Rico and federal laws and regulations.

 

  

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34.1.4

	
The confidentiality provisions contained in this Contract survive the termination of this Contract and shall bind the Contractor, and its PMGs and Network Providers, so long as they maintain any “protected health information” relating to Enrollees, as such term is defined by 45 CFR Parts 160 and 164.

 

	
34.2

	
HIPAA Compliance

	
  

	
34.2.1

	
The Contractor shall assist ASES in its efforts to comply with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and its amendments, rules, procedures, and regulations.  To that end, the Contractor shall cooperate with and abide by any requirements mandated by HIPAA and any other applicable laws.  The Contractor and ASES are bound by the terms and conditions of the Business Associate Agreement for HIPAA compliance purposes.  In addition, the Contractor is required to sign a business associate agreement with the PBM and the MBHO.  The Parties shall cooperate on these matters and sign all documents required to be HIPAA compliant including but not limited to the Business Associate Agreement.

 

	
  

	
34.2.2

	
The Contractor must inform ASES in writing within two (2) Business Days of any HIPAA compliance issues as a result of any breach or threatened breach of this Article 34.

 

	
34.3

	
Data Breach

 

	
  

	
34.3.1

	
Data Breach. Contractor shall report ASES, as required in § 13402 of the HITECH Act, of any event where the ASES Data could be exposed in a non-authorized circumstance or illegally circumstance and/or when any data breach occurs. Contractor must take all reasonable steps to mitigate the breach.

 

	
  

	
34.3.2

	
Security Breach Notification. Contractor agrees that without unreasonable delay but no later than twenty-four hours after suspects or determining that a Data Breach occurred, the Contractor will notify ASES of such Breach. The notification should include sufficient information for ASES to understand the nature of the Breach. For instance, such notification could include, to the extent available at the time of the notification, the following information:

 

	
  

	
34.3.2.1

	
One or two sentence description of the event;

 

	
  

	
34.3.2.2

	
Description of the roles of the people involved in the Breach (e.g., employees, Participant Users, service providers, unauthorized persons, etc.)

 

	
  

	
34.3.2.3

	
The type of Data/ Information as well as Protected Health Information that was breached;

 

  

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34.3.2.4

	
Enrollees likely impacted by the Breach.  Name, date of birth, member number, phone number and address shall be provided for each Enrollee likely impacted by the Breach;

 

	
  

	
34.3.2.5

	
Number of Individuals or records impacted/estimated to be impacted by the Breach;

 

	
  

	
34.3.2.6

	
Actions taken by the Contractor to mitigate the Breach;

 

	
  

	
34.3.2.7

	
Current status of the Breach (under investigation or resolved);

 

	
  

	
34.3.2.8

	
Corrective action taken and steps planned to be taken to prevent a similar Breach.

 

The Contractor shall have a duty to supplement the information contained in the notification as it becomes available and cooperate with ASES.  The notification required by this Section shall not include any PHI.

 

	
  

	
34.3.3

	
Once the Contractor notified ASES according to Clause 34.3.2, the Contractor will continue the internal investigation if so required and will remain in communication with ASES. The Contractor will be subject to ASES guidance with respect to the mitigation or correction plan/ processes. ASES reserves the right of performing a forensic analysis to the Contractor information system related to the Security Breach. The Contractor will assume and/or reimburse the total costs of the forensics analysis.

 

	
  

	
34.3.4

	
Any determination or official statement related to the Security Breach to the relevant authorities in compliance with the federal and state laws, potentially affected citizens, affected citizens and/or the media will be made by ASES, as the covered entity. Any determinations made by ASES shall not be understood as any waiver and/or release of liability to the Contractor.

 

	
  

	
34.3.5

	
ASES reserves the right to select and hire the resources needed to comply with federal and state provisions related to protection and mitigation of damages to the Enrollee. ASES reserves the right to request the formally contract and/or hire the necessary resources previously selected by ASES, if that process accelerates the mitigation of damages to the Enrollee’s and/or ASES public image.

 

  

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ARTICLE 35

	
TERMINATION OF CONTRACT

 

	
35.1

	
Termination by ASES

 

	
  

	
35.1.1

	
In addition to any other non-financial remedy set forth in this Contract or available by law, or in lieu of any financial remedy contained in Article 19 of this Contract or available by law, and subject to compliance with the termination procedures set forth in Section 35.4 below, ASES may terminate this Contract:

 

	
  

	
35.1.1.1

	
Termination Due to the Contractor’s Default.  Upon thirty (30) Calendar Days notice to the Contractor in the event the Contractor has failed to carry out the material terms of this Contract, unless ASES, in its reasonable discretion, determines that the Contractor has cured the default to ASES’s reasonable satisfaction within the notice period.  For purposes of this Section a default shall not include any delay or non-performance of the Contractor’s obligations that is caused by ASES’s failure to timely fulfill its obligations hereunder, including but not limited to payments of the Claims Payment under Section 22.3 of this Contract.

 

	
  

	
35.1.1.2

	
Termination Due to the Contractor’s Insolvency or Bankruptcy.  Immediately, upon ASES providing written notice to the Contractor, in the event of the Contractor is Insolvent or the Contractor files a petition in bankruptcy.

 

	
  

	
35.1.1.2.1

	
In the event of the filing of a petition in bankruptcy, the Contractor shall advise ASES within one (1) Business Day.  If ASES reasonably determines that the Contractor’s financial condition is not sufficient to allow the Contractor to perform its Administrative Functions as described herein in the manner reasonably required by ASES, ASES may terminate this Contract in whole or in part, Immediately or in stages.

 

	
  

	
35.1.1.2.2

	
In the event that this Contract is terminated the Contractor is Insolvent, the Contractor shall guarantee that Enrollees shall not be liable for:

 

  

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35.1.1.2.2.1

	
the Contractor’s debts; or

 

	
  

	
35.1.1.2.3

	
the Covered Services provided to the Enrollees for which ASES does not pay the Contractor or its Network Providers.

 

	
  

	
35.1.1.3

	
Termination Due to Insufficient Funding.  Immediately, upon ASES providing the Contractor written notice pursuant to Section 16.11.8.6 that appropriated  federal and/or Puerto Rico funds become unavailable or that such funds will be insufficient for the payment of ASES’s obligations under this Contract when due, unless both Parties agree, through a written Amendment, to a modification of the obligations under this Contract.

 

	
  

	
35.1.1.4

	
Termination Due to the Contractor’s Breach of Article 29. Immediately, upon ASES providing written notice to the Contractor, in the event that the Contractor or any of the persons listed in Section 29.1 of this Contract fall under the prohibition stated in Section 29.1 or 29.6 of this Contract; or, subject to Section 35.3 of this Contract, upon the occurrence of any of the events specified in Section 29.3 of this Contract, as required under Act 458 and Act 458 and Act 84.

 

	
  

	
35.1.1.5

	
Termination Due to Change In Law Adversely Affecting Finances.   Immediately, upon prior written notice, upon the occurrence of any circumstance described in Section 38.2.6 or any amendment of this Contract pursuant to Section 55.2 that would adversely affect the economic circumstances of ASES, in its reasonable determination.

 

	
35.2

	
Termination by the Contractor

 

	
  

	
35.2.1

	
In addition to any other remedy set forth in this Contract  or available by law, and subject to compliance with the termination procedures set forth in Section 35.4 below, the Contractor may terminate this Contract:

 

	
  

	
35.2.1.1

	
Termination Due to ASES’s Financial Breach. Upon fifteen (15) Calendar Days written notice, in the event ASES is in arrears more than ninety (90) Calendar Days with respect to the full payment of a monthly Administrative Fee, or defaults in making full payment of three (3) consecutive monthly payments of the Administrative Fee or in making full payment of two (2) consecutive monthly payments of Claims Payments, and fails to cure such breach within the notice period.  For purposes of this Section, a default in making full payment does not include instances where ASES has made any Withhold payments of the Administrative Fee pursuant to the terms of this Contract, provided that ASES has given the Contractor advance written notice of any such Withhold of the Administrative Fee.

 

  

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35.2.1.2

	
Termination Due to ASES’s General Breach. Upon thirty (30) Calendar Days written notice to ASES, in the event  ASES has failed to carry out the material terms of this Contract unless the Contractor, in its reasonable discretion, determines that ASES has cured the default to the Contractor’s reasonable satisfaction within the notice period.  For purposes of this Section, a default does not include the delay or failure in making payment of the Administrative Fee or Claims Payments due under this Contract.

 

	
  

	
35.2.1.3

	
Termination Due to Insufficient Funding.  Immediately, upon receipt from ASES of a written notice pursuant to Section 16.11.8.6 that appropriated  federal and/or Puerto Rico funds become unavailable or that such funds will be insufficient for the payment of ASES’s obligation under this Contract when due, unless both Parties agree, through a written Amendment, to a modification of the obligations under this Contract.

 

	
  

	
35.2.1.4

	
Termination Due to Change In Law Adversely Affecting Finances.   Immediately, upon prior written notice, upon the occurrence of any circumstance described in Section 38.2.6 or any amendment of this Contract pursuant to Section 55.2 that would adversely affect the economic circumstances of the Contractor, in its reasonable determination.

 

	
35.3

	
General Procedures

 

	
  

	
35.3.1

	
Opportunity to Cure.  Each Party shall have the opportunity to cure any default alleged in a termination notice sent pursuant to this Article 35, upon receiving a written termination notice the other Party.  With respect to termination by ASES, the Contractor shall have the right to submit to ASES a written Corrective Action Plan containing terms and conditions acceptable to ASES to cure such default or an explanation of non-default in the thirty (30) Calendar Day period from the date of receipt of ASES’ written termination notice and such plan or explanation of non-default is accepted by ASES, in ASES’ sole discretion, which acceptance shall not be unreasonably withheld, conditioned or delayed.  With respect to termination by the Contractor, ASES shall have the right to submit to the Contractor a written Corrective Action Plan containing terms and conditions acceptable to the Contractor to cure such default or an explanation of non-default in the thirty (30) Calendar Day period from the date of receipt of the Contractor’s written termination  notice and such plan or explanation of non-default is accepted by the Contractor, in the Contractor’s sole discretion, which acceptance shall not be unreasonably withheld, conditioned or delayed.  Failure to respond to a termination notice within such thirty (30) Calendar Day notice period, shall constitute the Party’s waiver of its right to contest the termination notice.

 

  

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35.3.2

	
Continuing Obligations of the Contractor.  Notwithstanding the termination of this Contract pursuant to this Article 35 for any reason, the Contractor shall remain obligated to provide the Administrative Functions as described in Article 36, including but not limited to the payment of Claims for Covered Services provided to Enrollees prior to the Termination Date and as specified in the Patient’s Bill of Rights Act through the Runoff Period.

 

	
  

	
35.3.3

	
Continuing Obligations of ASES. Notwithstanding the termination of this Contract for pursuant to this Article 35 for any reason, ASES shall remain obligated to pay to the Contractor the Administrative Fee through the Termination Date (inclusive of the Transition Period) and the Claims Payments through the end of the Runoff Period.

 

	
  

	
35.3.4

	
Termination Procedures to be Strictly Followed.  No termination of this Contract shall be effective unless the termination procedures under Section 35.4 of this Contract have been strictly followed or waived by the Parties.

 

	
35.4

	
Termination Procedures

 

	
  

	
35.4.1

	
Provision of Termination Notice.  ASES or the Contractor shall issue a written termination notice pursuant to this Article 35 by certified mail, return receipt requested, or in person with proof of delivery.  Any such termination notice shall cite the provision of this Contract giving the right to terminate, the circumstances giving rise to termination, and the Termination Date.  Notwithstanding such termination notice (including any Immediate termination), the Parties agree that this Contract shall remain in full force and effect during a period not to exceed one-hundred twenty (120) Calendar Days commencing  on the date: (i) of the termination notice if such notice is not challenged by the non-moving Party or the breach giving rise to the notice of termination is not cured in accordance with Section 35.3.1of this Contract; or (ii); or as the Parties otherwise mutually agree in writing (such period to be referred to as the “Transition Period”, as further described under Article 36 of this Contract).  Termination of this Contract shall be effective at 11:59 p.m. Puerto Rico time on the last day of the Transition Period, which shall be known as the Termination Date.

 

  

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35.4.2

	
Termination Procedure.  The Parties agree that the following actions must occur to effectuate the termination of this Contract:

 

	
  

	
35.4.2.1

	
The moving Party shall provide the written termination notice to the non-moving Party pursuant to Section 35.4.1 of this Contract, stating the reason for the termination and the Termination Date (inclusive of the Transition Period), which shall become effective unless the non-moving Party responds to the termination notice in a timely manner pursuant to Section 35.4.2 B below;

 

	
  

	
35.4.2.2

	
The non-moving Party shall provide to the moving Party a Corrective Action Plan to address the alleged breach stated in the termination notice or a written explanation of non-breach, within thirty (30) Calendar Days following receipt of such termination notice;

 

	
  

	
35.4.2.3

	
The moving Party shall provide written notice to the other Party of its determination as to whether the breach described in the termination notice has been waived or cured to its reasonable satisfaction within the thirty (30) Calendar Days period;

 

	
  

	
35.4.2.4

	
ASES, upon any termination, , shall give Enrollees notice of the termination and information consistent with 42 CFR 438.10 on their options for receiving Covered Services and Benefits following the Termination Date.

 

  

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35.4.3

	
Termination Procedures During Transition Period.  As provided in the Transition Plan required under Section 36.4 of this Contract, the Contractor shall, during the Transition Period leading up to the Termination Date:

 

	
  

	
35.4.3.1

	
Stop work under the Contract on the date and to the extent specified in the notice of termination;

 

	
  

	
35.4.3.2

	
Place no further orders or subcontract for materials, services, or facilities, except as may be necessary for completion of such portion of the work under the Contract as is not terminated;

 

	
  

	
35.4.3.3

	
Terminate all orders and subcontracts to the extent that they relate to the performance of work terminated by the notice of termination;

 

	
  

	
35.4.3.4

	
Assign to ASES, in the manner and to the extent directed by ASES, all of the right, title, and interest of Contractor under the orders or subcontracts so terminated, in which case ASES will have the right, at its discretion, to settle or pay any or all claims arising out of the termination of such orders and subcontracts;

 

	
  

	
35.4.3.5

	
With the approval of ASES, settle all outstanding liabilities and all claims arising out of such termination or orders and subcontracts, the cost of which would be reimbursable in whole or in part, in accordance with the provisions of the Contract;

 

	
  

	
35.4.3.6

	
Complete the performance of such part of the work as shall not have been terminated by the notice of termination;

 

	
  

	
35.4.3.7

	
Take such action as may be necessary, or as ASES may direct, for the protection and preservation of any and all property or information related to the Contract that is in the possession of Contractor and in which ASES has or may acquire an interest;

 

	
  

	
35.4.3.8

	
Promptly make available to ASES, or to another MCO or third party administrator acting on behalf of ASES, any and all records, whether medical or financial, related to the Contractor’s activities undertaken pursuant to this Contract and the Transition Plan.  Such records shall be provided at no expense to ASES;

 

  

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35.4.3.9

	
Promptly supply all information necessary to ASES, or a managed care plan or third party administrator acting on behalf of ASES, for payment of any outstanding Claims at the time of termination subject to the terms of this Contract; and

 

	
  

	
35.4.3.10

	
Submit a Transition Plan to ASES for review and approval, which approval shall not be unreasonably withheld, conditioned or delayed.  Such plan shall include commitments to carry out the following obligations:

 

	
  

	
35.4.3.10.1

	
Maintain Claims processing functions during the Transition Period and the Runoff Period, as necessary, in order to complete adjudication of all Claims.  No Administrative Fee will be paid during the Runoff Period;

 

	
  

	
35.4.3.10.2

	
Comply with all duties and/or obligations incurred prior to the Termination Date of the Contract, including but not limited to, any pending Appeal process as described in Section 14.5 of this Contract;

 

	
  

	
35.4.3.10.3

	
File all Reports require to Article 18 of this Contract during the Term of the Contract (including the Transition Period) in the manner described in this Contract;

 

	
  

	
35.4.3.10.4

	
Ensure the efficient and orderly transition of Enrollees from coverage under this Contract to coverage under any new arrangement developed or agreed to by ASES, including diligent cooperation with another contractor, upon the terms set forth in Article 36;

 

	
  

	
35.4.3.10.5

	
Maintain the financial requirements and insurance set forth in this Contract until the Termination Date;

 

	
  

	
35.4.3.10.6

	
Meet with ASES personnel, as requested, to ensure satisfactory completion of all obligations under the Transition Plan; and

 

  

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35.4.3.10.7

	
Submit Reports to ASES as directed, but no less frequently than every thirty (30) Calendar Days, detailing the Contractor’s progress in completing its obligations under this Contract during the Transition Period, unless otherwise established in Article 18 of this Contract.

 

	
  

	
35.4.4

	
Final Report.  On the Termination Date, the Contractor shall submit a final report to ASES describing how the Contractor has completed its obligations under this Contract as of the Termination Date (the “Final Report”).  ASES will advise, within twenty (20) Calendar Days of receipt of the Final Report, if all of the Contractor’s obligations are discharged.  If ASES finds that the Final Report does not evidence that the Contractor has fulfilled its continuing obligations, then ASES will require the Contractor to submit a revised Final Report to ASES for approval, and take any other action necessary to discharge all of its duties under this Contract, as directed by ASES.  ASES acknowledges that it shall not unreasonably withhold, condition or delay its approval of the Final Report or revised Final Report, as applicable.

 

	
35.5

	
Except as provided in this Article 35, a notification from a Party that it intends to terminate this Contract shall not release the other Party from its obligations under this Contract.

 

	
ARTICLE 36

	
  PHASE IN, PHASE-OUT AND COOPERATION  WITH OTHER CONTRACTORS

 

	
  

	
36.1

	
[Intentionally left blank].

 

	
  

	
36.2

	
If in the best interest of Enrollees of MI Salud, ASES develops and implements new projects that impact the scope of services in the Service Regions, the Contractor shall assist in the implementation process after receiving at least ninety (90) Calendar Days written notice from ASES of such change, and pursuant to written Amendment of the Contract.  The Per Member Per Month Administrative Fee shall be adjusted accordingly and documented in the Amendment.

 

	
  

	
36.3

	
In the event that ASES has entered into, or enters into, agreements with other contractors for additional work related to the Covered Services and Benefits made available by the Contractor hereunder, the Contractor agrees to cooperate fully with such other contractors.  The Contractor shall not commit any act or omission that will interfere with the performance of work by any other contractor, or actions taken by ASES to facilitate the work.

 

  

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36.4

	
If either Party exercises its right of termination under Article 35, the Contractor agrees that it will not engage in any behavior or inaction that prevents or hinders the work of another contractor or ASES, as the case may be.  The Contractor shall continue to comply with the terms of this Contract until the Termination Date, subject to compliance by ASES with its obligations under this Contract including those set forth in Article 22.  Upon receiving ASES’s notice that it intends to terminate the Contract or upon Contractor exercising its limited termination rights, the Parties shall formulate and agree on a written transition plan (the “Transition Plan”) within thirty (30) Calendar Days of receiving or giving the notice, as the case may be.  The Transition Plan shall include all the elements listed in Section 35.8 of this Contract.  The Parties agree that the Contractor will not have successfully met its obligation under this Section until ASES accepts the Contractor’s Transition Plan, which acceptance shall not be unreasonably withheld, conditioned or delayed.

 

	
  

	
36.5

	
Phase Out Transition Period

 

	
  

	
36.5.1

	
The Transition Period shall allow a new physical health care services plan designated by ASES under the MI Salud Program to take over for the Contractor in the Service Regions.  During the Transition Period, this Contract shall remain in full force and effect.

 

	
  

	
36.5.2

	
The Transition Period shall always be deemed to end on the last day of a month, and shall never be of a term of more than one hundred twenty (120) Calendar Days from the date specified under the applicable circumstances in Section 36.  Upon termination of the Transition Period, the Contractor shall not be obligated to continue to provide Administrative Services and arrange for Covered Services except as required under the Patient’s Bill of Rights Act.  The Contractor shall continue all reporting requirements in accordance with the Contract.

 

	
  

	
36.5.3

	
The Contractor will comply with any clarifications, amendments or supplements made to this Contract during the Transition Period as required by applicable federal law or CMS regulations; provided, that the Contractor may contact CMS directly to clarify any doubts regarding to the applicability of any such clarifications, amendments or supplements to this Contract.

 

  

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36.5.4

	
The Parties agree that during the Transition Period and, if applicable, the Runoff Period, the terms and conditions of the Contract shall remain in full force and effect, including but not limited to ASES’ ongoing obligation to pay the Administrative Fee during the Transition Period and Claims Payments during the Transition Period and Runoff Period.

 

	
  

	
36.5.5

	
Continuation and Access of Care

 

	
  

	
36.5.5.1

	
During the Transition Period, the Contractor shall arrange for the continuation of care and access to Covered Services and Benefits for Enrollees as provided and contemplated under the Contract.  To assure continuation of care and access of Covered Services and Benefits during the Transition Period, the Contractor shall comply with the requirements of Section 9.5 and 9.6 of the Contract.  Any proposed change, modification, or reduction in the Provider ratio requirements in Section 9.5 of this Contract or the Network Provider ratio requirements in Section 9.6 of this Contract during the Transition Period must be previously approved in writing by ASES.  If a Provider leaves the Network, the Contractor shall notify Enrollees pursuant to Sections 6.6 of this Contract.

 

	
  

	
36.5.5.2

	
Following the Transition Period, the Contractor shall have no obligation to arrange for the continuation of care and access to Covered Services and Benefits for any Enrollee, except as required under the Patient’s Bill of Right Act.

 

  

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36.5.6

	
Providers’ Claims Payment

 

	
  

	
36.5.6.1

	
The Contractor shall pay Providers’ Claims for Covered Services furnished prior to and during the Transition Period provided ASES has complied with its obligations under this Contract including those set forth in Article 22 of this Contract.

 

	
  

	
36.5.6.2

	
ASES or its designee shall have the right to audit and monitor payments made to Providers during the Transition Period and the Runoff Period.

 

	
  

	
36.5.6.3

	
ASES or its designee may verify the payment process once completed and the verification process may proceed as follows:

 

	
  

	
36.5.6.3.1

	
Final check register for each payment cycle will be provided to ASES or its designee and will be used as the master document for the validation of payments being produced and delivered to Providers.

 

	
  

	
36.5.6.3.2

	
Confirmation to ASES or its designee of the production of checks or electronic wire payments to the Providers, as per the final check registers.  ASES or its designee will confirm the production of the checks by being present at the Contractor’s facility when the Contractor is issuing the checks and at the time the processing of the electronic wire transfers is taking place.

 

	
  

	
36.5.6.3.3

	
Upon notification by the Contractor to ASES or its designee that the production of the checks or the wire transfer will take place, ASES or its designee agree to be present at the Contractor’s facilities as soon as practicable.

 

	
  

	
36.5.6.3.4

	
Confirmation to ASES or its designee of the delivery of payments to Providers either by checks or electronic wire transfer.  The confirmation to ASES may include the examination of the delivery of such payments by ASES or its designee.

 

  

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36.5.6.3.5

	
Certification issued by the Contractor that the checks to Providers reflected in the final check registers were duly issued and mailed to Providers.

 

	
  

	
36.5.6.3.6

	
ASES retains the ability to reasonably request and receive pertinent documents from the Contractor with respect to confirmation of payments made by the Contractor to Providers.  This may include, at ASES’s discretion, but pursuant to and as provided in the Contract, without limitation the actual examination of pertinent documents, other than checks, as they are processed through the payment cycle.

 

	
  

	
36.5.6.3.7

	
The monitoring process may include the verification by ASES or its designee of the delivery of the corresponding payments made by the Contractor to the corresponding Providers, including the presence of ASES or its designee at the time of actual delivery of the checks to the Providers.  In the case such delivery consists in payment by mail, ASES retains the ability to monitor the delivery of such payments to the US Post Office, either by the Contractor or by any Subcontractor retained by the Contractor to perform such delivery.

 

	
  

	
36.5.6.3.8

	
ASES or its designee may reasonably request information regarding advances of future payment of Claims made by the Contractor to its Providers.

 

	
  

	
36.5.6.3.9

	
The activities of ASES or its designee shall in no manner unduly or unreasonably delay, disrupt or interfere with the Contractor’s customary process for Claims payment to Providers.

 

  

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36.5.6.3.10

	
ASES acknowledges that in order for the Contractor to process the cycle of payments to Providers as hereby contemplated during the Contract Term (inclusive of the Transition Period) and the Runoff Period, it must receive the Claims Payment in accordance with the Contract.

 

	
  

	
36.5.6.4

	
The Contractor shall process all Claims for Covered Services provided during the Contract Term (inclusive of the Transition Period) and the Runoff Period, provided ASES has complied with its obligations under this Contract including those set forth in Article 22.

 

	
  

	
36.5.6.5

	
During the Transition Period and Runoff Period, the Contractor shall continue to comply with all Claims reporting requirements in this Contract.

 

	
  

	
36.5.7

	
Grievance System

 

	
  

	
36.5.7.1

	
The Contractor shall comply with all duties and/or obligations incurred under the Contract during the Transition Period, with respect to the Grievance System process established in Article 14 of the Contract.

 

	
  

	
36.5.8

	
Phase-Out Transition Reports and Meetings

 

	
  

	
36.5.8.1

	
The Contractor shall file, on a timely basis, all necessary Reports concerning the operations of the Contractor pursuant to the Contract, including the Transition Period and the Runoff Period as required by applicable law and as otherwise required pursuant to this Contract.  The Contractor shall also deliver Reports concerning the operations of the Contractor with respect to the MI Salud Program reasonably requested by ASES throughout the duration of the Transition Period or the Runoff Period, as the case may be (collectively “Transition Reports”).  Unless otherwise specifically indicated, the Contractor shall use Reasonable Efforts to submit to ASES any Transition Reports requested by ASES at least three (3) Calendar Days prior to the due date of any such Report, provided the request is made during normal business hours Monday through Thursday, excluding Friday and holidays, unless otherwise a shorter period is reasonably warranted under the then existing circumstances.

 

  

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36.5.8.2

	
ASES shall provide Transition Report templates.  ASES will provide training on the Transition Report templates.

 

	
  

	
36.5.8.2.1

	
Transition Reports may include the following: (i) Grievances and Appeals (Enrollee complaints, grievances, notices of Action, Appeals, and Administrative Law Hearing requests); (ii) Enrollee and Provider Mailings (ID cards mailed to Enrollees, Enrollee and Provider notices mailed and date mailed, Enrollee notices returned to the Contractor); (iii) Provider Network (network report by Provider type including Providers leaving the Contractor Provider network (General or PPN) to ensure network adequacy as defined in the Contract during the Transition Period); (iv) Financial Management and Claims Payment (financial records, encounter data, paid, pending, and denied Claims); (v) Call Center Operations, and (vi) PMG Services and Payments.

 

	
  

	
36.5.8.3

	
ASES and the Contractor shall meet with each other’s personnel, as reasonably requested, to ensure satisfactory completion of all obligations under the Contract, the Transition Period or Runoff Period, including, but not limited to weekly meetings and designating a transition team and a team leader.

 

	
36.6

	
Phase-In Transition Reports and Meetings

 

	
  

	
36.6.1

	
Upon request by ASES, the Contractor shall assist and diligently cooperate with other contractors that ASES enters into agreement with during the Transition Period.

 

  

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36.6.1.1

	
The Contractor cooperation and assistance includes, but is not limited to, submission of data and reports as reasonably required by ASES to protect the Enrollees and to promote continuity of care.

 

	
  

	
36.6.2

	
External Quality Review

 

	
  

	
36.6.2.1

	
The Contractor shall be available to participate in the EQRO’s onsite evaluation process during the Transition Period.  The Contractor shall assist the EQRO with all reasonable requests including, but not limited to, providing samples of Grievances for the period covered by the Contract Term, by Service Region.

 

	
  

	
36.6.2.2

	
The HEDIS activity for calendar year 2013 shall be prepared by the new physical health service provider or providers.  The Contractor shall provide all HEDIS data to the new physical health service provider or providers, as of the Termination Date of the Contract.

 

	
  

	
36.6.3

	
Notices and Communications to Enrollees and Providers

 

	
  

	
36.6.3.1

	
The Contractor shall make all necessary notices to Enrollees and Providers as may be legally required under the Contract, or otherwise required under applicable law during the Transition Period.  Such notices shall be previously approved in writing by ASES.

 

	
  

	
36.6.4

	
Call Centers

 

	
  

	
36.6.4.1

	
The call center scripts used during the Transition Period shall be previously approved in writing by ASES.

 

	
  

	
36.6.5

	
Records Retention

 

	
  

	
36.6.5.1

	
The Contractor shall abide by the record retention schedule provided by ASES in compliance with the Contract.  Records must be provided and made available to ASES for inspection and audit for a period of seven (7) years from the date of final payment under the Contract, the Transition Period or the Runoff Period, as applicable.  The Contractor shall provide ASES during normal business hours, the right to inspect these records during the seven (7) year period specified in the Contract.

 

  

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36.7

	
ASES Obligations

 

	
  

	
36.7.1

	
ASES shall continue to pay the Contractor its Administrative Fee pursuant to the terms of the Contract until the Termination Date of the Contract, inclusive of the Transition Period.

 

	
  

	
36.7.2

	
ASES shall process the Per Member Per Month Administrative Fee corresponding to Enrollees that were enrolled during the last month of the Transition Period to calculate the Administrative Fee.  This Administrative Fee will be due on the next month following the termination of the Transition Period.

 

	
  

	
36.7.3

	
During the Transition Period, ASES will continue submitting to the Contractor the eligibility files, including new eligible, cancellations, rejections and full files.

 

	
36.8

	
Contractor Objections to Payment

 

	
  

	
36.8.1

	
The Contractor shall present to ASES, in accordance with the provisions of the Contract, any objections to payment of Claims Payment or the Administrative Fee payment due or other amounts due by ASES to the Contractor under the Contract, as the case may be.

 

	
  

	
36.8.2

	
Once ASES submits to the Contractor the payment file corresponding to the last month of the Transition Period, the Contractor will have ninety (90) Calendar Days from the date the Contractor receives the detailed payment file to reconcile the Administrative Fee and submit the enrollment discrepancies and corrections to ASES for processing.

 

	
36.9

	
Runoff Period

 

	
  

	
36.9.1

	
During the Runoff Period the Contractor shall:

 

	
  

	
36.9.1.1

	
Arrange for the continuation of care and access to Covered Services and Benefits for those certain Enrollees specified, and under the circumstances described, in Section 36.5.5.2 of this Contract; provided, that ASES shall be responsible for the payment of such services in accordance with Article 22 of this Contract;

 

	
  

	
36.9.1.2

	
Pay Providers’ Claims for Covered Services furnished to Enrollees prior to and during the Transition Period provided ASES has complied with its obligations under this Contract including those set forth in Article 22 of this Contract;

 

  

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36.9.1.3

	
Provide to ASES upon its reasonable request Transition Reports regarding the operations of the Contractor with respect to the MI Salud Program during the Runoff Period; and

 

	
  

	
36.9.1.4

	
Cooperate and meet with representatives of ASES at mutually agreed upon times to review and facilitate the Contractor’s provision of its limited Administrative Services described in this Section 36.9.1 of this Contract during the Runoff Period.

 

	
  

	
36.9.2

	
During the Runoff Period ASES shall:

 

	
  

	
36.9.2.1

	
Make Claims Payments to the Contractor pursuant to Article 22 of this Contract to enable the Contractor to pay Providers’ Claims for Covered Services furnished to Enrollees prior to and during the Transition Period;

 

	
  

	
36.9.2.2

	
Provide to the Contractor upon its reasonable request such information, including but not limited to information described in Article 4 of this Contract, reasonably necessary for the Contractor to render its limited Administrative Services as described in Section 36.9.1 of this Contract during the Runoff Period; and

 

	
  

	
36.9.2.3

	
Cooperate and meet with representatives of the Contractor at mutually agreed upon times to review and facilitate the Contractor’s provision of its limited Administrative Services described in this Section 36.9.1 of this Contract during the Runoff Period.

 

	
ARTICLE 37

	
INSURANCE

 

	
  

	
37.1

	
The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance policies identified below at the Contractor’s own cost and expense and shall furnish ASES with proof of coverage at least in the amounts indicated.  It shall be the responsibility of the Contractor to require any Subcontractor to secure the same insurance coverage as prescribed herein for the Contractor, and to obtain a certificate evidencing that such insurance is in effect. In the event that any such insurance is proposed to be reduced, terminated or cancelled for any reason, the Contractor shall provide to ASES at least thirty (30) Calendar Days prior written notice.  Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall secure replacement coverage upon the same terms and provisions to ensure no lapse in coverage, and shall furnish, at the request of ASES, a certificate of insurance indicating the required coverage.  The provisions of this Section shall survive the expiration or termination of this Contract for any reason.  The Contractor shall maintain insurance coverage sufficient to insure against claims arising at any time during the term of the Contract, consisting of the following:

 

  

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37.1.1

	
Workers’ Compensation Insurance, the policy(ies) to insure the statutory limits established by law of the Commonwealth. The Workers’ Compensation Policy must include Coverage B – Employer’s Liability Limits of:

 

	
  

	
37.1.1.1

	
Bodily injury by accident:  five hundred thousand dollars ($500,000) each accident;

 

	
  

	
37.1.1.2

	
Bodily Injury by Disease: five hundred thousand dollars ($500,000) each employee; and

 

	
  

	
37.1.1.3

	
One million dollars ($1,000,000) policy limits.

 

	
  

	
37.1.2

	
The Contractor shall require all Subcontractors performing work under this Contract to obtain an insurance certificate showing proof of Worker’s Compensation Coverage.

 

	
  

	
37.1.3

	
The Contractor shall have commercial general liability policy(ies) as follows:

 

	
  

	
37.1.3.1

	
Combined single limits of one million dollars ($1,000,000) per person and three million dollars ($3,000,000) per occurrence;

 

	
  

	
37.1.3.2

	
On an “occurrence” basis; and

 

	
  

	
37.1.3.3

	
Liability for property damage in the amount of three million dollars ($3,000,000) including contents coverage for all records maintained pursuant to this Contract.

 

  

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ARTICLE 38

	
COMPLIANCE WITH ALL LAWS

 

	
38.1

	
Nondiscrimination

 

	
  

	
38.1.1

	
The Contractor shall comply with applicable federal and Puerto Rico laws, rules, and regulations, and the Puerto Rico policy relative to nondiscrimination in employment practices because of political affiliation, religion, race, color, sex, physical handicap, age, or national origin.  Applicable federal nondiscrimination law includes, but is not limited to, Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972, as amended; the Age Discrimination Act of 1975, as amended; Equal Employment Opportunity and its implementing regulations (45 CFR 74 Appendix A (1), Executive Order 11246 and 11375); the Rehabilitation Act of 1973; and the Americans with Disabilities Act of 1993 and its implementing regulations (including but not limited to 28 CFR § 35.101 et seq.). Nondiscrimination in employment practices is applicable to employees for employment, promotions, dismissal and other elements affecting employment.

 

	
  

	
38.1.2

	
The Contractor shall comply with all applicable provisions of the Puerto Rico Patient’s Bill of Rights and its implementing regulation, which prohibit discrimination against any patient.

 

	
38.2

	
Compliance with All Laws

 

	
  

	
38.2.1

	
Each Party agrees that it will comply fully with and abide by all federal and Puerto Rico laws, rules, regulations, statutes, policies, or procedures that may govern the Contract, including but not limited to those listed in Attachment 1, to the extent applicable.

 

	
  

	
38.2.2

	
Subject to Sections 35.1.1.5, 35.1.3.4, 38.26 and 55.2 of this Contract, all Puerto Rico and federal laws, rules, and regulations, consent decrees, court orders, policy letters and normative letters, and policies and procedures, including but not limited to those described in Attachment 1, are hereby incorporated by reference into this Contract to the extent applicable.

 

	
  

	
38.2.3

	
To the extent that applicable laws, rules, regulations, statutes, policies, or procedures require the Contractor to take action or inaction, any costs, expenses, or fees associated with that action or inaction shall be borne and paid by the Contractor solely.  Such compliance-associated costs include, but are not limited to, attorneys’ fees, accounting fees, research costs, or consultant costs, where these costs are related to, arise from, or are caused by compliance with any and all laws.

 

  

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38.2.4

	
The Contractor shall include notice of grantor agency requirements and regulations pertaining to reporting and patient rights under any contracts involving research, developmental, experimental or demonstration work with respect to any discovery or invention which arises or is developed in the course of or under such contract, and of grantor agency requirements and regulations pertaining to copyrights and rights in data.

 

	
  

	
38.2.5

	
The Contractor certifies and warrants to ASES that at the time of execution of this Contract: (i) it is a corporation duly authorized to conduct business in Puerto Rico, and has filed all the required income tax returns for the preceding five years; and (ii) it filed its report due with the Office of the Commissioner of Insurance during the five (5) years preceding the Effective Date of this Contract.

 

	
  

	
38.2.6

	
Notwithstanding any other provision of this Contract to the contrary, if, as a result of (i) any change in or adoption of any Puerto Rico and/or federal laws, rules, regulations, policies, or procedures, or the interpretation of such laws, rules, regulations, policies, or procedures, including without limitation, those from CMS or any change to the Medicaid State plan, (ii) any amendment of this Contact pursuant to Section , (iii) any change required pursuant to Section 56.2 due to changes, clarifications, or supplementations as a result of CMS requirements, or (iv) any change in an adoption of any MI Salud Policies and Procedures, either Party is adversely affected by such change, it may so notify the other Party.  The Parties shall use good faith efforts to promptly renegotiate, in a term not to exceed thirty (30) Business Days, the Administrative Fee and amend the Contract to reflect the additional cost and expenses to the Contractor as a result of such change or amendment.

 

	
ARTICLE 39

	
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

 

	
39.1

	
The duty to provide information about interests and conflicting relations is continuous and extends throughout the Contract Term.

 

	
39.2

	
The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirect, that would conflict in any material manner or degree with, or have a material adverse effect on the performance of its services hereunder.  The Contractor further covenants that in the performance of the Contract no person having any such interest shall be employed.  The Contractor shall submit a conflict of interest form, attesting to these same facts, by January 10 of each calendar year; and at any time, within fifteen (15) Calendar Days of request by ASES.  The form will be included in Attachment 12.

 

  

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39.3

	
It shall be the responsibility of the Contractor to maintain independence and to establish necessary policies and procedures to assist the Contractor in determining if the actual Contractors performing work under this Contract have any impairment to their independence.

 

	
39.4

	
The Contractor further agrees to take all necessary actions to eliminate threats to impartiality and independence, including but not limited to reassigning, removing, or terminating Providers or Subcontractors.

 

	
39.5

	
ASES acknowledges that it has no objections to the Contractor during the Term of this Contract acquiring and operating, through an affiliated HMO organized under Chapter 19 of the Puerto Rico Insurance Code, health facilities that may provide Covered Services to Enrollees in the MI Salud Program. Upon the request of the Contractor, ASES shall request the opinion of the Puerto Rico Department of Justice confirming that any such action by the Contractor and its affiliated HMO would not adversely affect the Contractor’s ability to comply with applicable Puerto Rico law.

 

	
39.6

	
ASES acknowledges that: (i) the Contractor has disclosed to ASES that the Contractor holds a minority ownership interest in NeoDeck Holdings, Inc., a software development company that offers a certified EHR system that meets the specifications in Attachment 15 of this Contract; and (ii) Network Providers may select the NeoDeck EHR system, from among other EHR Systems produced by other software developers with which the Contractor has no affiliation, to meet their obligations to implement and maintain an EHR system in accordance with the specifications set forth in Attachment 15 of this Contract.  The Contractor acknowledges that it will not require the use of NeoDeck Holdings, Inc.’s EHR system to satisfy such Provider obligation.

 

	
ARTICLE 40

	
CHOICE OF LAW OR VENUE

 

	
40.1

	
This Contract shall be governed in all respects by the laws of Puerto Rico.  Any lawsuit or other action brought against ASES or the Commonwealth based upon or arising from this Contract shall be brought in a court or other forum of competent jurisdiction of the Commonwealth of Puerto Rico.

 

	
ARTICLE 41

	
THIRD-PARTY BENEFICIARIES

 

	
 

	
41.1

	
Except as expressly provided herein, no term or provision hereof shall be construed in any way to grant, convey or create any rights or interest to or in any person or entity not a Party to this Contract, except with respect to payments to Providers that have rendered Covered Services and Benefits to Enrollees in the MI Salud Plan as set forth in this Contract.

 

  

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ARTICLE 42

	
SURVIVABILITY

 

	
  

	
42.1

	
The representations and warranties made by the Parties in this Contract shall survive the delivery or provision of all services hereunder.

 

	
ARTICLE 43

	
PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

 

	
  

	
43.1

	
The Contractor certifies that it is not presently debarred, suspended, proposed for debarment or declared ineligible for award of contracts by any federal or Puerto Rico agency, as provided in Section 13.4 of this Contract.  In addition, the Contractor certifies that, to the best of its knowledge based on its compliance with the procedures established in Section 9.4.9 of this Contract, it does not presently employ or subcontract with any person or entity that could be excluded from participation in the Medicaid Program under 42 CFR 1001.1001 (exclusion of entities owned or controlled by a sanctioned person) or 1001.1051 (exclusion of individuals with ownership or control interest in sanctioned entities).  Any violation of this Article shall be grounds for termination pursuant to Article 35 of this Contract.

 

	
ARTICLE 44

	
WAIVER

 

	
  

	
44.1

	
The waiver by either Party of any breach of any provision contained in this Contract by the other Party shall not be deemed to be a waiver of such provision on any subsequent breach of the same or any other provision contained in this Contract and shall not establish a course of performance between the Parties contradictory to the terms hereof.

 

	
ARTICLE 45

	
FORCE MAJEURE

 

	
  

	
45.1

	
Neither Party to this Contract shall be responsible for delays or failures in performance resulting from acts beyond the control of such Party. Such acts shall include, but not be limited to, acts of God, strikes, riots, lockouts, acts of war, epidemics, fire, earthquakes, or other disasters.

 

	
ARTICLE 46

	
BINDING

 

	
  

	
46.1

	
This Contract and all of its terms, conditions, requirements, and amendments shall be binding on ASES and the Contractor and their respective successors and permitted assigns.

 

  

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ARTICLE 47

	
TIME IS OF THE ESSENCE

 

	
  

	
47.1

	
Time is of the essence in this Contract. Any reference to “Days” shall be deemed Calendar Days unless otherwise specifically stated.

 

	
ARTICLE 48

	
AUTHORITY

 

	
  

	
48.1

	
ASES has full power and authority to enter into this Contract, and the person signing on behalf of ASES has been properly authorized and empowered to enter into this Contract on behalf of ASES and to bind ASES to the terms of this Contract.  The Contractor has full power and authority to enter into this Contract, and the person signing on behalf of the Contractor has been properly authorized and empowered to enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms of this Contract.  Each Party further acknowledges that it has had the opportunity to consult with and/or retain legal counsel of its choice, read this Contract.  Each party acknowledges that it understands this Contract and agrees to be bound by it.

 

	
ARTICLE 49

	
ETHICS IN PUBLIC CONTRACTING

	
  

	
49.1

	
The Contractor understands, states, and certifies that it made its proposal without collusion or fraud and that it did not offer or receive any kickbacks or other inducements from any other contractor, supplier, manufacturer, or subcontractor in connection with its proposal.

	
ARTICLE 50

	
INFORMAL DISPUTE RESOLUTION PROCEDURES.

	
  

	
50.1

	
The Parties agree that, at all times, they will attempt in good faith to resolve all disputes that may arise under this Contract.  The Parties further agree that, upon receipt of written notice of a dispute from a Party, the Parties shall refer the dispute to the designated person of each Party.  The designated persons shall negotiate in good faith to resolve the dispute, conferring as often as they deem reasonably necessary, and shall gather and in good faith furnish to each other the information pertinent to the dispute.  Statements made by representatives of the Parties during the dispute resolution mechanisms set forth in this Article 51 and documents specifically created for such dispute resolution mechanisms shall be considered part of settlement negotiations and shall not be admissible in evidence in any proceeding without the mutual written consent of the Parties.

 

  

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50.2

	
The Parties agree that this Article 50 will not apply to the procedures in Articles 19 and 20 of this Contract.

 

	
ARTICLE 51

	
SECTION TITLES NOT CONTROLLING

 

	
  

	
51.1

	
The Section and Article titles used in this Contract are for reference purposes only and shall not be deemed a part of this Contract.

 

	
ARTICLE 52

	
HOLD HARMLESS

 

	
  

	
52.1

	
The Contractor shall indemnify and hold ASES, and its officers and directors harmless from and against all losses, damages, claims, demands, fines, costs, penalties, liabilities and expenses of every kind, including but not limited to reasonable attorneys’ fees (collectively, “Losses”) to which they may be subjected based on or arising from (i) the acts or omissions of the Contractor, or its employees and permitted assigns in the conduct, performance, or execution of any obligation of the Contractor under this Contract; or (ii) any breach by the Contractor of any of its representations or warranties contained in this Contract.  The Parties acknowledge that the Contractor shall not be liable for any such Losses to the extent that such Losses are caused by or arise from the negligence or willful misconduct of ASES.

 

	
  

	
52.2

	
ASES shall indemnify and hold the Contractor, Triple-C, Inc., and their respective officers and directors harmless from and against all Losses to which they may be subjected: (i) based on or arising from the acts or omissions of the ASES or its employees, and permitted assigns in the conduct, performance, or execution of any obligation of ASES under this Contract; (ii) based on or arising from any breach by ASES of any of its representations or warranties contained in this Contract; (iii) by any FQHC with respect to any dispute regarding payment for any FQHC Service provided outside the scope of this Contract; or (iv) by any Provider, PMG or Enrollee on account of the conduct, performance, execution, decisions, and representations of MCS during its tenure and administration of the MI Salud Program in the Service Regions.  ASES further agrees that the Contractor shall not be liable for the financial condition of any PMG or Provider who served an Enrollee in the Service Regions during such tenure and administration or for monies owed or that may be owed by MCS to such PMG or Provider.  The Parties acknowledge that ASES shall not be liable for any such Losses to the extent that such Losses are caused by or arise from the negligence or willful misconduct of the Contractor.

 

  

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ARTICLE 53

	
COOPERATION WITH AUDITS

 

	
  

	
53.1

	
The Contractor agrees to assist and cooperate with ASES in any and all matters and activities related to or arising out of any audit or review, whether federal or internal in nature.

 

	
  

	
53.2

	
The Parties also agree that each Party shall be solely responsible for any costs it incurs for any audit related inquiries or matters.  Moreover, neither party may charge or collect any fees or compensation from the other party for any matter, activity, or inquiry related to, arising out of, or based on an audit or review.

 

	
ARTICLE 54

	
OWNERSHIP AND FINANCIAL DISCLOSURE

 

	
  

	
54.1

	
The Contractor shall disclose financial statements for each person or corporation with a direct ownership or control interest of five percent (5%) or more in the Contractor’s entity.

 

	
ARTICLE 55

	
AMENDMENT IN WRITING

 

	
  

	
55.1

	
No amendment, waiver, termination or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either party unless confirmed in writing.  Additionally, CMS approval shall be required before any such amendment is effective.  Any agreement of the Parties to amend, modify, eliminate, or otherwise change any part of this Contract shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.

 

	
  

	
55.2

	
ASES reserves the authority to seek an amendment of this Contract at any time if such amendment is necessary in order for the terms of this Contract to comply with federal law or a CMS requirement, and the Contractor shall consent to any such amendment, subject to its renegotiation rights under Section 38.2.6 of this Contract and its termination rights under Section 35.1.3.4 of this Contract.

 

	
ARTICLE 56

	
CONTRACT ASSIGNMENT

 

	
  

	
56.1

	
Contractor shall not assign this Contract, in whole or in part, without the prior written consent of ASES, and any attempted assignment not in accordance herewith shall be null and void and of no force or effect. Notwithstanding the foregoing, the Contractor shall have a right to delegate any obligation arising hereunder or to assign this Contract to Triple-C, Inc., its corporate affiliate, upon prior written notice to ASES.

 

  

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ARTICLE 57

	
SEVERABILITY

 

	
  

	
57.1

	
Any section, subsection, paragraph, term, condition, provision, or other part of this Contract that is judged, held, found or declared to be voidable, void, invalid, illegal or otherwise not fully enforceable shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be of full force and effect as set out herein.

 

	
ARTICLE 58

	
ENTIRE AGREEMENT

 

	
  

	
58.1

	
This Contract constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations or contracts. No written or oral agreements, representatives, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding or of effect between the parties.

 

	
  

	
58.2

	
All applicable laws as in effect on the Effective Date of the Contract are incorporated by reference into this Contract, as provided in Section 38.2.

 

	
  

	
58.3

	
Subject to Section 38.2.6 of this Contract, the Contractor acknowledges that it may be necessary or convenient during the Term of this Contract to clarify or supplement certain terms and conditions of this Contract to conform it to or otherwise to incorporate CMS requirements.  In any of these events, the Contractor agrees that ASES shall have the right to issue from time to time normative letters which shall be then incorporated into the Contract.  Such normative letters are advisory in nature, and shall not, absent an amendment to the Contract, change the Contractor’s obligations under this Contract.

 

	
ARTICLE 59

	
NOTICES

 

	
  

	
59.1

	
All notices, consents, approvals and requests required or permitted shall be given in writing and shall be effective for all purposes if hand delivered or sent by (a) personal delivery, (b) expedited prepaid delivery service, either commercial or United States Postal Service, with proof of attempted delivery, or (c) telecopier or (d) electronic mail (in each case of (c) and (d), with answer back acknowledged, addressed as follows:

 

	
  

	
59.1.1

	
If to ASES at:

 

  

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Mailing Address:

 

Administración de Seguros de Salud

P.O. Box 195661

San Juan, PR 00919-5661

	
Physical Address:

 

Urb. Caribe 1552

Ave. Ponce de León, Sec. El Cinco

San Juan, PR 00926-2706

 

Attention: Executive Director

 

	
  

	
59.1.2

	
If to Contractor at:

 

	
Mailing Address:

 

Triple-S Salud, Inc.

P.O. Box 363628

San Juan, PR  00936-3628

	
Physical Address:

 

Triple-S Salud, Inc.

1441 Ave. Roosevelt, 6th Floor

San Juan, PR  00920

 

Attention:  President

 

	
  

	
59.1.3

	
All notices, elections, requests and demands under this Contract shall be effective and deemed received upon the earliest of (i) the actual receipt of the same by personal delivery or otherwise, (ii) two (2) Business Days after being deposited with a nationally recognized overnight courier service as required above, (iii) three (3) Business Days after being deposited in the United States mail as required above or (iv) on the day sent if sent by facsimile with voice confirmation on or before 4:00 p.m. Puerto Rico time on any Business Day or on the next Business Day if so delivered after 4:00 p.m. Puerto Rico time or on any day other than a Business Day.  Rejection or other refusal to accept or the inability to deliver because of changed address of which no notice was given as herein required shall be deemed to be receipt of the notice, election, request, or demand sent.

 

	
ARTICLE 60

	
OFFICE OF THE COMPTROLLER

 

	
  

	
60.1

	
ASES will file this Contract before the Office of the Comptroller of Puerto Rico within fifteen (15) Calendar Days from the Effective Date.

 

	
ARTICLE 61

	
PHASE OUT AND PHASE IN OF ADDITIONAL SERVICE REGIONS

 

	
  

	
61.1

	
ASES and Humana Health Plans of Puerto Rico, Inc., (“Humana”) entered into a Restated Contract dated as of June13, 2011 (the “Humana Contract”) for the provision of Covered Services in the Southwest, Southeast and East Regions (collectively the “Humana Regions”).  ASES and Humana were unable to agree on the Per Member Per Month fee for each of the Humana Regions for Fiscal Year 2013-2014, and therefore, ASES elected not to renew the Humana Contract, which terminated under the terms thereof on June 30, 2013 (the “Humana Termination Date”).

 

  

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61.2

	
Under the terms of Section 34.8.2.10 and Section 35.4 of the Humana Contract, Humana is required to submit a transition plan (the ”Transition Plan”) which, among other requirements, (i) must maintain Claims processing functions for ten (10) consecutive months from the Humana Termination Date, (ii) complete adjudication of all Claims and (iii) ensure the efficient and orderly transition of Enrollees in the Humana Regions from coverage under the Humana Contract to any new arrangement agreed to by ASES, including cooperation with the contractor selected by ASES to take over the provision of Covered Services in the Humana Regions.  In addition, and as mandated by the Patient’s Bill of Rights, Humana is required to notify the Beneficiaries in the Humana Regions of the non-renewal of the Humana Contract and is obligated to continue to render Covered Services during a period of ninety (90) Calendar Days from the Humana Termination Date (such period, as may be shortened by ASES and Humana in writing, shall be referred to as the “Transition Period”).

 

	
  

	

61.3

	
The Contractor and ASES have agreed that (i) once the Transition Period terminates and (ii) the terms and conditions of the Transition Plan have been complied with by Humana, to ASES’ satisfaction, but (iii) no later than October 1, 2013, the Contractor shall commence to render Covered Services to Enrollees in the Humana Regions under the terms and conditions of this Contract (the “Humana Regions Effective Date). The Parties agree to execute a written instrument confirming the Humana Regions Effective Date, which instrument shall be considered as a supplement to this Contract.

 

	
  

	

61.4

	

Commencing on the Human Regions Effective Date, subject to all the terms and conditions of the Contract:

 

	
  

	
61.4.1

	
Each of the Humana Regions shall be considered a Service Region for all purposes of the Contract;

 

	
  

	
61.4.2

	
The Contractor shall perform the Administrative Services in each Humana Region; and

 

	
  

	
61.4.3

	
ASES shall pay the Contractor the Per Member Per Month Administrative Fee indicated below for each Humana Region:

 

  

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	Southwest	$5.44;
	 	 
	Southeast	$5.50; and
	 	 
	East	$5.21.

 

	
  

	

61.5

	

The Parties agree to negotiate in good faith with respect to any circumstances; needs or requirements not contemplated in the Transition Plan or that otherwise arise during the Transition Period to ensure the efficient and orderly transition of Enrollees in the Humana Regions from coverage under the Humana Contract to coverage under the Contract.

 

(Signatures on following page)

 

  

Page 326 of 327

  

SIGNATURE PAGE

IN WITNESS WHEREOF, the parties state and affirm that they are duly authorized to bind the respected entities designated below as of the Effective Date.

ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

 

	(signed) 	 	 7/1/2013	 
	Ricardo A. Rivera Cardona 	 	 Date
	Executive Director 	 	 

	 TRIPLE-S SALUD, INC.	 	 	 
	 	 	 	 
	(signed) 	 	 7/1/2013	 
	Pablo Almodóvar 	 	 Date
	President and Chief Executive Officer	 	 
	 	 	 

                                                                          

 

  

Page 327 of 327

  

                                                                                

Puerto Rico MiSalud Model TPA Contract

Index of Attachments

 

	
Attachment

	
Attachment #

	
Applicable Federal and Puerto Rico Laws

	
1

	
Map of Geographical Service Regions

	
2

	
ASES Universal Beneficiary Guidelines

	
3

	
List of CPTET Centers and Community Board Organizations 

	
4

	
Master Formulary (as of March 21, 2013 for Physical Health, and December 13 for Mental Health). 

Includes the following documents:

	
5 

	
● 

	
“List of Specialty Drugs (contracted) Physical Health 2013-2014”

	  
	
● 

	
Normative Letter 11-0119

	  
	
● 

	
“List of Preferred Drugs – Physical Health 2013-2014”

	  
	
Retail Pharmacy Reimbursement Levels

	
6

	
Uniform Guide for Special Coverage (as of July, 2009)

	
7

	
Enrollee Co-Payment Chart (as of July 1, 2013)

	
8

	
Information System Process and Data Exchange Layout, including:

	  
	
● 

	
Enrollment Manual (as of June 2011)

	  
	  	
o 

	
Addendum b – Enroll Relationship Requirements (Enrollment Record Layout)

	  
	  	
o 

	
Addendum c – Error Code Table (Subscription File Error Description)

	  
	  	
o 

	
Addendum d – Carrier Eligibility File Layout (Family Record, Member Record)

	  
	  	
o 

	
Addendum e – Flow Diagram

	  
	
● 

	
ASES 820 Mapping

	
9

	
 ● 

	
ASES Query Process

	  
	  	
o 

	
Eligibility File Layout (as of August 1, 2008)

	  
	  	
o 

	
Query Response File Layout, with Query Response Flow (as of October 2008)

	  
	
● 

	
Carrier to ASES Data Submissions: Version 1.7C (File layouts as of May 10, 2011)

	  
	
Projected Medical Cost by Region

Calculation to threshold Per Member Per Month

	
10

	
Administrative Fee

	
11

	
Deliverables

	
12

	
Normative Letters:

	  
	
 ● 

	
ASES Normative Letter 10-10-06  “Medical Services Contracted for the year 2011”

	  
	
 ● 

	
Amendment to ASES Normative Letter 10-10-06 (issued October 2, 2011)

	  
	
 ● 

	
Normative Letter 11-06-29 (issued June 29, 2011)

	  
	
 ● 

	
ASES Normative Letter 04-130 (issued February 13, 2004)

	
13

	
 ● 

	
PRICO Normative Letter CA-I-2-1232-91 (issued February 21, 1991)

	  
	
 ● 

	
Special Needs Children Diagnostic Codes (issued December 23, 2008)

	  
	
Program Integrity Guidelines (2013-2014)

	
14

	
Electronic Health Record Specifications

	
15

	
Distribution of Risk for Covered Risks

	
16

	
List of Subcontractors

	
17

	
ASES 90 Day Supple (10-25-2011)

	
18

	
Auto Enrollment: Protocol for Dispatch of Prescription Drugs

	
19

	
Authorization of Automated Clearing House (ACH) Payment

	
20

	
Network Provider Lists (Master File Templates)

●       Mental Health

●       Physical Health

	
21

	
Strategic Plan for Health Information Organization (HIO)

	
22

	
Provider Fee Schedule Locators

	
23

	
ASES Template Reports

	
24

 

  

  

  

 

ATTACHMENT 1

Relevant Puerto Rico and Federal Laws and Regulations

Applicable Puerto Rico laws and regulations:

 

	
●

	
Act 72 of September 7, 1993, as amended, known as “Puerto Rico Health Insurance Administration Law”.

	
●

	
Puerto Rico Insurance Code and its applicable regulations.

	
●

	
Act 81 of May 14, 1912; known as “Organic Law for the Puerto Rico Health Department”

	
●

	
Act 194 of August 25, 2000, as amended, known as “The Declaration of Patient’s Rights and Responsibilities”

	
●

	
Act 408 of October 2, 2000, as amended, known as “Puerto Rico Pharmacy Law”

	
●

	
Act 11 of April 11, 2011, as amended, known as “Organic Law of the Office of Patient Advocate”

	
●

	
Act 247 of September 3, 2004, as amended, known as the “Puerto Rico Pharmacy Law”

	
●

	
Act 139 of August 1, 2008, as amended, known as “Law for the Medical Licensing and Discipline Board”

	
●

	
Act 109 of June 28, 1974, as amended, known as “Law for the Puerto Rico Public Services Commission”

	
●

	
Act 225 of July 23, 1974, as amended, known as “Law for Ambulance Services”

	
●

	
The Public Services Commission’s Regulations for ambulance services in Puerto Rico, Regulation Num. 6737 of December 1, 2003.

	
●

	
Act 86 of August 16, 1997, known as “Law for Residents of Culebra and Vieques”

	
●

	
Act 27 of August 12, 1999, known as “Law for the Implementation of the Public Policy on Suicide Prevention”

	
●

	
Act 243 of November 10, 2006, known as “Law to establish the public policy concerning the use of the Social Security Number for identification and the protection of its confidentiality”

	
●

	
Act 84 of June 18, 2002, known as “Code of Ethics for Contractors, Suppliers and Applicants for Economic Incentives from the Executive Agencies of the Commonwealth”

	
●

	
Act 12 of July 24, 1985, as amended, known as the “Government Ethics Law”

	
●

	
Act 458 of December 29, 2000, as amended, known as “Law to Prohibit the Adjudication of Auctions to convicts of Fraud, Embezzlement or Illegal Misappropriation of Public Funds”

	
●

	
Act 70 of August 12, 1988, as amended, known as the “Puerto Rico Uniform Administrative Proceedings Law”

 

Applicable federal laws and regulations:

	
  

	 

	
●

	
Puerto Rico Health Department’s State Plan (“Medicaid State Plan” and “CHIPS State Plan”

	
●

	
Title XIX of the Medical Assistance Program (“Grants to States for Medical Assistance Programs”)

	
●

	
Title XXI of the Social Security Act, Children’s Health Insurance Program (“CHIP”)

	
●

	
Federal rules and Regulations as established by the Center for Medicare & Medicaid Services (“CMS”) and the Checklist for Managed Care Contract Approval including, but not limited to: 42 CFR 422.208 and 210 (Physician incentive plans); 422.560-422.626; 42 CFR 438 (managed care) including subsections 56, 60, 66, 206(b), 214, 242; 42 CFR 431 (fair hearings and appeals); 42 CFR 455 (fraud and abuse reporting); 42 CFR 447 (timely claims payment); 45 CFR 74.53 (retention requirements for records); 42 CFR 433 Subpart D, 42 CFR 447.20 and 42 CFR 434 (third party liability); 42 CFR 435.911 and 435.914; 42 CFR 431.52-53 (ambulance services); 42 CFR 405.2402; 42 CFR Part 455.104; 42 CFR Part 455.106; 42 CFR 447.20 and 42 CFR 434.6(a)(9)

 

  

  

  

 

	
●

	
Federal rules and regulations as established by the United States Department of Labor in Title XXIX of the Code of Federal Regulations as applicable

	
●

	
Davis-Bacon Act, 40 U.S.C. 276a, et seq.;

	
●

	
The Social Security Act, including Titles VI, VII, XIX and XXI

	
●

	
Copeland Anti-Kickback Act, 40 U.S.C 276c

	
●

	
Fair Labor Standards Act of 1938, 29 U.S.C 201 et seq.

	
●

	
Clean Air Act, 42 U.S.C. 7401 et seq.

	
●

	
Federal Water Pollution Control Act as Amended, 33 U.S.C. 1251 et seq.

	
●

	
Federal Rehabilitation Act of 1973

	
●

	
Byrd Anti-Lobbying Amendment, 31 U.S.C. 1352

	
●

	
The Clinical Laboratory Improvement Amendments of 1988;

	
●

	
The Health Insurance Portability and Accountability Act of 1996 (HIPAA);

	
●

	
Omnibus Budget Reconciliation Act of 1981, P.L. 97-38;

	
●

	
Debarment and Suspensions, 45 CFR 74 Appendix A(8) and Executive Orders 12549 and 12689

	
●

	
Americans with Disabilities Act, 42 USC 12101 et seq.;

	
●

	
Medicare Modernization Act of 2003, P.L. 108-173

	
●

	
Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343

	
●

	
Children Health Insurance Program Act of 2009, P.L. No. 111-5; and

	
●

	
Health Reform Act of 2010, P.L. 111-148

	
Medicaid Laws, regulations and requirements pertain only to the Medicaid population.

  

  

  

 

ATTACHMENT 2

 

Insurers / Third Party Administrators / Direct Contracting

 

The island is divided in eight (8) regions: North, San Juan, Metro North, Northeast, East, Southeast, Southwest and west.

 

 

www.misaludpuertorico.com

 

  

  

  

 

Mental Health Service Organizations

 

 

www.misaludpuertorico.com

 

  

  

  

 

Pharmacy Benefit Administrators

 

 

www.misaludpuertorico.com

 

  

  

  

 

ATTACHMENT 3

 

July 1, 2013

Dear Enrollee:

Greetings and welcome to MI Salud, the Health Plan of the Government of Puerto Rico!

The Health Insurance Administration (ASES, by its Spanish acronym) has developed this Uniform Guide for the Enrollees to keep them informed on the use of the benefits provided by MI Salud. In this way enrollees have available the information they need to satisfy their information needs, regardless of the company that provides the services.

MI Salud offers the broadest benefit coverage through a Coordinates Care model.  Under the new MI Salud model you will be able to move freely within the Preferred Network and visit your specialists, sub-specialists, laboratories, x-rays and other health provider without the need or referrals and without copays. Your Primary Care Group and your Insurer will inform you the providers that compose the Preferred Network.

You must choose a Primary Care Group and your primary care physician, who will keep a complete clinical record on your health, including your conditions, alergies and medications, among others. In this way we can assure that all the services offered comply with the strictest quality and cost–effectivity standards required by the federal and state regulations relato to the health industry.

You must remember to keep your address and personal information updated by contacting with the Medicaid Program Office in which you submitted your Plan eligibility application. Besides, you must attend your re-certification appointments, so you don ot lose this benefit that is so necessary for your health.

Visit your primary care provider, for the doctor to order the necessary tests to keep your cholesterol, sugar, and blood pressure and be able to detect early diseases such as cardiovascular dieases, diabetes and cancer, among others.

We invite you to make good use of this benefit offered by the Government of Puerto Rico, whose aim is to safeguard your health.

Cordially,

Ricardo A. Rivera-Cardona

Executive Director

 

  

 

  

 

TABLE OF CONTENT

 

	
TELÉFONOS

	
5

	
LANGUAGE

	
6

	
DEFINITIONS

	
6

	
HIPAA

	
10

	
IMPORTANT INFORMATION ON YOUR HEALTH PLAN

	
10

	
Mi Salud

	
10

	
Who are elegible to enjoy the services and benefits of Mi Salud?

	
10

	
AUTO-ENROLLMENT

	
12

	
Auto-Assignment

	
12

	
THIS YOUR ID CARD OF THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO

	
12

	
FRAUD AND ABUSE

	
13

	
What is fraud?

	
13

	
What is abuse?

	
14

	
What can I do to avoid fraud and abuse?

	
14

	
How can I report situations on fraud and/or abuse?

	
14

	
PRIMARY MEDICAL GROUP AND PRIMARY CARE PHYSICIAN

	
15

	
Can I change my Primary Medical Group or the Primary Care Physician?

	
15

	
Choosing the Primary Care Group and the Primary Care Physician

	
16

	
RECERTIFICATION OF ELIGIBILITY

	
17

	
PUBLIC EMPLOYEE

	
17

	
What can I do if my eligibility to the Plan is cancelled?

	
18

	
How can I enroll in another of the plans contracted for  government employees?

	
18

	
Can the members of the Police Department of Puerto Rico enroll in Mi Salud?

	
19

	
WHAT IS COORDINATED CARE?

	
19

	
YOUR PRIMARY MEDICAL GROUP AND YOUR PRIMARY CARE PHYSICIAN

	
19

	
What is a Primary Medical Group?

	
19

	
What is a Preferred Providers Network?

	
20

	
Are all my specialists within the Preferred Network of my Primary Medical Group?

	
21

	
What is Triple S General Network?

	
22

	
Will I need the Countersignature on the Prescriptions of Medications?

	
22

	
KNOW THE RESPONSIBILITY OF YOUR PRIMARY CARE PHYSICIAN

	
22

	
HOW TO OBTAIN INFORMATION ABOUT PARTICIPATING PHYSICIANS

	
23

	
THESE ARE YOUR RIGHTS

	
23

	
THESE ARE YOUR RESPOSIBILITIES

	
24

	
EMERGENCIES  AND URGENCIES

	
25

	
How do I know when it is an emergency?

	
25

	
When can I receive emergency services?

	
25

	
And then, what is an urgency?

	
26

 

 

  

2

  

 

	  	  
	
How can I receive urgency services?

	
26

	
How can I receive services outside business hours from my Primary Care Physician, the Primary Medical Group or the Preferred Network of Providers?

	
26

	
WHAT IS AN ADVANCE DIRECTIVE?

	
26

	
GRIEVANCES AND APPEALS

	
27

	
What is a grievance?

	
27

	
How can you file a complaint?

	
27

	
What is a Notice of Action?

	
28

	
What can I do if I do not agree if the Notice of Action?

	
28

	
What is an appeal?

	
28

	
Who will hear your appeal?

	
28

	
How much time will they take to make a determination on my appeal?

	
28

	
TIME TO SOLVE REQUESTS, COMPLAINTS AND APPEALS

	
29

	
DENTAL SERVICES

	
29

	
MENTAL HEALTH SERVICES

	
30

	
How can I receive mental health services or services against drug dependence?

	
30

	
PREVENTIVE SERVICES

	
30

	
What are preventive services?

	
30

	
HIV-AIDS

	
31

	
HEPATITIS-C

	
36

	
This is your Benefits Coverage

	
36

	
Preventive Services

	
37

	
Dental Services

	
38

	
Diagnostic Testing Services

	
39

	
Ambulatory Rehabilitation Services

	
39

	
Medical and Surgical Services

	
40

	
Ambulance Services

	
40

	
Maternity and Prenatal Services

	
40

	
Emergency Room Services

	
41

	
Hospitalization Services

	
41

	
Mental Health Services

	
42

	
Mental Health Hospitalization Services

	
43

	
Pharmacy Services

	
43

	
Services Excluded from the Basic Coverage

	
43

	
Special Coverage Services

	
45

	
Services excluded from the Special Coverage

	
48

	
Medicare Coverage Services

	
48

	
DISEASE MANAGEMENT AND SPECIAL CONDITION REGISTRY

	
49

	
Chronic Disease Management

	
49

	
Case Management

	
49

	
 Special Condition Registry

	
49

	
THESE ARE YOUR COPAYMENTS AND COINSURANCES

	
50

 

 

  

3

  

	
HEALTH REGION MAPS

	
53

 

 

  

4

  

 

TELÉFONOS

 

		
TELE MI SALUD

	 	 
	Metro area 	787-775-1352	 
	 	Toll-free	1-800-981-1352	 
	 	TTY	1-855-295-4040	 

 

 

	

	
MENTAL HEALTH

	 
	 	 	1-888-695-5416
	 	Toll-free	787-641-0785
	 	TTY	 

 

	 	
Patients Advocate Office

 

Toll-free 

Metro Area

	
1-800-981-0031

          787-977-1100

 

	 	
Puerto Rico Health Insurance Administration 

 

Toll-free 1-800-981-2737

	 

 

 

  

5

  

 

LANGUAGE

 

This Guide is provided in Spanish and English for your benefit. If any member of your family is enrolled in Mi Salud and the person has problems to read or has a disability such as blindness and needs special services to be able to receive the information provided in this Guide, the person may request help to Triple S. Triple S must have different formats for the information to make them available to the enrollees.

If the information provided in this guide is confusing or if you need to clarify any questions, you may contact Triple S for assistance. Information is a vital component of the commitment of Mi Salud with you, our enrollees. You may contact Triple S at the telephones numbers found on the back of your Mi Salud ID card.

 

DEFINITIONS

 

Abuse: An action carried out by a provider or health professional, a private or public institution or any other person that intentionally causes and injury or submits the person to unreasonable confinement, intimidation or punishment that may result in physical or mental harm to a patient.

 

Access to services: The guarantee that the enrollee will be able to receive all the medically necessary services included in the Mi Salud coverage without any impediment.

 

Administrative Referral: Written authorization issued by Triple S for the enrollee to receive the required service, if medically necessary

 

Advance Directives:  Written or verbal instructions, such as wills or powers-of attorney related to decisions about services and health care expressed by the person in advance in case an event occurs and he may be unable to make such decisions.

 

Ancillary Services: All those supplementary services provided to the patient to assist in the diagnosis and treatment of illness or injury. Examples of these services include laboratory, radiology, therapies, etc.

 

Authorization:  A written document through which  a person freely and voluntarily authorizes  another person or provider to represent, him, apply, use and disclose your health information for medical or treatment purposes or to initiate an action such as a grievance. It may also be used to annul a previous authorization.

 

CHIP:  Children Health Insurance Program, a federal program that provides medical Service coverage to low-income children under age 18 through health plans qualified to offer coverage under this program.

 

Coinsurance: A percentage of the cost of a health service which the enrollee must pay after receiving the service.

 

 

  

6

  

 

Complaint: informal claim on the quality of care, customer service or treatment received by suppliers, personnel of Triple S, Primary Care Group or ASES. It does not include disputes involving medical services, coverage or payment for services.

 

Confidentiality of information: The right of an individual to have his personal or health information kept private, which will not be disclosed to any person or entity without the person’s consent.

 

Consultation: An opinion health professional requests to another health professional on a matter related to the health condition of a patient

 

Coordinated Care: Is the service provided to enrollees by doctors who are part of the preferred network of providers Primary Medical Group. The Primary Care physician is the leading provider of services for he is responsible to periodically evaluate their health and coordinate all medical services they need.

 

Coordination of benefits: The order in which health services are paid when the person has more than one medical plan. One of the plans is considered the primary plan and the other the secondary plan or secondary payer.

 

Copayment: An established fixed amount that is the enrollee’s contribution to the expense for a medical Service he receives.

 

Covered Services: Those services and benefits included in Mi Salud coverage

Deductible: A fixed amount pre-determined by ASES, which the enrollee must pay when he receives, health services.

 

Disclosure: The transfer, access or release of information to a person or entity outside the entity holding the information.

 

ELA Puro: An option available to public employees so they can maintain medical coverage when they lose eligibility in the Medicaid Program and the enrollment for other health plans contracted under Law 95 has ended. This coverage is the same as the coverage of Mi Salud.

 

Elective surgery: A medically necessary surgical procedure carried out at a time convenient for the patient and the surgeon because it is performed to correct a condition that is not life-threatening,

 

Enrollee: A person who after being certified as eligible under the Medicaid Program has completed the enrollment process with Triple S and for whom they have issued the ID card that identifies the person as a Mi Salud enrollee.

 

Fair cause:  It refers to situations that allow enrollees to change his PCP or Primary Care Group. These are: 1) The enrollee moved outside the Region, 2) For reasons of moral or religious nature, the supplier does not perform the services the insured needs, 3) The insured need services that can be provided at the same time and not all services are available; failure to receive all the services as ordered may expose the insured to unnecessary risk, 4) Other acceptable reasons include, but are not limited to, poor quality of care, lack of access to services covered or lack of providers with experience to provide the health care the enrollee needs. ASES will determine if the reason constitutes a fair cause.

 

 

  

7

  

 

Grievance: formal claim made by the insured in writing, by telephone or by visiting Triple S, the Patients Advocate Office or ASES, requesting a solution be granted when a service has been denied or allowed on a limited basis a service; reduction , suspension or termination of a previously authorized service; total or partial denial of payment for a service; not having received services in a timely manner; when Triple S has not acted on a situation according to the established terms, refusal of Triple S let the insured exercise his right to receive services outside the network

 

Guardian: Person with authority to take care of a minor or adult, who for some reason has no civil capacity to handle his situation.

 

HIPAA (Health Insurance Portability and Accountability ACT): The law that includes regulations for establishing safe electronic health registers that will protect the privacy of a person’s medical information and prevent the misuse of this information. It is also called the Health Insurance Portability and Accountability Act and the Kassebaum Kenney Act.

 

Hospital: A facility that provides medical-surgical services to hospitalized patients.

 

Identification Card: A card Triple S delivers to the enrollee once he completes the subscription process, which identifies the enrollee by name and contract number, and includes information on coverages, copayments and telephones to receive information on customer service and health advice.

 

Insurer: An entity duly authorized by the Insurance Commissioner to do business in Puerto Rico with a contract with PRHIA to offer services and benefits to the population insured under Mi Salud.

 

Medical emergency: a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who has average knowledge of medicine and health would reasonably expect the absence of immediate medical attention to result in placing a person’s health in serious jeopardy, serious impairment of bodily functions or serious dysfunction of any bodily organ or part. In case of a pregnant woman that has contractions it may be that there is not enough time to transfer her to any facility before delivery or, that transferring her to a facility, may seriously jeopardize her health or the health of the unborn child.

 

Medical record:   Detailed collection of data and information on the treatment and care the patient receives from a health professional.

 

Medicare Beneficiary: Persons aged 65 or more, who are disabled or have renal disease, who have Medicare Parts A coverage for hospital services or Parts A and B for hospital, ambulatory and medical services.

 

Medicaid: Program that provides health insurance for people with low or no income and limited resources, according to federal regulations

 

 

  

8

  

 

Primary Care Physician: A health professional licensed to practice medicine and surgery in Puerto Rico that provides specialized and complementary medical services to the services provided by primary care physicians. Physicians in this category include: cardiologists, endocrinologists, neurologists, surgeons, radiologists, psychiatrists, ophthalmologists, nephrologists, urologists, physiatrists, orthopedists, and other physicians not included in the definition of PCP.

Patient: Person receiving treatment for his mental and physical health

Preauthorization: Permission Triple S grants in writing to the insured, at the request of the PCP, specialist or sub-specialist, to obtain a specialized service.

 

Prescription: original written order issued by a duly licensed health professional, ordering the dispensing of a product, drug or formula

Preferred Provider Network: Health Professionals duly licensed to practice medicine in Puerto Rico contracted by Triple S for the enrollee to use as the first option. Enrollees can access these providers without referral or co-payments if they belong to the insured’s Primary Care Group.

 

Primary Care Group: Health Professionals grouped to contract with Triple S to provide health services under a coordinated care model.

 

Referral: Written authorization a PCP issues to an enrollee to receive services from a specialist, sub-specialist or facility outside the preferred network of the Primary Care Group.Semi-private room: Hospital room with two beds.

 

Special Coverage Registry: A form Triple S fills out at the request of the PCP when the insured is diagnosed with one or more of the conditions that are part of the Special Coverage, for the patient to receive treatment and services directly from specialists or sub-specialists without the need of a referral.

Specialist: A health professional licensed to practice medicine and surgery in Puerto Rico that provides specialized medical and complementary services to the primary physicians. This category includes: cardiologists, endocrinologists, neurologists, surgeons, radiologists, psychiatrists, ophthalmologists, nephrologists, urologists, physiatrists, orthopedists, and other physicians not included in the definition of PCP.

 

Service Coverage: All the services offered to Mi Salud enrollees under the Basic, Special, Mental, Dental and Pharmacy Coverages.

 

Second Medical Opinion: additional consultation the enrollee makes to another physician with the same medical specialty to receive or confirm that the initially recommended medical procedure is the treatment indicated for his condition.

Subscription Application: Form to be completed by the participant eligible to become an enrollee of Mi Salud and be able to receive medically necessary services.

 

 

  

9

  

 

Treatment: To provide, coordinate or manage health care and related services offered by health care providers.

 

Urgency: A medical condition that poses no risk of imminent death that can be treated in the doctor’s office or in the facilities with extended hours and not in emergency rooms. An urgency can become an emergency if not properly dealt with at the right time.

HIPAA

The Health Insurance Administration (ASES) and the Insurance Companies are committed to maintain the confidentiality of your information. We may use and share information related to your treatment, payment for medical services  and everything related to health care within the strictest standards of confidentiality. With your written authorization we may provide your information to others for any purpose

If you are interested in more information about the privacy practices or have questions or concerns, contact Triple S of the Region to which you belong.

 

	
IMPORTANT:

	
As a member of MI Salud Plan, you authorize the Federal Government, ASES, and the Patients Advocate Office, the Insurers or their representatives, to see your medical records to assess the quality, convenience, cost and promptness of services rendered to you.

 

 

IMPORTANT INFORMATION ON YOUR HEALTH PLAN

 

Mi Salud

Now, the new Mi Salud Health Plan of Government of Puerto Rico offers more services and benefits. It also offers a Preferred Provider Network within the Primary Medical Group of your choice, which you can visit freely without the need for referrals or paying copayments.

Under Mi Salud you will not require the countersignature of the Primary Care Physician on the prescriptions ordered by specialists or sub-specialists within the Preferred Provider Network of your Primary Care Group. You can freely choose dentists and pharmacies of your choice, among those contracted by Mi Salud.

In addition, you can receive mental health services within the same facility of Primary Care Group. Mi Salud offers physical and mental health integrated services,  so you can receive these services in one place.

Who are elegible to enjoy the services and benefits of Mi Salud?

 

The persons eligible under Law 72 of September 7, 1993, are:

 

 

  

10

  

 

	
  

	
·

	
American citizens.

	
  

	
·

	
Persons with low or no income

	
  

	
·

	
Population of Federal Medicaid Program: persons over age 65, persons that are blind or disabled and  pregnant women

	
  

	
·

	
Children under the CHIP Program.

	
  

	
·

	
Government employees, retirees and their dependents whose payroll is processed by the Treasury Department.

	
  

	
·

	
Members of the Police Department of Puerto Rico, their widows, widowers and children that survive them.

	
  

	
·

	
Veterans.

	
  

	
·

	
Children under State custody through the Family and Children Administration (ADFAN, for its acronym in Spanish)

	
  

	
·

	
Survivors of domestic violence through the Women’s Advocate Office.

The Medicaid program will determine whether you are eligible for Mi Salud Plan of the Government of Puerto Rico. Once you are certified eligible for Medicaid, they will give you form MA-10 entitled “Notice of Action Taken on Application and/or Re-Assessment” which indicates that you have been certified eligible. The date to determine how long the person is insured is indicated in the section entitled “Certification Date” of the MA-10. They will also give the welcome letter to Mi Salud Plan, from Triple S in your region.

You will receive your card by mail within 5 to 7 days after being certified eligible for Medicaid. If you do not receive the card that period and you need medical services, you can show the welcome letter and the MA-10 form to the contracted service provider with a contract with Mi Salud Plan to show that your name is on the MA-10, that it is signed and you are authorized to receiving services. The welcome letter allows you to access medical services during a period of 30 days. After the 30-day period the letter will not be valid to receive medical services. You may only receive services if you show your Mi Salud Plan card.

 

 

  

11

  

 

AUTO-ENROLLMENT

As of July 1, 2011, every new beneficiary, who is eligible to Mi Salud Plan of the Government of Puerto Rico, will be automatically enrolled and insured. This means you no longer have to visit Triple S to select your Primary Care Group or your primary physician.

 

Auto-Assignment

Triple S will send you the cards and information regarding your Primary Medical Group and the Primary Physician the Insured assigned so you can access medical services immediately. You must receive your ID card by mail with 5 to 7  days from the date you were certified as eligible. If you do not receive your card within this period, you must contact ASES Customer Service at 1-800-091-2737, where they will inform you if your case is already registered in the system and the location of Triple S Service Office and their telephone number, so you can go there to get your card. If you do not agree with Medical Group or the Primary Care Physician, you have the right to request a change within 90 days from the date you received your plan ID card.

 

THIS YOUR ID CARD OF THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO

 

 

On the front of the card, you will find the following information:

	
  

	
·

	
Your name and both last names;

	
  

	
·

	
Your contract number;

	
  

	
·

	
The group to which you belong;

 

 

  

12

  

 

	
  

	
·

	
Your coverages;

	
  

	
·

	
Your copayments and coinsurances.

Be sure that:

	
  

	
-

	
You take your ID card with you when you visit your physicians,  request laboratory or  X- rays services or need health services.

 

	
  

	
-

	They give you your ID card back after you receive medical services.

 

	
  

	
-

	Each insured person in your family even if he is a baby, has his own ID card.

	 	
-

	You keep your card in a safe place to avoid losing and having to wait for a new card.

 

On the back of your ID card you will find the toll-free numbers for Tele-Mi Salud, Customer Service and the Mental Health Crisis helpline.

If you lose your card, you may request a duplicate by visiting the Insurance Company Service Centers or by calling Customer Service at the number that appears on the back of your card.

 

	
IMPORTANT:

	 
	 	 
	
No hospital can refuse emergency services for not having Mi Salud card. Under EMTALA you have the right to receive adequate emergency services, including evaluation and treatment of a emergency condition or delivery in Hospital Emergency Rooms.

	 

 

FRAUD AND ABUSE

 

What is fraud?

Fraud affects adversely insured beneficiaries, health plans and professionals and entities that render health services. Fraud refers to any intentional and deliberate act to deprive another of property or money through deception or any other unfair action.  It is done with the purpose of deceiving or making false misrepresentation with the purpose of obtaining a personal benefit or to benefit another person.

You have the responsibility of reporting any situation you understand may involve fraud against the Medicaid Program.  Some examples of fraud are:

	
  

	
·

	
Billing for medical services or procedures not actually performed.

	
  

	
·

	
Billing for supplies or medications not dispensed.

 

 

  

13

  

 

	
  

	
·

	
Lending an ID card to someone who is not entitled to it (misrepresentation) to obtain clinical services or medications

	
  

	
·

	
Billing for a more costly payment that the one actually performed to obtain a higher payment.

	
  

	
·

	
Submitting false documents to obtain reimbursements.

	
  

	
·

	
Billing for the same service more than once.

	
  

	
·

	
Providing false information in a health enrollment form.

	
  

	
·

	
Billing for the dispensing of full prescription when the prescription was actually filled partially.

	
  

	
·

	
Receiving services rendered by a provider that has been excluded from the Medicaid Program.

	
  

	
·

	
Receiving reimbursement for services that are not medically necessary or that do not comply with the health care professional standards.

It is important that any illegal or fraudulent action be reported immediately to Triple S’s Complaint Unit, the Patient’s Advocate Office or to ASES.

What is abuse?

It is the excessive and improper use of a product, Service or benefit, which results in unnecessary or excessive costs for the health care system. 

Some examples are:

 

	
  

	
·

	
Overuse of services that are not medically necessary, such as the constantly using the emergency room instead of going to the primary care physician

	
  

	
·

	
Excess in the orders for diagnostic tests that do not have a medical justification.

	
  

	
·

	
Waiving health plan copayments or coinsurances to attract customers.

 

What can I do to avoid fraud and abuse?

 

	
  

	
·

	
Protect your ID card information: never provide information on your health plan to strangers or to callers by phone.

 

	
  

	
·

	
Learn the terms of your coverage and keep a copy of the medical studies to avoid duplicating services. If you visit a doctor, keep a copy of your laboratory results and other tests performed and have on hand a list of the medications you are taking. In this way you will not have to repeat tests that will consume time and money.

 

	
  

	
·

	
Verify the information before signing any insurance enrollment form or health service form

 

	
  

	
·

	
Request and review the quarterly summary of the services you receive. You may request the summary of services directly to Triple S that provides you Mi Salud Services.  .

 

How can I report situations on fraud and/or abuse?

 

 

  

14

  

 

If you have information or suspicion that you have been a victim of health plan fraud, you may contact Triple S through Tele Mi Salud at the numbers that appear on the back of your ID card. You may also contact the Health Advocate Office at 787-977-0909 or, ASES at 1-800-981-2737 or by visiting Triple S, PAO or ASES Offices or Customer Service Centers.

Your call or written communication will be handled confidentially and your Mi Salud Coverage will not be affected by this referral. If the investigation carried out shows that fraud was committed, the case will be referred to the corresponding authorities.

 

PRIMARY MEDICAL GROUP AND PRIMARY CARE PHYSICIAN

Can I change my Primary Medical Group or the Primary Care Physician?

Yes, you may change your Primary Medical Group or your Primary Care Physician either by visiting Triple S Service Centers or by calling Tele-Mi Salud at the number that appears on the back of your Mi Salud Plan ID card.

Changes to the Primary Medical Group – you will only be able to change within the first 90 days following the date in which you received your Mi Salud Plan ID card. After this 90-day period, you may only change your Primary Medical Group once a year. If there is a fair cause, you may change your Primary Medical Group or your Primary Care Physician at any time.

The following events are considered a fair cause for a change:

	
  

	
1.

	
The beneficiary moved out of the Region;

	
  

	
2.

	
For moral or religious reasons, the provider does not render the services the beneficiary needs;

	
  

	
3.

	
The beneficiary needs services that must be rendered at the same time and the services are available. Not receiving all the services as ordered may put   the beneficiary at risk unnecessarily.

Other acceptable reasons include, but are not limited to:

	
  

	
a.

	
bad quality of services,

	
  

	
b.

	
lack of access to covered services,

	
  

	
c.

	
lack or providers with experience to take care of the beneficiary’s health care needs.

ASES will determine if the reason is a fair cause.

Changing the Primary Care Physician and the Primary Medical Group must be made during the first 5 days of the month, so the change becomes effective the next month (e.g. If you make the change on January 5, the change will be effective on February 1). Nevertheless, if you change after the first 5 days of the month, the change will be effective on the subsequent month.  (e.g. If you  make the change on January 6, it will be effective on March 1).

To change the Primary Care Physician within the same Primary Medical Group, you only have to choose the new Primary Care Physician within same Primary Medical Group you have now and the change will be effective on the following month.

 

 

  

15

  

 

	
IMPORTANT:

	 
	
The Medicaid Program is the only office authorized to make changes on your personal information and your residential address. You must notify the Medicaid Program of any changes such as changes in address, family group, marital status, your income, corrections to names, and dates of birth, among others.

	 

 

Triple S must keep you informed when a Primary Care Physician. Specialist or Sub-specialist is no longer their medical service provider, so you can choose a new Primary Care Physician, Specialist or Sub-specialist. You must receive the notice sent by Triple S within 15 days from the date Triple S was informed that the provider will not continue providing services. Triple S must provide you in the notice the instructions for you to be able to choose a new physician among those with a contract in the Primary Medical Group.

 

Choosing the Primary Care Group and the Primary Care Physician

Remember that you have the freedom to choose the Primary Medical Group and the Primary Care Physician you want if you do not agree with auto-assignation made by Triple S. The Primary Medical Group and the Primary Care Physician you choose must render services with the region to which you belong. 

You must choose a Primary Care Physician for each insured beneficiary in your family. The primary care physicians you use for you and your dependents that are included in the contract may be different, but they must belong to the same Primary Medical Group.

If you are a woman, you may choose a gynecologist/obstetrician in addition to any other  Primary Care Physician. If you are pregnant, your Primary Care physician will be your gynecologist/obstetrician during your pregnancy. When your pregnancy ends you will go back to receive care from the primary care physician you chose: a Generalist, Internist, and gynecologist/obstetrician during your pregnancy. When your pregnancy ends you will go back to receive care from the primary care physician you chose: a Generalist, Internist, Family Practitioner, or Pediatrician for your baby. Your gynecologist will still be your other primary care physician to meet your gynecological situations.

 

	
IMPORTANT:

	
Remember, you must register your baby in the Medicaid Program before he is 90 days of age. You must bring with you the birth certificate. 

 

 

 

  

16

  

 

RECERTIFICATION OF ELIGIBILITY

 

Once the Medicaid Program (PAM, for its acronym in Spanish) of the Health Department certifies you as eligible, you must attend all the appointments to all reevaluation appoints, so you don’t lose your eligibility. If you lose eligibility you will lose the benefits of Mi Salud, because you will not have the benefits of your health plan. Triple S will send you a letter at 90 days, 60 days and 30 days before your eligibility ends as a reminder that you must visit the Medicaid Office in your hometown recertify your eligibility.

If you miss your recertification appointment, you must immediately to the Medicare Program Call Center at the toll-free number 1-885-400-4224 or visit your Medicaid Office located in your hometown to request a new appointment.

You must notify the Medicaid Program of any changes in address, income level, to add or disembroil dependents, make corrections to you address or name, inform changes in marital status (married, divorced widower, etc.)

 

If you are pregnant, when you have your baby, you must visit the Medicaid Program Office and submit the birth certificate to enroll the baby in Mi Salud. If you do not comply with this requirement, the baby will lose the right to receive services under Mi Salud Health Plan of the Government of Puerto Rico. It is possible that with the arrival of this new baby you can obtain more benefits if your level of poverty changes.

 

	IMPORTANT:	 
	
Remember, it is your responsibility to keep appointments and update your information and mailing address in the Office of the Medicaid program in order to receive communications related to your recertification. If you do not receive the notification from the Insurer, it is your responsibility to request the reevaluation appointment.

 

	 

 

PUBLIC EMPLOYEE

 

IF you are a public employee or a retiree from the Government of Puerto Rico and your payroll is process by the Treasury Department, you may enroll in Mi Salud during the open enrollment period to choose public employees health insurance plans. If you choose Mi Salud, the employer contribution will go to ASES and you will pay the difference, if any.

You can also visit the Medicaid Program for them to evaluate your case and, if found eligible and medically indigent, you will not have to pay the difference, if any, between the premium and the employer contribution as it will be paid with government funds.

 

 

  

17

  

 

Medical indigence is granted for a period of 12 months. Triple S will send you a letter 90 days prior to the end of your eligibility period, reminding you that your eligibility is about to end and that you must visit your Medicaid Program Office located in your town of residence and request the reevaluation of your case

In case of public employees that are married, they may enroll in Mi Salud combining both employer contributions (known as joint enrollment) for your eligibility. Your employer will the contributions ASES, while you remain active and eligible under the Medicaid Program.

If after the evaluation, it results that you are no longer eligible to Mi Salud as medically indigent, you can enroll in Mi Salud as ELA Puro until the new health plan open enrollment period for public employees or you may enroll in any other health insurance plans contracted for public employees. It is your choice!

	IMPORTANT:	 
	
Remember to attend on time to your eligibility reevaluations, so you do not lose your Mi Salud benefits.

	 

 

What can I do if my eligibility to the Plan is cancelled?

 

If the Medicaid Program determined that you are no longer eligible to Mi Salud,  and you are an employee or retiree of the Government of Puerto Rico, you have the right to enroll in Mi Salud Plan  under ELA Puro with the 30 days following the date in which you lost your eligibility. In this way, you will not lose your medical coverage until the new government employee open enrollment period and you can choose any of the health plans contracted, including enrolling in Mi Salud.

If you are not an employee or retiree of the Government of Puerto Rico and you lose your eligibility, you may enroll in a Pago Directo Plan by submitting an application with Triple S. You must complete the formalities within 30 days from the date your eligibility to Mi Salud was cancelled.

How can I enroll in another of the plans contracted for  government employees?

 

IF you decide to join another plan from among the plans contracted for government employees according to Law 95, which is not Mi Salud, before you enroll in the new plan you will have to go to the Medicaid Program Office in your hometown to cancel your eligibility. The cancelation of your Mi Salud coverage will be effective on the first day of the month following the date in which you requested your cancellation under the Medicaid Program.

 

If you do not cancel your eligibility to the Medicaid Program, ASES will continue receiving you employer contribution and you will have to pay  the total premium of the Private Plan you chose.

 

	 	
IMPORTANT:

	 	Remember that for you to be able to enroll in another plan, you must have lost your eligibility and may only enroll in another plan during the open health insurance enrollment period for the employees of the Government of Puerto Rico established by ASES.

 

  

18

  

 

Can the members of the Police Department of Puerto Rico enroll in Mi Salud?

The members of the Police Department of Puerto Rico, their spouses and children may also enroll in Mi Salud Plan of the Government of Puerto Rico and the Police Department of Puerto Rico will transfer to ASES  their employer contribution.

You must visit the Medicaid Program Office located in your town of residence to be certified under the Medicaid Program. This  benefit will remain valid  even if the member of the Police Department dies under any circumstance and as long as the widow does not re-marry and the children are under age 26 and are not married.

WHAT IS COORDINATED CARE?

MI Salud uses a coordinated care model in which you health is under the care of a Primary Care Physician, who will be responsible to evaluate the beneficiary periodically and coordinate all the health services the person may need.. Under this model your Primary Care Physician will keep an updated record of all the services you receive.

 

YOUR PRIMARY MEDICAL GROUP AND YOUR PRIMARY CARE PHYSICIAN

What is a Primary Medical Group?

Primary Medical Group (PCG)- is composed of several physicians who have joined to provide the services you need to keep you healthy. What was known as IPA, now it is known as PMG. Within this Group, there are physicians with different specialization which have been classified as Primary Care Physicians, among which there are:

	
  

	
·

	
General Practitioners

	
  

	
·

	
Family Physicians

	
  

	
·

	
Pediatricians

	
  

	
·

	
Gynecologists/Obstetricians

	
  

	
·

	
Internists

Besides these five categories of Primary Care Physicians, under the new model of Mi Salud you will also have specialists, sub-specialists, laboratories, X-rays facilities and hospitals, among others, to form what we call the Preferred Providers Network of the Primary Medical Group. You have the freedom to visit the physicians and providers that are part of the Preferred Network without the need of a referral or copayment.

 

 

  

19

  

 

	
IMPORTANT:

 

	 
	
Physical Exam - You must make an appointment with your Primary Care Physician for him to make your annual physical exam.

 

	 
	
Routine Medical Appointments- services that are not urgent, but that present symptoms, must be coordinated within a term that does not exceed 14 days. Regarding routine mental services, the term should not exceed 15 days.

 

	 
	
Appointment for urgent situations – as long there is not a risk of death or damage to the body or body organs, they must be obtained within a period of 24 hours..

 

	 
	
These conditions must be treated at the medical office or offices with extended business hours, not at emergency rooms.

 

	 

 

What is a Preferred Providers Network?

They are a Group of specialists, sub-specialists and health service facilities with a contract with Triple S to provide services under your Primary Medical Group. As long as you visit your Primary Medical Group Preferred Network, you will not have to wait for a referral or pay copayments.

 

The information below tells about some physicians and providers, without limiting to these specializations, that may belong to the Primary Medical Group of your choice:

 

	
  

	
·

	
Specialists and sub-specialists (Cardiologists, Orthopedians, Rheumatologists, Endocrinologists, Urologists, Gastroenterologist, Oncologists and Physiatrists, among others, without it being understood that it is limited to only these specialist.

	
  

	
·

	
Ancillary medical services providers: Physical therapists, nutritionists, speech pathologists, among others:

	
  

	
·

	
Clinical laboratories

	
  

	
·

	
Specialized diagnostic tests

	
  

	
·

	
Imaging Centers

	
  

	
·

	
Cardiovascular Surgery and Catheterism Centers

	
  

	
·

	
Hospitals

	
  

	
·

	
Urgency Rooms

	
  

	
·

	
Emergency Rooms

Another benefit you will now have under Mi Salud is that you will no longer need the countersignature of your Primary Care Physician on the prescriptions ordered by any other physician that is not your primary care physician, as long as the physician ordering the prescription is part of the Preferred Network of your Primary Medical Group.

 

 

  

20

  

 

For laboratory and X-rays services you will need an order from the prescribing physician, but the authorization of your Primary Care Physician, as long as you receive the services at a laboratory or X-rays belong to your Primary Medical Group. 

 

The preferred networks will guarantee Access, quality and availability of the health services to be rendered to beneficiaries.

 

Are all my specialists within the Preferred Network of my Primary Medical Group?

In case that the specialist or sub-specialist that you need is not part of the Preferred Network  of your Primary Medical Group, your Primary Care Physician must give you a referral so you can visit a  the specialists or sub-specialists outside the Preferred Network of your Primary Medical Group and you will have to pay corresponding copayments. Your Primary Care Physician will be the one to coordinate the visits to physician and providers of medical services outside the Preferred Network of Providers of your Primary Medical Group.

 

You may visit specialists or sub-specialists from Triple S’s General Network of Providers as long as your Primary Care Physician gives you the corresponding referral and coordinates the visit, which will be subject to the applicable copayments.

 

If you wish to visit a specialist or sub-specialist that does not belong to the Preferred Network of your Primary Medical Group, when there is a physician with the same specialty in the Preferred Network of the Primary Medical Group , you will also need a referral from your Primary Care Physician and you will be responsible of paying the corresponding copayment..

 

Referrals to visit a specialist must be provided within 5 days and, authorizations or preauthorizations for services must be provided within 72 hours. Non-compliance with these terms will be a reason to submit a complaint.  Nevertheless, if you are in the Special Coverage Registry you will not need referrals from your Primary Care Physician, as long as the treatment you are going to receive corresponds to the diagnostic of the Special Coverage.

 

	
IMPORTANT:

 

	 
	
Your Primary Care Physician is the only authorized to give you the referrals you need for your health condition. None of the Administrator, the Medical Director or the Board of the Primary Medical Group, cannot issue or authorize the referral. If your Primary Care Physician does not provide you the referral, you can request an administrative referral from Triple S  by submitting a complaint.

	 

 

Triple S will mail to you the Directory of the Providers of the Primary Medical Group and General Directory.

 

 

  

21

  

 

What is Triple S General Network?

They are the specialists, sub-specialists and health services facilities Triple S has contracted to provide support to the Primary Medical Groups. This General Network of Triple S will be available to provide those services the beneficiary cannot obtain through the Preferred Network of his Primary Medical Group, as long as his Primary Care Physician gives him a referral.

To be able to receive services from Triple S General Network, you must obtain a referral from your Primary Care Physician and pay the corresponding copayments. Prescription drugs or other service orders issued by Triple S General Network will need the countersignature or authorization of your Primary Care Physician. That is, you will always have to go back to your Primary Care Physician for him to authorize the service ordered (laboratory, x-rays) and to countersign the prescription of the medications for the pharmacy to be able to dispense them.

Will I need the Countersignature on the Prescriptions of Medications?

 

No participating pharmacy of Mi Salud can request the countersignature of the Primary Care Physician on prescriptions ordered by specialists or sub-specialists that belong to the Preferred Network of the Primary Medical Group.

If the prescription of medications is from a specialist or sub-specialist that belong to Triple S General Network or the Preferred Network of another Primary Medical Group that is not the Primary Medical Group you chose, you will need the countersignature of Primary Care Physician for the prescription to be dispensed.

Remember, you must visit the specialists and sub-specialists within the Preferred Network of your Primary Medical Group, so you will not need the countersignature of your Primary Care Physician.

 

	
IMPORTANT:

	 
	
Remember to use the specialists and sub-specialists within the Preferred Network of your Primary Medical Group, so you do not need the countersignature of your Primary Care Physician on your prescriptions.

	 

 

KNOW THE RESPONSIBILITY OF YOUR PRIMARY CARE PHYSICIAN

 

 Your Primary Care Physicians is responsible of:

	
  

	
·

	
Perform medical assessments relevant to your health.

	
  

	
·

	
To provide, coordinate and manage all health services and treatments that you and your family need.

	
  

	
·

	
Provide preventive health services to keep you healthy.

	
  

	
·

	
Provide care when you feel or are sick.

	
  

	
·

	
Tell you  when he believes it is necessary that you visit a specialist or sub-specialist

	
  

	
·

	
Provide referrals when necessary, if you should visit a specialist or sub-specialist outside of the Preferred Network of Primary Medical Group or when you want a second opinion.

	
  

	
·

	
Coordinate visits to specialists or sub-specialists outside the Preferred Network of the Primary Medical Group

 

 

  

22

  

 

	
  

	
·

	
Provide the prescriptions for your medications or the orders for your treatments.

	
  

	
·

	
Keep your medical record updated with all the information on your health conditions, medications, treatments, etc.

	
  

	
·

	
Consult with other health professionals about your diagnosis and treatment.

Call or visit your primary care physician every time you need medical services.

 

HOW TO OBTAIN INFORMATION ABOUT PARTICIPATING PHYSICIANS

 

Triple S will mail you the Directory of Participating Physicians and Providers that are part of the Preferred Network of your Primary Medical Group, which also includes the Medical Groups that belong to the Region. You will also receive the Directory of Triple S’s General Network Physicians and Providers. These Directories will also be available in the Primary Medical Groups and at Triple S’s Service Centers. The directories provide the following information about the physicians:

	
  

	
·

	
Medical Specialty

	
  

	
·

	
Name

	
  

	
·

	
Address

	
  

	
·

	
Telephone numbers

	
  

	
·

	
Office days and business hours

 

You can contact Triple S to receive information on the providers available in your Region at the telephones that appear on the back of your ID card, calling Tele Mi Salud, going to Triple S’s office or through Triple S’s website. You may also contact your Primary Medical Group, which will provide information on the providers that belong to your Primary Medical Group.

Besides, when you contact Triple S, you can request  additional information on your providers such as, where the physician studies, what did he studied, certifications of specialties the physician has, as well as all the information required to practice medicine.

 

THESE ARE YOUR RIGHTS

 

	
  

	
·

	
You have the right to demand to be kept informed and receive information about:

 

	
  

	
o

	
your health plan

	
  

	
o

	
health care facilities

	
  

	
o

	
health care professionals

	
  

	
o

	
health services covered,

	
  

	
o

	
access to contracted services.

	
  

	
·

	
The right to be treated with respect and with due regard for your dignity and privacy.

 

	
  

	
·

	
Select freely your Primary Medical Group, your primary care physician, laboratory, X-rays, hospital, specialist and sub-specialists available within the Preferred Network of Primary Medical Group

 

 

  

23

  

 

	
  

	
·

	
Contact your primary care physician or specialist, freely and under the strict confidentiality.

 

	
  

	
·

	
Be free to receive emergency services 24 hours a day, 7 days a week.

 

	
  

	
·

	
Receive information about treatment alternatives and options available and, that these alternatives and options be presented to you in a manner appropriate to your condition and ability to understand.

 

	
  

	
·

	
Participate in decisions regarding your health care, including the right to refuse treatment.

 

	
  

	
·

	
Request a second opinion if you are interested in confirming a diagnosis or treatment plan.

 

	
  

	
·

	
Express with advance directives, either verbally or in writing, your wish as to what treatment and services you want to be provided or do not want to be provided if you become unable to make such decisions.

 

	
  

	
·

	
Be free from any form of restraint or seclusion used as a means of limitation, discipline, convenience or retaliation.

 

	
  

	
·

	
Receive copies of your medical records.

 

	
  

	
·

	
Receive highest quality services.

 

	
  

	
·

	
Continuity of health care

 

	
  

	
·

	
Access to adequate health services

 

	
  

	
·

	
Filing complaints and appeals, when you understand that your rights have been violated by denial of, limitation of or, improper collection for services.

 

	
  

	
·

	
Do not allow to be discriminated against for any reason

 

	
  

	
·

	
Have the freedom to choose the pharmacy or dentist of your preference among those contracted by Triple S.

 

THESE ARE YOUR RESPOSIBILITIES

 

	
  

	
·

	
Inform yourself about Mi Salud Coverage, its limits and exclusions.

 

	
  

	
·

	
Give your physician all your health-related information.

 

	
  

	
·

	
Inform your doctor of any changes in your health.

 

	
  

	
·

	
Follow the medical treatment as recommended by your primary care physician, specialist or sub-specialist.

 

	
  

	
·

	
Inform your physician when you do not understand an instruction or does not clearly understand what you are being inform.

 

 

  

24

  

 

	
  

	
·

	
Inform your physician when there is a reason why you cannot comply with the recommended treatment.

 

	
  

	
·

	
Recognize when you need to make changes to your lifestyle to benefit your health.

 

	
  

	
·

	
Participate in any decision regarding your health.

 

	
  

	
·

	
Communicating either verbally or in writing any advance directive you want to be fulfilled regarding your decision on medical treatment for the extension of your life.

 

	
  

	
·

	
Maintain appropriate behavior, so your behavior does not affect or does not allow other patients to receive necessary medical care.

 

	
  

	
·

	
Maintain an appropriate behavior, so your behavior does not affect the operation of Triple S Service Centers or prevent other beneficiaries from receiving the services provided at the Service Centers.

 

	
  

	
·

	
Provide all the information on other health insurance plans you may have.

 

	
  

	
·

	
Inform ASES of any fraud or improper action related to the services, providers and health facilities.

 

EMERGENCIES  AND URGENCIES

 

How do I know when it is an emergency?

“It is a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson who has average knowledge of medicine and health would reasonably expect the absence of immediate medical attention to result in placing a person’s health in serious jeopardy, serious impairment of bodily functions or serious dysfunction of any bodily organ or part. In case of a pregnant woman that has contractions it may be that there is not enough time to transfer her to any facility before delivery or, that transferring her to a facility, may seriously jeopardize her health or the health of the unborn child.

 

When can I receive emergency services?

You just have to arrive at any emergency room throughout Puerto Rico. You do not need referrals or pre-authorization for emergency services.

 

 You can also call the Tele Mi Salud at the toll-free number listed on the back of your Mi Salud ID card my. When you contact Tele MI Salud for information and medical advice, you will be provided a code, so you do not have to pay copayments if you had to go to an ER.

 

 

  

25

  

 

And then, what is an urgency?

 

A medical condition that poses no risk of imminent death that can be treated in the doctor’s office or in the facilities with extended hours and not in emergency rooms. An urgency can become an emergency if not properly dealt with at the right time.

 

How can I receive urgency services?

Visit or call your Primary Care Physician.  If you have an urgency or a question about your health, you may call toll-free to the Tele Mi Salud hotline for medical information and advice. The telephone to this hotline, which is available 24 hours a day, 7 days a week, appears on the back of your Mi Salud ID card.

 

How can I receive services outside business hours from my Primary Care Physician, the Primary Medical Group or the Preferred Network of Providers?

 

You must consult the Directory of Providers Triple S provided you, to learn about the business hours of your physicians. In addition, the Directory gives you the number for Tele Mi Salud, so you can receive information and advice regarding your health condition as well as how to obtain services on extended hours.

 

If you understand that it is necessary to go to an emergency room, nobody can stop that right. When you use Tele Mi Salud for information and medical advice, they will provide you a code, so you do not have to pay copayments if you need to go to an emergency room. They will have to give you the code, regardless of your condition.

 

WHAT IS AN ADVANCE DIRECTIVE?

 

AN Advance Directive is a written legal document which allows you to instruct your attending physician on your treatment preferences in case there is a moment that you lose your capacity to approve the treatment. The written document that states the Advance D is known as a living will.

The instructions regarding your treatment may be stated before a lawyer, who will prepare a legal document with your instructions or before your attending physician with two witnesses, of legal age and legal capacity, who are not relatives.

Your physician can provide you information on how you can exercise your right to advance directives.  In case you are confined in a hospital, the staff from the Hospital Administration Office can provide you the necessary information and the forms you must you fill out to validate your Advance Directives. You may also contact the Senior Citizens Advocate Office at 787-721-6121, who provides information booklets on this topic.

 

 

  

26

  

 

GRIEVANCES AND APPEALS

 

What is a grievance?

It is a formal complaint a beneficiary makes in writing, by telephone or by visiting any of Triple S’s Service Centers, the Patient’s Advocate Office (OPP, for its acronym in Spanish) or the Puerto Rico Health Insurance Administration (ASES, for its acronym in Spanish), requesting their intervention when you do not agree with any of the following determinations:

 

	
  

	
·

	They have denied or partially approved a service.

 

	
  

	
·

	
They have reduced, suspended or terminated a Service previously authorized.

 

	 	
·

	They have denied the total or partial payment of a Service.

 

	 	
·

	
You did not receive timely services.

 

	
  

	
·

	
Triple S has not taken any action on any situation according to the terms established.

	
  

	
·

	
Insurer’s refusal to your receiving services outside the Preferred Network of your Primary Medical Group or outside Triple S General Network, if the covered Service is not available in the contracted networks or if there is a shortage of such services.

In addition, you may also file a complaint or a grievance if you feel dissatisfied with the quality of health services offered or the harsh treatment received from a provider or employee of the health facility you visited or if you feel that your rights as beneficiary have been violated.

 

How can you file a complaint?

You  can call write or visit Triple S Service Centers for them to take your complaint. Your physician, a relative or a person authorized by you,  can file the complaint on your behalf. Triple S staff can provide help for you to file your claim.

You have up to 365 days from the date of the event to file your complaint. Once Triple S receives your complaint, they will acknowledge receipt of your complaint within 20 days from the date they received it.

 

 

  

27

  

 

What is a Notice of Action?

After you receive the acknowledgement of receipt of your complaint, Triple S will send you another communication in which it will inform you the decision made on your complaint. This communication is known the Action Notice and you must receive it within a 30-day term. The time limit for Triple S to make its determination will not exceed 90 days from the date it received the complaint.

If they need additional time they could be granted up to 14 additional days after the 90 days as long as said extension is for the benefit of the beneficiary or when they need additional documents to be able to make the determination. The beneficiary may also request the 14-day extension if he needs to submit any additional evidence to support his case and does not have it available.

The request for an additional time extension must be submitted to ASES for your approval.

What can I do if I do not agree if the Notice of Action?

If you do not agree with Triple S’s determination, you have the right to appeal the determination before Triple S, the Patients Advocate Office (OPP, for its acronym in Spanish) or before ASES.

What is an appeal?

An appeal is a formal request that you file with Triple S, the Patients Advocate Office or the Puerto Rico Health Insurance Administration (ASES, for its acronym in Spanish) when you do not agree with the determination (Notice of Action) or with the denial of a service, procedure, study, collection or payment. Once you receive the Notice of Action from Triple S, you have a period between 20 and 90 days to file your appeal with Triple S, the Patients’ Advocate Office (OPP, for its acronym in Spanish) or the Puerto Rico Health Insurance Administration (ASES, for its acronym in Spanish) or both.

Who will hear your appeal?

 

Your appeal will be evaluated by a team of experts in your health condition that did not take part in the determination or in the notice of action that you received when you filed your complaint for the first time.  In this way it is assured that it a fair, transparent and dependable.

 

How much time will they take to make a determination on my appeal?

 

if it were an appeal in which your health condition  does not affect you even more or your life is not at risk, you must receive the determination on your appeal within a period that does not exceed 45 days. However, is your health condition requires an expedite determination; you will receive an answer within a period of 3 days or less.

 

 

  

28

  

 

Triple S can request ASES a 14-day extension to send its determination, as long as this extension benefit the beneficiary or when you request it because you need more time to find evidence or data that may benefit your case.

If you understand that the final determination does not favor you, you may then appeal the determination before ASES or the Patients’ Advocate Office, or both. If the unfavorable determination is sustained, you may request an Administrative Hearing before ASES or the Patients’ Advocate Office between 20 to 90 days from the date you received the adverse decision. At this hearing all the parties will meet to try to reach a final agreement. If at the hearing the parties sustain the initial unfavorable decision, you may appeal the decision before a Court of First Instance of Puerto Rico.

TIME TO SOLVE REQUESTS, COMPLAINTS AND APPEALS

	
  

	
·

	
To be able to receive services outside the preferred network, your Primary Care Physician must give you a referral or the referrals in a period that does not exceed 5 days.

 

	
  

	
·

	
Authorizations for covered services must be granted within a period that foes not exceed 72 hours.

      

	
  

	
·

	Expedite authorizations for covered services must be given within 24 hours.

 

	
  

	
·

	
Determinations on standard complaints must be notified to the affecter parties within a term that does not exceed 90 days.

	
  

	
·

	
The beneficiary can appeal the determination within a period of 20 to 90 days after receiving the notice of action.

	
  

	
·

	
The notices of action on standard appeals must be set to the affected parties within a period that does not exceed 45 days. Triple S may request a 14-day extension, as long as it is for the benefit of the beneficiary.

	
  

	
·

	
Decisions on expedited appeals will always depend on the patient’s health condition and may not exceed 3 days. They may request a 14-day extension as long as it is for the benefit of the beneficiary.

	
  

	
·

	
The beneficiary may request an Administrative Hearing before ASES between 20 to 90 days from the date you received notification of action on your appeal

 

DENTAL SERVICES

 

Dental services are free choice services and do not need referrals, that is, you can visit the dentist whenever you need dental services. You can visit your dentist as you have always done, as long as they are participating dentists of Mi Salud.

The information on participating dentists is included in the Directory of Contracted Providers which Triple S will mail to you. Dentists are not part of the Preferred Networks.

 

 

  

29

  

 

MENTAL HEALTH SERVICES

 

How can I receive mental health services or services against drug dependence?

 

Mental Health services and services against substance abuse are directly contracted by ASES. To receive these services you do not need a referral from your Primary Care Physician, you my request these services by yourself when you understand it is necessary.

 

MI Salud offers integrated Mental Health and Physical Health services. Under Mi Salud you can receive Mental Health services at the same facility where you visit your Primary Care Physician.

 

This means that when your Primary Care Physician detects that you need Mental Health Services, he does not have to send you to another office to receive the services. The psychologist and social worker will be there physically at least two days a week during the regular business hours of your Primary Medical Group.

 

Depending on the severity of the condition, it may be necessary that you receive the services at the Mental Health facilities APS Healthcare has throughout the Island.

 

When you fill out your enrollment form at Triple S’s Service Centers, among the materials you will receive there will be information about APS Healthcare that will provide you detailed information on the services they offer and how to obtain them when you need them. In addition, the Directory of Providers will indicate the address and telephone numbers of the providers that render Mental Health Services in your Region. For additional information regarding the services and benefits, you may refer to the Mental Health Coverage Section this Guide offers.

 

You may also contact Tele Mi Salud helpline if you do not know where to go. Tele Mi Salud will provide you all the information you need to this regard or you may contact the Mental Health Crisis Hotline at the numbers that appear on the back of your card.

 PREVENTIVE SERVICES

Your Government of Puerto Rico Health Plan offers you a variety of services under preventive services.

 

What are preventive services?

 

are health care services offered to will help you keep your health in optimal condition. If you have any condition, preventive services will help you have better knowledge of your condition, Aso you can keep it under control and prevent that it gets worse deteriorating your health. These services not only will help you understand your condition, but also will tell you what to do to keep you healthy. Refer to the Preventive Service Coverage found in this Guide, so you find out all the services covered under Mi Salud.

To keep your health in optimal conditions you must:

 

 

  

30

  

 

	
 

	
●

	
Maintain health nutrition.

 

●      Exercise, such as walking, at least 30 minutes 4 to 5 days a week

 

	
  

	
●

	
Avoid being overweight.

 

	
  

	
●

	
Be calm and in peace.

 

	
  

	
●

	
Take a few minutes daily to relax. This will help you reduce stress.

 

	
  

	
●

	
Get enough rest.

 

	
  

	
●

	
Do not smoke.

 

	
  

	
●

	
Do not use drugs or alcohol.

 

	
  

	
●

	
Visit or consult your doctor whenever you feel sick.

 

Triple S will provide you the Preventive Services, as required by Mi Salud and some additional services about which Triple S will provide information in booklets to be added to this Enrollee Manual.

 

HIV-AIDS

 

If you are diagnosed with the Acquired Immunodeficiency Syndrome or the Human Immunodeficiency Virus (HIV), your Primary Care Physician must request that you be included in the Special Coverage Registry. Once the Insures includes you in the Special Coverage Registry, they will mail you a letter authorizing you to receive services under the Special Coverage. This letter will include information on the effective date and the expiration of this coverage.

 

This letter will allow you to Access all the services and treatments for your condition without referrals, countersignatures on your prescriptions or Service orders for laboratory, X-rays services, among others, from your Primary Care Physician.

 

There are certain medications for your HIV/AIDS condition that will be provided by the Health Department, which may be acquired through the following Immunology Centers and Pharmacies:

 

Centers for the Prevention and Treatment of Communicable Diseases (CPTET, for its acronym in Spanish)

Updated as of August 2010

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	
ARECIBO

	
Dr. Evelyn Reyes García

INTERNIST

	
(787) 878-7895

(787) 881-5773

(787) 879-3388

 

	
Antiguo Hosp. Distrito

Carr. 129 hacia Lares

Box 897

Arecibo, PR 00618

 

  

31

  

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	
Contracted Pharmacies:

	
Farmacia Garcia (en Hatillo)

Lcdo. Daniel Mahiques

 

	
(787) 898-3975

(787) 820-9048 fax

	
121 Calle Vidal Feliz

Hatillo, PR

	
Farmacia Camuy Health Services, Inc.

	
787-898-2660

787-262-4822

	
53 Avenida Muñoz Rivera

Camuy

 

	
Farmacia CDT Quebradillas

 

	
787-895-2670

787-895-1540

 

	
Calle Muñoz Rivera

Quebradillas

	
Farmacia Centro de Salud de Lares, Inc.

	
787-897-3610

787-897-2725

	
Carretera 111 KM 1 HM 9

Lares

 

	
Farmacia Ciales Primary Health Care Services, Inc.

	
787-871-0601

787-871-3960

 

	
Carretera 149 KM 12.3

Ciales

	
Farmacia San Miguel

	
787-898-5764

787-262-3984

	
127 Avenida Dr. Susoni

Hatillo

 

	
Farmacia García

	
787-898-3975

787-820-9048

	
121 Calle Vidal Feliz

Hatillo

 

	
CPTET

BAYAMON

	
Dr. Aileen Romero (Administrator)

Physicians:

Dr. Francisco R. Bellaflores

(Internist)

Dr. Verónica Pérez

(Family Physician)

 

	
(787) 787-5151

Ext. 2224 /2435

(787) 787-5154 (d)

(787) 787-4211

(787) 778-1209 fax

	
Hosp. Regional Bayamón

Dr. Ramón Ruiz Arnau

Ave. Laurel Santa Juanita

Bayamón, PR  00956

	
Contracted Pharmacies:

	
Farmacia Caridad 4

	
787-269-3140

787-269-0022

	
Carretera 862 KM 1.9

Bayamon

 

	
Farmacia Centro de Salud Integral en Comerío

 

	
787-875-3375

787-875-4230

	
18 Calle Georgetti

Comerio

	
Farmacia Centro de Salud Integral en Corozal

 

	
787-859-2560

787-859-5390

	
Calle Nueva Final

Corozal

 

  

32

  

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	 	
Farmacia Centro de Salud Integral en Naranjito

 

	
787-869-1290

787-869-1800

	
Barrio Achiote Sector Desvío

Naranjito

	
Farmacia Plaza 3

	
787-785-0000

787-785-2387

	
57 Calle Barbosa

Bayamon

 

	
CPTET

CAGUAS

 

	
Dr. Gloria Morales

 

	
Ext. 11142, 11150

(787) 744-8645

(787) 746-2898 fax

	
Hosp. San Juan Bautista

Apartado 5729

Caguas, PR

 

	
Contracted Pharmacies

	
Farmacia Arleen

Lcdo. Roberto Peirats

	
(787) 746-5952

(787) 744-3397

	
Urbanización Villa del Rey

Caguas, PR

 

	
Farmacia Central

	
787-852-0520

787-850-5500

	
11 Calle Noya y Hernández

Humacao

 

	
Farmacia COSSMA

	
787-852-2551

787-937-0062

	
50 Calle Ulises Martínez Norte

Humacao

 

	
Farmacia COSSMA

	
787- 937-0058

787-037-0064

 

	
186 Calle Muñoz Rivera

San Lorenzo

	
Farmacia COSSMA

	
787-739-8182

787-714-1444

 

	
Carretera 172 Avenida El Jíbaro, Cidra

 

	
Farmacia Gurabo Community Health Center

 

	
787-737-2311

787-737-1242

 

	
Carretera 941 Salida Barrio Jaguas, Gurabo

	
Farmacia Hospital Ryder Memorial

	
787-852-0768

787-850-1444

 

	
Avenida Font Martelo

Humacao

	
Satellite Clinic  Humacao

 

	  	
(787) 640-0980

	
Centro Comercial Humacao

Ave. Font Martelo 100

Humacao, PR

 

 

  

33

  

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	
Contracted Pharmacies:

 

	
Farmacia Central

Lcdo. Julio Garriga

	
(787) 852-0520

(787) 850-5500

	
#11 Calle Nolla y Hernández

Humacao, PR

 

	
Farmacia Centro de Salud Integral en Orocovis

	
787-867-6010

787-867-6008 fax

	
Carretera 155 Salida Desvío

Orocovis

 

	
Farmacia Sonia

	
787-837-2666

787-837-4602 fax

	
61 Calle Comercio

Juana Díaz

 

	
Farmacia Centro de Salud Integral en Barranquitas

	
787-857-5923

787-857-1730 fax

	
Calle Barceló Salida A Comerio

Barranquitas

 

	
Farmacia Centro de Salud Familiar de Patillas

	
787-839-4320

787-271-0004 fax

	
99 Calle Guillermo Riefkhol

Patillas

 

	
Farmacia Centro de Salud Familiar Dr. Julio Palmie

	
787-839-4150

787-839-3989 fax

	
Calle Morse Esquina Valentina

Arroyo

 

	
CPTET

CAROLINA

	
Dr. Milton Garland

Médico Internista

	
(787) 757-1800

Ext. 454, 459

(787) 257-3615 (d)

(787) 257-3615 fax

 

	
Hosp. Universitario de Carolina

P.O. Box 8969

Carolina, PR 00984-3869

 

	
Contracted Pharmacies:

	
Farmacia Hospital Universitario Dr. Federico Trill

 

	
787-757-1800

787-750-4214

	
Carretera 3 KM 8.3

Carolina

	
FAJARDO

	
Dr. Arturo Hernández

Médico Generalista

Dr. Jorge Ruiz

Médico Infectólogo

	
(787) 801-1992

(787) 801-1995

(787) 801-6767

(787) 863-5487 fax

 

	
Calle Rafael #55

Fajardo, PR

	
Contracted Pharmaciesas:

	
Farmacia Denirka

Lcdo. Gil Nieves

	
(787) 863-7788

(787) 863-1422

	
305 Ave. General Valero

Fajardo, PR 00738

 

	
Farmacia Concilio de Salud Integral

	
787-876-2042

787-876-2005

	
Carretera 187 INT 188

Loíza

 

	
Farmacia Denirka

	
787-863-7788

787-863-1422

	
305 Avenida General Valero

Fajardo

 

 

  

34

  

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	
CPTET

MAYAGUEZ

	
Dr. Ramón Ramírez Ronda

Médico Infectólogo

	
(787) 884-2110

(787) 884-2115

(787) 884-2118

Ext. 4634

(787) 881-4495 fax

 

	
Centro Médico Mayagüez

Hosp. Ramón Emeterio Betances, Suite 6, Ave. Hostos # 40 Mayagüez, PR  00680

 

	
Contracted Pharmacies:

	
Farmacia Migrant Health Center Western

	
787-896-1665

787-896-1690

	
Carretera 119 KM 35.2

San Sebastián

 

	
Farmacia Centro de Prevención y Tratamiento de ETS

	
787-834-2115

787-834-6488

	
PR-2 KM 157.0 Antigua Casa Salud

Mayaguez

 

	
Farmacia Migrant Health Center

	
787-805-2920

787-805-4707

	
Carretera 1 KM 7.1

Mayaguez

 

	
Farmacia Rincón Health Center

 

	
787-823-5555

787-823-2990

 

	
28 Calle Muñoz Rivera

Rincón

	
CPTET

PONCE

 

	
Sra. Ineabelle Alameda

Clínica ETS

 

 

Dr. Gladys Sepúlveda

Coordinadora CIR

Médico Infectólogo

 

	
787) 848-2000

(787) 848-5574 (d)

(787) 844-2080

Ext. 1516

(787) 842-1948 fax

(787) 259-4731

(787) 259-4046

(787) 842-8626

(787) 259-8998 fax

 

	
Antiguo Hosp. Distrito-Ponce Dr. José Gándara, ahora Hosp. San Lucas II Carr. Estatal, Bo. Machuelo 14

Ponce, PR  00731

 

	
Contracted Pharmacies:

	
Farmacia El Apotecario

	
787-844-2135

787-284-2135    fax

	
Urbanización La Rambla

Ponce

 

	
Farmacia El Tuque

	
787-844-2805

787-841-5551    fax

	
553 Ernesto Ramos Antonini

Ponce

 

	
Farmacia Sección de Prevención de ETS

	
787-843-2188

787-840-7427      fax

	
Antiguo Hospital Regional San Lucas 2, Ponce

 

	
Farmacia Hospital General Castañer

	
787-829-5010

787-829-2913       fax

 

	
Carretera 135 KM 64.2 Castañer, Adjuntas

 

 

  

35

  

 

	
REGION

	
Coordinator

	
TELEPHONE/FAX

	
ADDRES

	 	
Farmacia MedCentro Consejo de Salud de Puerto Rico

 

	
787-843-9370

787-843-9395       fax

	
1034 Avendia Hostos

Ponce

	
Farmacia Migrant Health Center

 

	
787-821-4511

787-821-4511     fax

 

	
23 Calle Montalva

Guánica

	
NIVEL

CENTRAL

 

	
Dr. Hermes Garcia

Division Director Prevention and Treatment of Communicable Diseases

	
(787) 274-5504

(787) 274-5505

(787) 274-5501

(787) 274-5502

(787) 274-5508 fax

 

	
Antiguo Hosp. Psiquiatría

Pabellón 1, Primer Piso

Centro Médico

Río Piedras,

P.O. Box 70184

San Juan, PR 00936

 

	
CLETS

(Medical Center, Rio Piedras)

	
Dr. Hermes García

Internist

	
(787) 754-8118 (c)

(787) 754-8128 (d)

(787) 754-8127

(787) 754-8199 fax

 

	
P.O. Box 71423

Correo General

San Juan, PR 00936-8523

 

	
IMPORTANT:

	 
	 	 
	
The Special Coverage is authorized for a specific time period. When this period expires, your physician must justify any extension that is medically necessary for your condition and will have to request your registration in the Special Coverage again.

	 

 

HEPATITIS-C

 

If you were diagnosed with Hepatitis C, once laboratory tests are performed confirming that you have been infected with this disease, all the services and treatments  will be provided through the Health Department. Your Primary Care Physician must inform your diagnostic to Triple S Disease Management Program, for Triple S to provide you information and coordinate your enrollment in the Hepatitis C Program of the Health Department.

 

This is your Benefits Coverage

 

I Salud offers a broad service coverage with a minimum of exclusion. Your services will not be reduced, limited or will be excluded because you had a preexisting conditions before enrolling in Mi Salud. You will either have to comply with a waiting period to receive any of the covered services. Services will be covered from the moment Medicaid grants your eligibility.

 

  

36

  

 

The information that follows details all the services covered:

 

Preventive Services

 

	
  

	
●

	
Vaccines – Provided by the Health Department. Mi Salud will cover the administration of the vaccines following the dates established in the schedule provided by the Health Department.

 

	
  

	
●

	
Healthy Child Care - during the child’s first 2 years of life. 

 

	
  

	
●

	
Healthy Child Care - One comprehensive annual assessment performed by a certified health professional. This annual assessment supplements the services for children and young adults is provided during the period established in the schedule of the American Academy of Pediatrics and Title XIX (EPSDT)

 

	
  

	
●

	
Vision Test.

 

	
  

	
●

	
Hearing exam, including the newborn hearing screening before they are released from the hospital nursery.

 

	
  

	
●

	
Nutritional evaluations and tests.

 

	
  

	
●

	
Laboratory tests and all the diagnostic and screening tests according to the beneficiary’s age, sex and health condition.

 

	
  

	
●

	
Prostate and gynecologic cancer screening according to the accepted medical practices, including Papanicolau, mammography and PSA tests when medically necessary and according to the age of the beneficiary.

 

	
  

	
●

	
Puerto Rico public policy sets the age of 40 years as a starting point for mammograms and breast cancer screening.

 

	
  

	
●

	
Sigmoidoscopy and colonoscopy to detect colon cancer in adults aged 50 or more, classified by risk Group, according to the accepted medical practices.

 

	
  

	
●

	
Education on physical, nutritional and oral health.

 

	
  

	
●

	
Reproductive Health Counseling (Family Planning). Health Care Organizations, Insurers and Primary Medical Groups, through their providers, will ensure access to contraceptives, which will be provided, as available, by the Health Department.

 

●      Syringes for the administration of medications at home.

 

	
  

	
●

	
Health certificates covered under the Government Health Plan Mi Salud (Any other health certificates are excluded)

 

  

37

  

 

	
  

	
●

	
Health Certificates that include tests for sexually transmitted diseases (VDRL) and tuberculin tests. The certificate must have the seal of the Health Department with a copayment that will not exceed $5.00.

 

	
  

	
●

	
Any certification for Mi Salud beneficiaries related to the Medicaid Program eligibility (e.g. Medications History) will be provided to the beneficiary free of charge.

 

	
  

	
●

	
Any copayment that applies to necessary procedures and laboratory tests for the issuance of a Health Certificate will the responsibility of the beneficiary..

 

	
  

	
●

	
Annual physical exam and follow-up to diabetic patients according to treatment guidelines for the treatment of diabetic patients and the protocols of the Health Department.

 

Dental Services

 

You may visit the dentist of your choice that accepts Mi Salud. Covered dental services will be identified using the codes published by the American Dental Association  (ADA) for the procedures established by ASES. The services that follow are covered under Mi Salud:

 

	
  

	
●

	
Preventive services for children

 

	
  

	
●

	
Preventive services for adults

 

	
  

	
●

	
Restorative services

 

	
  

	
●

	
A comprehensive oral exam

 

	
  

	
●

	
A periodic oral evaluation every 6 months

 

	
  

	
●

	
Limited oral evaluation- problem focused

 

	
  

	
●

	
Intraoral X-rays complete series, including bitewings, every 3 years.

 

	
  

	
●

	
One intraoral/periapical first film.

 

	
  

	
●

	
Up to a maximum of 5 additional intraoral/periapical  X-rays a year

 

	
  

	
●

	
Bitewing single film a year

 

	
  

	
●

	
One Bitewings double film a year

 

	
  

	
●

	
One set of panoramic film every 3 years.

 

	
  

	
●

	
Prophylaxis – adult, every 6 months

 

	
  

	
●

	
Prophylaxis – children, every 6 months

 

  

38

  

 

	
  

	
●

	
Topical fluoride application for children under age 19, every 6 months.

 

	
  

	
●

	
Topical application of sealant, per tooth, on posterior teeth for beneficiaries up to 14 years old. Includes deciduous molars up to 8 years of age when it is medically necessary because of a tendency to cavities. This service is limited to one lifetime treatment.

 

	
  

	
●

	
Resin composite  restorations

 

	
  

	
●

	
Amalgam restoration

 

	
  

	
●

	
Pediatric therapeutic pulpotomy

 

	
  

	
●

	
Stainless steel crowns for primary teeth followed by a pediatric therapeutic pulpotomy.

 

	
  

	
●

	
Root canals

 

	
  

	
●

	
Palliative treatment

 

	
  

	
●

	
Oral surgery

 

Diagnostic Testing Services

 

	
  

	
●

	
High tech laboratories

 

	
  

	
●

	
Clinical laboratories including, but not limiting to, any laboratory order with the purpose of diagnosing the disease, even if the diagnosis is an excluded condition or disease.

 

	
  

	
●

	
X-rays

 

	
  

	
●

	
Radiotherapy

 

	
  

	
●

	
Electrocardiograms

 

	
  

	
●

	
Pathology

 

	
  

	
●

	
Arterial blood gases

 

	
  

	
●

	
Electroencephalograms

 

Ambulatory Rehabilitation Services

 

	
  

	
●

	
Physical therapy – a minimum of 15 physical therapy treatments a year per condition, per beneficiary, when prescribed by an orthopedist  or a physiatrist.

 

	
  

	
●

	
Occupational therapy – unlimited

 

	
  

	
●

	
Speech therapy – unlimited

 

  

39

  

 

Medical and Surgical Services

 

	
  

	
●

	
Visits to primary care providers, including primary care physicians and nursing services.

	
  

	
●

	
Treatments by specialists and sub-specialists, without referral, if they belong to the Preferred Network of your Primary Medical Group

	
  

	
●

	
Treatments by specialists and sub-specialists outside the Preferred Network of the Primary Medical Group with a referral of the Primary Care Physician you chose.

	
  

	
●

	
Physician home visits when it is medically necessary.

	
  

	
●

	
Respiratory therapy, without limits

	
  

	
●

	
Anesthesia services, except epidural anesthesia

	
  

	
●

	
Radiological services

	
  

	
●

	
Pathology services

	
  

	
●

	
Surgery

	
  

	
●

	
Use of ambulatory surgery facilities

	
  

	
●

	
Diagnostic services for cases of learning disabilities

	
  

	
●

	
Practical nurse services

	
  

	
●

	
Voluntary sterilization for men and women of appropriate age after being previously informed on the consequences of the medical procedure. The physician must have the written consent of the patient.

	
  

	
●

	
Prosthesis: includes the supply of all body extremities including therapeutic ocular prosthesis, segmented instrument tray and spinal fusion in scoliosis and vertebral surgery.

	
  

	
●

	
Ostomy equipment for patients ostomized ambulatorily.

	
  

	
●

	
Blood, plasma and their derivatives

	
  

	
●

	
Services to patients with chronic kidney disease in the first two levels (levels 3 to 5 are included in the Special Coverage).

	
  

	
●

	
Breast reconstruction surgery after a mastectomy because of cancer.

	
  

	
●

	
Treatments and surgery in cases of morbid obesity

 

Ambulance Services

 

	
  

	
●

	
Sea, air and land transportation will be covered within Puerto Rican territory limits in cases of emergency. These services do not require preauthorization or precertification.

 

Maternity and Prenatal Services

 

	
  

	
●

	
Women have the freedom to choose a gynecologist/obstetrician  among the providers of the Primary Medical Group or from Triple S General Network or any gynecologist/obstetrician, subject to the final coordination with the provider. The different interventions until the confirmation of the pregnancy  are not part of this coverage. Any procedure after the pregnancy is confirmed will be Triple S’s risk.

 

  

40

  

 

	
  

	
●

	
Pregnancy tests

	
  

	
●

	
Pre-natal services’

	
  

	
●

	
Services of the physician and an obstetric nurse during a normal delivery, c-section and in any other complication that may arise.

	
  

	
●

	
Maternity hospitalization or for pregnancy secondary conditions , when medically recommended.

	
  

	
●

	
Hospitalization of at least 48 hours for the mother and the newborn in case of a vaginal delivery and of 96 hours in case of c-section.

	
  

	
●

	
Anesthesia, except epidural anesthesia

	
  

	
●

	
Use of incubator, unlimited

	
  

	
●

	
Nursery room care for the newborn

	
  

	
●

	
Circumcision and dilatation services for the newborn

	
  

	
●

	
Transportation of the newborn to tertiary facilities

	
  

	
●

	
Assistance of a Pediatrician during a c-section or high risk delivery..

 

Emergency Room Services

 

	
  

	
●

	
Visits, medical attention, routine emergency room necessary services.

	
  

	
●

	
Services for trauma

	
  

	
●

	
You do not need a preauthorization or a precertification to receive these services.

	
  

	
●

	
Use of emergency room and surgery

	
  

	
●

	
Necessary and routine emergency room services

	
  

	
●

	
Respiratory services, without limitations

	
  

	
●

	
Treatment by a specialist or a sub-specialist when requested by the emergency room physician.

	
  

	
●

	
Anesthesia, excluding epidural anesthesia

	
  

	
●

	
Surgical supplies

	
  

	
●

	
Clinical laboratory tests

	
  

	
●

	
X-rays

	
  

	
●

	
Drugs, medications and intravenous solutions to be used in the emergency room

	
  

	
●

	
Blood, plasma and their derivatives, without limitations

 

	
  

	
●

	
Emergency services outside Puerto Rico will be covered for the federal population according to non-participating providers’ fees and by reimbursement.

 

Hospitalization Services

 

	
  

	
●

	
Semi-private room, available 24 hours a day, year round

	
  

	
●

	
Isolation room for medical reasons

 

  

41

  

 

	
  

	
●

	
Nursery

	
  

	
●

	
Meals, including specialized nutrition services

	
  

	
●

	
Regular nursing services

	
  

	
●

	
Use of specialized rooms such as surgery room, recovery room, treatment and delivery room, without limitations

	
  

	
●

	
Drugs, medications and contrast agents, without limitations

	
  

	
●

	
Materials such as bandages, gauze, plaster bandages or any other therapeutic dressing materials

	
  

	
●

	
Therapeutic and maintenance care services, including the use of the necessary equipment to render the service

	
  

	
●

	
Specialized diagnostic tests such as electrocardiograms, electroencephalograms, arterial blood gases, and other specialized test available at the hospital and necessary during the beneficiary’s hospitalization.

	
  

	
●

	
Supply of oxygen, anesthesia and other gases, including their administration

	
  

	
●

	
Respiratory therapy, without limitations.

	
  

	
●

	
Rehabilitation services while the patient is confined in the hospital, including physical, occupational and speech therapy.

	
  

	
●

	
Blood, plasma and their derivatives, without limitations

 

Mental Health Services

 

	
  

	
●

	
Evaluation, screening and treatment to individuals, couples, families and groups

	
  

	
●

	
Ambulatory services rendered by psychiatrists, psychologists and social workers

	
  

	
●

	
Hospital and ambulatory services for substance abuse and alcoholism

	
  

	
●

	
Intensive ambulatory services

	
  

	
●

	
Emergency and crisis intervention services available 24 hours a day, 7 days a week

	
  

	
●

	
Detoxification services for beneficiaries that use illegal drugs, have had suicidal attempts or accidental poisoning

	
  

	
●

	
Administration of and treatment with Buprenorphine (requires preauthorization)

	
  

	
●

	
Clinics for injectable extended-release medications

	
  

	
●

	
Escort, professional assistance and ambulance services when the services are necessary

	
  

	
●

	
Prevention services and secondary education

	
  

	
●

	
Pharmacy coverage and access to medications within 24 hours

	
  

	
●

	
Laboratory tests that are medically necessary

	
  

	
●

	
Treatment for patients diagnosed with Attention Deficit Disorder (ADD) with or without hyperactivity. This includes, but is not limited to, visits to neurologists and tests related to the treatment of this diagnosis.

	
  

	
●

	
Consultations and coordination with other Agencies.

 

  

42

  

 

Mental Health Hospitalization Services

 

	
  

	
●

	
Partial hospitalization services for cases referred by a psychiatrist for primary phase diagnostic and treatment, according to the parity provisions of Law 408 of October 2, 2000.

	
  

	
●

	
Hospitalization that presents a mental pathology that is not drug abuse when referred by a psychiatrist for primary phase diagnosis and treatment, according to the parity provisions of Law 408 of October 2, 2000

Pharmacy Services

 

	
  

	
●

	
Copayments for prescribed medications

	
  

	
●

	
Medications included in the Preferred Medications List (PDL)

	
  

	
●

	
Medications included in the Master Formulary are covered through the exception   processes.

 

Services Excluded from the Basic Coverage

 

	
  

	
●

	
Services to patients not eligible to Mi Salud

	
  

	
●

	
Services for non-covered illnesses or trauma

	
  

	
●

	
Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its acronym in Spanish)

	
  

	
●

	
Accidents on the job that are covered by the State Insurance Fund Corporation

	
  

	
●

	
Services covered by another insurance or entity with primary responsibility (third party liability)

	
  

	
●

	
Specialized nursing services for the comfort of the patient when they are not medically necessary

	
  

	
●

	
Hospitalizations for services that can be rendered on an outpatient basis

	
  

	
●

	
Hospitalization of a patient for diagnostic services only

	
  

	
●

	
Expenses for services or materials for the patient’s comfort such as telephone, television, admission kits, etc.

	
  

	
●

	
Services rendered a patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.)

	
  

	
●

	
Organ and tissue transplants

	
  

	
●

	
Weight control treatments (obesity or weight increase for aesthetic reasons

	
  

	
●

	
Sports medicine, music therapy and naturopathy

	
  

	
●

	
Tuboplasty, vasovasectomy and any other procedure to restore the ability to procreate

	
  

	
●

	
Cosmetic surgery to correct physical appearance defects

	
  

	
●

	
Services, diagnostic tests ordered or provided by naturopaths, chiropractors, iridologists and osteopaths

	
  

	
●

	
Mammoplasty or plastic reconstruction of breast for aesthetic purposes only

	
  

	
●

	
Ambulatory use of fetal monitor

 

  

43

  

 

	
  

	
●

	
Services, treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications. The following are considered induced abortions (code and description)

	
  

	
ü

	
59840 – Induced abortion – dilation and curettage

	
  

	
ü

	
59841 – Induced abortion – dilation and expulsion

	
  

	
ü

	
59850 – Induced abortion – intra-amniotic injection

	
  

	
ü

	
59851 – Induced abortion – intra-amniotic injection

	
  

	
ü

	
59852 - Induced abortion – intra-amniotic injection

	
  

	
ü

	
59855 - Induced abortion – by one or more vaginal suppositories (e.g. prostaglandin) with or without cervical dilation  (e.g. laminate) including admission and visits, expulsion of the fetus and afterbirth

	
  

	
ü

	
59856 - Induced abortion – by one or more vaginal suppositories (e.g. prostaglandin) with dilation and curettage or evacuation

	
  

	
ü

	
59857 - Induced abortion – by one or more vaginal suppositories (e.g. prostaglandin) with hysterectomy (failed medical evaluation)

 

	
  

	
●

	
Rebetron or any other prescribed medication for Hepatitis C treatment, both treatment and medications are excluded from the Mental Health and Physical Coverages. The medications as well as the treatment will be provided by the Hepatitis Program of the Health Department. For additional information refer to the Hepatitis Section previously mentioned in this Handbook.

	
  

	
●

	
Epidural anesthesia services

	
  

	
●

	
Polisomnography studies

	
 

	
●

	
Services that are not reasonable or necessary according to the regulations accepted in the practice of medicine. Services rendered in excess to those normally required for diagnostics, prevention, diseases, treatment, injury or organ system dysfunction or pregnancy condition.

	
  

	
●

	
Mental health  services that are not reasonable or necessary according to the accepted regulations for the practice of medical Psychiatry or the services rendered in excess to those usually required for the diagnostic, prevention and treatment of a mental illness.

	
  

	
●

	
Treatment for chronic if it is determined that the pain is of psychological or psychosomatic.

	
  

	
●

	
Treatment to stop smoking

	
  

	
●

	
Educational tests, educational services

	
  

	
●

	
Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage)

	
  

	
●

	
New or experimental procedures not approved by ASES to be included in the Basic Coverage.

	
  

	
●

	
Custody, rest and convalescence one the disease is under control or in irreversible terminal cases

	
  

	
●

	
Expenses for payments issued by the beneficiary to a participating provider, without a contractual limit to do it

	
  

	
●

	
Neurological and cardiovascular surgeries and related services (Services covered under the Special Coverage)

 

  

44

  

 

	
  

	
●

	
Services received outside the territorial limit of the Commonwealth of Puerto Rico

	
  

	
●

	
Expenses incurred as a result of procedures or benefits not covered by MI Salud. Maintenance prescriptions and laboratories required for the continuity of a stable healthy condition, as well as any emergency that may alter the result of the preferred procedure will be covered.

	
  

	
●

	
Judicial order for evaluations for legal purposes

	
  

	
●

	
Psychological/Psychometric tests and evaluations to obtain an employment, an insurance or a related administrative/judicial procedure

	
  

	
●

	
Travel expenses, even when ordered by the Primary Care Physician are excluded.

	
  

	
●

	
Eyeglasses, contact lenses and hearing aids

	
  

	
●

	
Acupuncture services

	
  

	
●

	
Rental or purchase of durable medical equipment (DME) wheelchairs or any other means of transportation for the disabled, be it manual ort electric and, any expense for the repair or alteration of said equipment, except when the life of the patients depends on this service. The determination regarding this exception is Triple S’s responsibility.

	
  

	
●

	
Procedures for sex changes, including hospitalizations and complications.

	
  

	
●

	
Services for the treatment of infertility and services related to conception by artificial means.

 

Special Coverage Services

 

Beneficiaries have the freedom to choose the providers for these services among the providers in the Preferred Network of the Primary Medical Group  or Triple S’s General Network, Differential diagnostic interventions up to the verification of the final diagnosis are not part of the Special Coverage. Any procedure performed after the diagnosis has been confirmed will be Triple S’s risk

 

Medications, laboratory test, diagnostic test and other related procedures specified in this coverage as necessary for ambulatory treatment or convalescence  are part of this coverage and do not require the preauthorization of the Primary Care Physician or of Triple S. Triple S must identify the patients included under this coverage to facilitate access to the contracted services. MI Salud Special Coverage will be activated when the beneficiary reaches the limit of any other Special Coverage he may have under any other plan.

The purpose of this coverage is to facilitate the effective management of beneficiaries with special health condition that require specialized medical attention. This Coverage will become effective when the diagnosis is confirmed through the results of tests or procedures performed..

 

The benefits under this coverage are::

 

●      Coronary disease services and intensive care, without limitations

 

	
  

	
●

	
Maxillary surgery.

 

  

45

  

 

	
  

	
●

	
Neurosurgical and cardiovascular procedures, including pacemakers, valves and  any other instrument or artificial device (Requires preauthorization)

 

	
  

	
●

	
Peritoneal dialysis, hemodialysis and related services (Requires preauthorization).

 

	
  

	
●

	
Clinical and pathological laboratory test that must be sent outside Puerto Rico for their processing (Requires preauthorization)

 

	
  

	
●

	
Neonatal intensive care unit services, without limitations

 

	
  

	
●

	
Treatment with radioisotopes, chemotherapy, radiotherapy and cobalt.

 

	
  

	
●

	
Gastrointestinal conditions, allergies and nutritional evaluation for autistic patients.

 

	
  

	
●

	
The following procedures and diagnostic tests, when medically necessary (Require preauthorization):

 

	
  

	
ü

	
Computerized Tomography

 

	
  

	
ü

	
Magnetic resonance tests

 

	
  

	
ü

	
Cardiac Catheterisms

 

	
  

	
ü

	
Holter Test

 

	
  

	
ü

	
Doppler Test

 

	
  

	
ü

	
Stress Test

 

	
  

	
ü

	
Lithotripsy

 

	
  

	
ü

	
Electromyography

 

	
  

	
ü

	
Tomography test (SPECT)

 

	
  

	
ü

	
Ocular Pletismography test (OPG)

 

	
  

	
ü

	
Impedance Pletismography (IPG)

 

	
  

	
ü

	
Other neurological cerebral-vascular and cardiovascular tests, invasive or non-invasive

 

	
  

	
ü

	
Nuclear Medicine tests

 

	
  

	
ü

	
Diagnostic Endoscopies

 

	
  

	
ü

	
Genetic Studies

 

  

46

  

 

	
  

	
●

	
Physical therapy – up to 15 additional treatments per condition per beneficiary a year, when ordered by an Orthopedist or Physiatrist (Require preauthorization from Triple S)

 

	
  

	
●

	
General Anesthesia.

 

	
  

	
ü

	
General anesthesia for dental treatment to children with special needs.

 

	
  

	
●

	
Hyperbaric chamber.

 

	
  

	
●

	
Immunosuppressive drugs and laboratory tests required for the maintenance treatment of patients who have been operated to receive any transplant, which assure the stability of the beneficiary’s health and the emergencies that may arise after this surgery.

 

	
  

	
●

	
Treatment for the following conditions after being confirmed by the results of laboratory tests and the diagnosis has been established:

 

	
  

	
ü

	
Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory and hospitalization services are included. You do not need a referral or preauthorization from Triple S or the Primary Care Physician for the visits and treatment at the Immunology Regional Clinics of the Health Department  .

 

	
  

	
ü

	
Tuberculosis

 

	
  

	
ü

	
Leprosy

 

	
  

	
ü

	
Lupus

 

	
  

	
ü

	
Cystic fibrosis

 

	
  

	
ü

	
Cancer

 

	
  

	
ü

	
Hemophilia

 

	
  

	
ü

	
Children with special needs, including the conditions described in the Manual of Diagnosis for Children with Special Needs of the Health Department, Office of Health Protection and Promotion, Habilitation Division (the manual) which is part of this part of this document, except:

 

	
  

	
m

	
Asthma and diabetes, which are included in the Disease Management Program

	
  

	

m

	
Mental disorders, and

	
  

	

m

	
Mental retardation, behavior manifestations will be managed by the mental health providers under the basic coverage, with the exception of a catastrophic disease. Triple S must request ASES authorization for any special condition not included in the manual for which the Primary Care Group or the Primary Medical Group request the activation of the Special Coverage.

 

	
  

	
●

	
Scleroderma

 

  

47

  

 

	
  

	
●

	
Multiple Sclerosis

 

	
  

	
●

	
Services for the treatment of conditions resulting from self-inflicted damage or as a result of a felony committed by a beneficiary or negligence.

 

	
  

	
●

	
Chronic renal disease in levels 3, 4 and 5. (Levels 1 and 2 are included in the Basic Coverage).

 

The following is a description of the stages of chronic renal disease:

 

Level 3 - FG (glomerular filtration - ml / min. bu 1.73 m 2 per unit of body area) between 30 and 59, a moderate decrease in kidney function

 

Level 4 - TFG between 15 and 29, a serious decrease in kidney function

 

Level 5 - TFG under 15, renal failure with probability of dialysis or kidney transplantation.

 

	
  

	
●

	
The medications required for the ambulatory treatment of Tuberculosis and Leprosy re included under the Special Coverage. Medications required for the ambulatory treatment or hospitalization for beneficiaries diagnosed with AIDS or that are VIH positive  are covered under the Special Coverage, except protease inhibitors, which will be provided by the Clinics for the Prevention and Treatment of Sexually Transmitted Diseases (CPTEST, for its acronym in Spanish).

 

Services excluded from the Special Coverage

 

Exclusions and limitations under the Basic Coverage are not covered under the Special unless expressly included in the Special Coverage.

 

Medicare Coverage Services

 

For Medicare Parts A and B beneficiaries, the following factors will be considered to determine the Coverage to be offered:

 

	
  

	
●

	
Beneficiaries eligible to Part A:

 

	
  

	
ü

	
They will be offered the regular MI Salud coverage, excluding the benefits covered by Part A until they reach their limit. In other words, once you reach the benefit limit of Medicare Part A coverage, Mi Salud will be activated.

	
  

	
ü

	
Part A deductibles are not included.

	
  

	
ü

	
The payment of deductibles for the regular coverage will be according to the payment capacity table provided to all Mi Salud beneficiaries.

 

	
  

	
●

	
Beneficiaries eligible to Parts A/B:

 

	
  

	
ü

	
They are offered the regular Mi Salud pharmacy and dental coverage.

 

  

48

  

 

	
  

	
ü

	
Part A deductibles are not included.

 

	
  

	
ü

	
Part B Deductibles and copayments will be included.

 

DISEASE MANAGEMENT AND SPECIAL CONDITION REGISTRY

 

Chronic Disease Management

 

Triple S Salud has programs that will help you control your chronic diseases, such as Diabetes Mellitus, Hypertension, and Congestive Heart Failure (CHF). Obesity, Kidney Failure and Bronchial Asthma. To benefit from these programs you may call at 1-866-788-6770. Triple S has a nursing and nutritionist staff available to manage your condition in coordination with the primary care physician.

 

Case Management

 

Triple S Salud has a Case Management Program, which is designed to help you with the coordination of medically necessary services for high cost conditions or catastrophic diseases.  This program has a staff of nurses, social workers and nutritionists to assist you. You physician, the hospital staff, your family or you may seek help through this program by calling at   (787)277-6544.

 

Special Condition Registry

 

Your primary care physician, the personnel designated by the Primary Medical Group or the case coordinator of the Primary Medical Group can instruct you on the conditions that qualify for the special coverage. Any of them can help you to be included in the Special Coverage by sending all the necessary information on your medical condition to Triple-S Salud to the fax number (787) 774-4835.

 

  

49

  

 

THESE ARE YOUR COPAYMENTS AND COINSURANCES

	  	  	  	  	  	  	  	  	  
	
CO-PAYS & CO-INSURANCE - Effective on November 1st, 2011

	
Services

	
Federal

	
CHIPS

	
Población Estatal

	
ELA*

	
100

	
110

	
230

	
300

	
310

	
320

	
330

	
400

	
HOSPITAL

	
HOSPITAL

	
HOSPITAL

	
HOSPITAL

	
HOSPITAL

	
Admissions

	
$0

	
$3

	
$0

	
$3

	
$5

	
$6

	
$20

	
$50

	
Nursery

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
EMERGENCY ROOM (ER)

	
EMERGENCY ROOM (ER)

	
EMERGENCY ROOM (ER)

	
EMERGENCY ROOM (ER)

	
EMERGENCY ROOM (ER)

	
Emergency Room (ER) Visit

	
$0

	
$0

	
$0

	
$1

	
$5

	
$10

	
$15

	
$20

	
Non-emergency visit to a   hospital emergency room.

	
$3.80

	
$3.80

	
$0

	
$15

	
$15

	
$15

	
$15

	
$20

	
Trauma

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
AMBULATORY VISITS TO

	
  AMBULATORY VISITS TO  

	
AMBULATORY VISITS TO

	
AMBULATORY VISITS TO

	
  AMBULATORY VISITS TO  

	
Primary Care Physician (PCP)

	
$0

	
$1

	
$0

	
$0

	
$1

	
$2

	
$2

	
$3

	
Specialist

	
$0

	
$1

	
$0

	
$1

	
$1

	
$3

	
$4

	
$7

	
Sub-Specialist

	
$0

	
$1

	
$0

	
$1

	
$1

	
$3

	
$5

	
$10

	
Pre-natal services

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
OTHER SERVICES

	
OTHER SERVICES

	
OTHER SERVICES

	
OTHER SERVICES

	
OTHER SERVICES

	
High-Tech Laboratories**

	
$0

	
50¢

	
$0

	
$1

	
$1

	
$2

	
$3

	
20%

	
Clinical Laboratories**

	
$0

	
50¢

	
$0

	
$1

	
$1

	
$2

	
$3

	
20%

	
X-Rays**

	
$0

	
50¢

	
$0

	
$1

	
$1

	
$2

	
$3

	
20%

	
Special diagnostic Tests**

	
$0

	
$1

	
$0

	
$1

	
$2

	
$2

	
$6

	
40%

	
Therapy – Physical

	
$0

	
$1

	
$0

	
$1

	
$2

	
$2

	
$3

	
$5

	
Therapy – Respiratory

	
$0

	
$1

	
$0

	
$1

	
$2

	
$2

	
$3

	
$5

	
Therapy – Occupational

	
$0

	
$1

	
$0

	
$1

	
$2

	
$2

	
$3

	
$5

	
Vaccines

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
Healthy Child Care

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
DENTAL

	
DENTAL

	
DENTAL

	
DENTAL

	
DENTAL

	
Preventive (Child)

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
Preventive (Adult)

	
$0

	
$1

	
$0

	
$0

	
$1

	
$2

	
$3

	
$3

	
Restorative

	
$0

	
$1

	
$0

	
$0

	
$1

	
$5

	
$6

	
$10

	
PHARMACY***

	
PHARMACY***

	
PHARMACY***

	
PHARMACY***

	
PHARMACY***

	
Generic (Children 0-21)

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$5

	
Generic (Adult)****

	
$1

	
$1

	
 N/A

	
$1

	
$2

	
$3

	
$5

	
$5

	
Brand (Children 0-21)

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$0

	
$10

	
Brand (Adult)****

	
$3

	
$3

	
 N/A

	
$3

	
$4

	
$5

	
$7

	
$10

	
Services

	
Federal

	
CHIPS

	
Población Estatal

	
ELA*

	
100

	
110

	
230

	
300

	
310

	
320

	
330

	
400

 

  

50

  

 

*Code 400 in ELA column refers to the population that subscribes as public employees of the Puerto Rico Government.

** Apply to diagnostic tests only.  Copays do not applied to tests required as part of a preventive service.

***Copays apply to each drug included in the same prescription pad.  Pharmacy exception (children 0- 21) does not apply to 400 ELA employees.

****Co-pays for children 0-21 years of age are not applicable for Medicaid,Commonwealth medically indigent eligible, and for children 0-18 enrolled in the  CHIP Program in group ages 0-18.

 

Co-pays may apply to children ages over twenty one  (21)  as well as to adults.

 

As established in 42 CFR 447.53(b) the following exceptions will be applicable for federal population under code 110:

 

(b) Exclusions from cost sharing. The plan may not provide for impositions of a deductible, coinsurance, copayment, or similar charge upon categorically or medically needy individuals for the following:

 

(1) (Children. Services furnished to individuals under 18 years of age (and, at the option of the State, individuals under 21, 20, or 19 years of age, or any reasonable category of individuals 18 years of age or over but under 21) are excluded from cost sharing.

 

(2) Pregnant women. Services furnished to pregnant women if such services related to the pregnancy, or to any other medical condition which may complicate the pregnancy are excluded from cost sharing obligations. These services include routine prenatal care, labor and delivery, routine post-partum care, family planning services, complications of pregnancy or delivery likely to affect the pregnancy, such as hypertension, diabetes, urinary tract infection, and services furnished during the postpartum period for conditions or complications related to the pregnancy. The postpartum period is the immediate postpartum period which begins on the last day of pregnancy and extends through the end of the month in which the 60-day period following termination of pregnancy ends. States may further exclude from cost sharing all services furnished to pregnant women if they desire.

 

(3) Institutionalized individuals. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution if the individual is required (pursuant to §435.725, §435,733, §435.832, or §436.832), as a condition of receiving services in the institution, to spend all but a minimal amount of his income required for personal needs, for medical care costs are excluded from cost sharing.

 

  

51

  

 

(4) Emergency services. Services as defined at section 1932(b)(2) of the Act and §438.114(a).

 

(5) Family planning. Family planning services and supplies furnished to individuals of child-bearing age are excluded from cost sharing.

 

(6) American Indians. Items and services furnished to an American Indian directly by an American Indian health care provider or through referral under contract health services.

 

Pharmacy Management Program

 

Program of 90 days dispensing for patients with chronic conditions:  Providers can prescribe a 90-day supply for certain medications.  This program allows the beneficiary to pay one (1) co-payment for a 90-day supply of medications instead of paying three (3) co-payments (1 co-payment per month).

 

  

52

  

 

HEALTH REGION MAPS

 

 

  

53

  

ATTACHMENT 4

OFFICE OF AIDS AFFAIRS AND TRANSMISSION DISEASES

Directory of Centers for Prevention and Treatment of Transmissible Diseases (CPTET, by its Spanish acronym)

	
REGION

	
MEDICAL DIRECTOR

	
TELEPHONE/FAX

	
ADDRESS

	  
	
 

ARECIBO

 

 

	
Dr. Evelyn Reyes García

Director

Internist

	
(787) 878-7895

Fax (787) 881-5773

Fax of Medical Director

Fax (787) 878-8288

Tel. (787) 879-3168

	
Former District Hospital

129 Rd. to Lares

#627 San Luis Avenue

Arecibo, PR 00612-3666

	  
	
BAYAMON

	
Dr. Odette García Viña

Director

 

Dr. Francisco Bellaflores

Internist

	
(787) 787-5151

Ext. 2224 /2435

(787) 787-5154 (d)

Fax  (787) 778-1209  (787) 787-4211

	
Former Health Home

Bayamón Regional Hospital

Dr. Ramón Ruiz Arnau

Ave. Laurel Santa Juanita

Bayamón, PR  00956

	  
	
CAGUAS

 

	
Dr. Gloria Morales

Director

General Physician

 

	
(787) 653-0550

Ext. 1142, 1150

(787) 744-8645

(787) 746-2898 fax

	
San Juan BautistaHospital

PO Box 8548

Caguas, PR 00726-8548

	  
	
Satellite Clinic Humacao

 

	  	
(787) 640-0980

(787) 852-0665

	
Humacao Shopping Center

Ave. Font Martelo 100

Humacao, PR

	  
	
CAROLINA

	
Dr. Milton Garland

Director

Internist

	
(787) 757-1800

Ext. 454, 459

Direct and fax (787) 257-3615

	
Dr. Federico Trilla UPR Hospital 

P.O. Box 6021

Carolina, PR 00984-6021

Road 3, Km. 8.3

	
CLETS

	
Dr. Hermes García

Internist

	
(787) 754-8118 (c)

(787) 754-8128 (direct)

(787) 754-8127

Fax (787) 754-8199

	
P.O. Box 70184

San Juan, PR 00936-8523

	
FAJARDO

	
Dr. Arturo Hernández

Director

General Physician

	
(787) 801-1992

(787) 801-1995

Fax (787) 863-5437

	
St. Rafael  #55

Fajardo, PR

	
MAYAGUEZ

	
Dr. Ramón Ramírez Ronda

Infectious Disease Physician

	
(787) 884-2115, 2118

Ext. 4634

 

Regional Director’s fax

(787) 806-3440

	
Centro Médico Mayagüez

Ramón Emeterio Betances Hospital

Suite 6

Ave. Hostos # 410

Former Health Home

Mayagüez, PR  00680

	
PONCE

 

	
Dra. Gladys Sepúlveda

Director

Infectious Disease Physician

	
(787) 259-4731

(787) 259-4046, (787) 842-8626

Fax (787) 259-3998

Phamacy fax (787) 843-2188

	
Antiguo Hosp. Distrito-Ponce Dr. José Gándara, ahora

Hosp. San Lucas II

Rd.Estatal, Bo. Machuelo 14

Ponce, PR  00731

 

	
CENTRAL LEVEL

 

 

	
Dr. Greduvel Durán

Executive Director

Medical Services Director

OCASET

 

	
(787) 765-2929

Ext. 4026, 4027

Fax (787) 274-5523

 

	
P.O. Box 70184

San Juan, PR 00936

Former Psychiatric Hospital

Pavillion 1, First Floor, 4th Door

Medical Center, Río Piedras

 

  

  

  

 

ATTACHMENT 5

	
#

	
Restriction

	
Product by category

	  	  	  
	
1

	  	
ANTIDOTES/DETERRENTS/POISON CONTROL

	
2

	  	
ALCOHOL DETERRENTS

	
3

	
PA

	
DISULFIRAM ORAL

	
4

	  	
ANTIDOTES/DETERRENTS/POISON CONTROL EXCHANGE RESINS

	
5

	  	
SODIUM POLYSTYRENE SULFONATE PWDR

	
6

	  	
SODIUM POLYSTYRENE SULFONATE RTL SUSP

	
7

	  	
SODIUM POLYSTYRENE SULFONATE SUSP

	
8

	  	  
	
9

	  	
ANTIHISTAMINES

	
10

	  	
PROMETHAZINE HCL TAB, SYP, SUPP, INY

	
11

	  	
DIPHENHYDRAMINE 50MG

	
12

	  	
HYDROXYZINE ORAL

	
13

	
AL 6 MO-2 Y/O

	
CETIRIZINE SYR (OTC)

	
14

	  	
NON-SEDATING ANTIHISTAMINES

	
15

	  	
FEXOFENADINE TAB

	
16

	  	
LORATADINE TAB, CHEW TAB, SYR, RDT TAB (OTC)

	
17

	  	
LORATADINE/PSEUDOPHEDRINE TAB SR (OTC)

	
18

	  	  
	
19

	  	
ANTIMICROBIALS

	
20

	  	
ANTIBIOTICS

	
21

	  	
PENICILLINS

	
22

	  	
PENICILLIN G BENZATHINE INJ

	
23

	  	
PENICILLIN G PROCAINE INJ

	
24

	  	
PENICILLIN VK ORAL

	
25

	  	
AMOXICILLIN ORAL

	
26

	  	
AMOXICILLIN/CLAVULANATE K ORAL

	
27

	  	
AMPICILLIN ORAL

	
28

	  	
CARBENICILLIN ORAL

	
29

	  	
CEPHALOSPORINS

	
30

	  	
CEPHALEXIN ORAL

	
31

	
AL < 12 Y/O

	
CEFADROXIL SUSP.

	
32

	  	
CEFACLOR ORAL

	
33

	  	
CEFPROZIL ORAL

	
34

	  	
CEFDINIR ORAL

	
35

	  	
ERYTHROMYCIN / MACROLIDES

	
36

	  	
AZITHROMYCIN ORAL

	
37

	  	
CLARITHROMYCIN TAB, SUSP

	
38

	  	
ERYTHROMYCIN ORAL

	
39

	  	
ERYTHROMYCIN / SULFA

	
40

	  	
TETRACYCLINES

	
41

	  	
DEMECLOCYCLINE HCL ORAL

	
42

	  	
AT LEAST ONE OF THE FOLLOWING

	
43

	  	
DOXYCYCLINE ORAL

	
44

	  	
MINOCYCLINE HCL ORAL

	
45

	  	
TETRACYCLINE HCL ORAL

	
46

	  	
AMINOGLYCOSIDES

	
47

	  	
STREPTOMYCIN SULFATE INJ

	
48

	
PA

	
TOBRAMYCIN INH

	
49

	  	
LINCOMYCINS

	  	  	  
	
50

	  	
CLINDAMYCIN ORAL

	
51

	  	
CLINDAMYCIN PALMITATE ORAL SOLN

	
52

	  	
ANTITUBERCULARS

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
53

	  	
CAPREOMYCIN INJ

	
54

	  	
CYCLOSERINE ORAL

	
55

	  	
ETHAMBUTOL HCL ORAL

	
56

	  	
ETHIONAMIDE ORAL

	
57

	  	
ISONIAZID ORAL

	
58

	  	
ISONIAZID / RIFAMPIN ORAL

	
59

	  	
PYRAZINAMIDE ORAL

	
60

	  	
RIFAMPIN ORAL

	
61

	  	
RIFABUTIN

	
62

	  	
NITROFURANS ANTIMICROBIALS

	
63

	  	
NITROFURANTOIN MONOHYDRATE MACROCRYSTAL ORAL

	
64

	  	
NITROFURANTOIN MACROCRYSTAL ORAL

	
65

	  	
SULFONAMIDE/RELATED ANTIMICROBIALS

	
66

	  	
SULFADIAZINE ORAL OR TRIPLE SULFA

	
67

	  	
SULFAMETHOXAZOLE/TRIMETHOPRIM ORAL

	
68

	  	  
	
69

	  	
ANTIFUNGALS

	
70

	  	
FLUCONAZOLE ORAL

	
71

	  	
GRISEOFULVIN ORAL

	
72

	
PA

	
VORICONAZOLE ORAL (TAB, SUSP)

	
73

	
VIH/SIDA

	
ITRACONAZOLE ORAL

	
74

	  	
KETOCONAZOLE ORAL

	
75

	  	
NYSTATIN SUSP

	
76

	  	
TERBINAFINE HCL ORAL

	
77

	  	
FLUCYTOSINE ORAL

	
78

	  	
CLOTRIMAZOLE TROCHE

	
79

	  	  
	
80

	  	
ANTIVIRALS

	
81

	  	
ANTI-HERPES AGENTS

	
82

	  	
ACYCLOVIR ORAL

	
83

	  	
ANTI-HEPATITIS B AGENTS

	
84

	
PA

	
LAMIVUDINE ORAL (EPIVIR HBV)

	
85

	
PA

	
ENTECAVIR ORAL (TAB. SOL.)

	
86

	  	
MISCELLANEOUS ANTIVIRALS

	
87

	
PA

	
PALIVIZUMAB

	
88

	  	
GANCICLOVIR ORAL

	
89

	  	
VALGANCICLOVIR ORAL

	
90

	  	
AMANTADINE HCL CAP, SYR

	
91

	  	
RIMANTADINE HCL ORAL

	
92

	  	
VIDARABINE INJ

	
93

	  	
NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

	
94

	  	
ABACAVIR ORAL

	
95

	  	
ABACAVIR / LAMIVUDINE ORAL

	
96

	  	
ABACAVIR / LAMIVUDINE / ZIDOVUDINE ORAL

	
97

	  	
DIDANOSINE ORAL

	
98

	  	
EMTRICITABINE

	
99

	  	
EMTRICITABINE / TENOFOVIR

	
100

	  	
EMTRICITABINE / TENOFOVIR / EFAVIRENZ

	  	  	  
	
101

	  	
EMTRICITABINE / RILPIVIRINE / TENOFOVIR

	
102

	  	
LAMIVUDINE ORAL

	
103

	  	
LAMIVUDINE / ZIDOVUDINE ORAL

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

	
104

	  	
STAVUDINE (d4T) ORAL

	
105

	  	
ZALCITABINE (ddC) ORAL

	
106

	  	
ZIDOVUDINE INJ

	
107

	  	
ZIDOVUDINE ORAL

	
108

	  	
NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITOR

	
109

	  	
TENOFOVIR

	
110

	  	
NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

	
111

	  	
DELAVIRDINE ORAL

	
112

	  	
EFAVIRENZ ORAL

	
113

	  	
NEVIRAPINE IR, SR

	
114

	
PA

	
ETRAVIRINE ORAL

	
115

	  	
RILPIVINE ORAL

	
116

	  	  
	
117

	  	
FUSION OF HIV INHIBITOR

	
118

	
PA

	
ENFUVIRTIDE INJ

	
119

	  	
HIV INTEGRASE STRAND TRANSFER INHIBITOR (HIV-INSTI)

	
120

	  	
RALTEGRAVIR ORAL

	
121

	  	
CCR5 CO-RECEPTOR ANTAGONIST

	
122

	
PA

	
MARAVIROC ORAL

	
123

	  	  
	
124

	  	
THE FOLLOWING PROTEASE INHIBITORS ARE COVERED ONLY THROUGH OCASET (PUERTO RICO DEPARTMENT OF HEALTH)

	
125

	  	
AMPRENAVIR

	
126

	  	
ATAZANAVIR

	
127

	  	
FOSAMPRENAVIAR

	
128

	  	
INDINAVIR S04 ORAL

	
129

	  	
NELFINAVIR ORAL

	
130

	  	
RITONAVIR ORAL

	
131

	  	
SAQUINAVIR 200MG CAP, 500MG TAB

	
132

	  	
LOPINAVIR / RITONAVIR

	
133

	  	  
	
134

	  	
QUINOLONES

	
135

	  	
CIPROFLOXACIN IR

	
136

	  	
AT LEAST ONE OF THE FOLLOWING

	
137

	  	
LEVOFLOXACIN

	
138

	  	
MOXIFLOXACIN

	
139

	  	  
	
140

	  	
MISCELLANEOUS ANTI-INFECTIVES

	
141

	  	
CLOFAZIMINE ORAL

	
142

	  	
DAPSONE ORAL

	
143

	  	
METRONIDAZOLE ORAL

	
144

	
PA

	
VANCOMYCIN CAP

	
145

	  	  
	
146

	  	
ANTIPARASITICS

	
147

	  	
HYDROXYCHLOROQUINE SULFATE ORAL

	
148

	  	
PRIMAQUINE PHOSPHATE ORAL

	
149

	  	
PYRIMETHAMINE ORAL

	  	  	  
	
150

	  	
CHLOROQUINE PHOSPHATE

	
151

	  	
QUININE SULFATE

	
152

	  	
IODOQUINOL

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
153

	  	
QUINACRINE

	
154

	  	
MEFLOQUINE

	
155

	  	
SULFADOXIME/PYRIMETHAMINE

	
156

	  	
ATOVAQUONE ORAL

	
157

	  	
PENTAMIDINE ISETHIONATE+C108 INHL SOLN

	
158

	  	
FURAZOLIDONE

	
159

	  	
ALBENDAZOLE ORAL

	
160

	  	
MEBENDAZOLE ORAL

	
161

	
PA

	
NITAZOXANIDE TAB, SUSP

	
162

	  	
THIABENDAZOLE ORAL

	
163

	  	
LINDANE CREAM

	
164

	STEP THERAPY; LC =60ML  LINDANE LOTION
	
165

	
LC = 60MG

	
PERMETRIN CREAM 0.5%

	
166

	  	  
	
167

	  	
ANTINEOPLASTICS

	
168

	  	
BUSULFAN INJ

	
169

	  	
BUSULFAN ORAL

	
170

	  	
CARMUSTINE INJ

	
171

	  	
CHLORAMBUCIL ORAL

	
172

	  	
CYCLOPHOSPHAMIDE INJ

	
173

	
PA

	
CYCLOPHOSPHAMIDE ORAL

	
174

	  	
IFOSFAMIDE INJ

	
175

	  	
IFOSFAMIDE/MESNA INJ

	
176

	  	
LOMUSTINE ORAL

	
177

	  	
MECHLORETHAMINE INJ

	
178

	  	
MELPHALAN HCL INJ

	
179

	  	
MELPHALAN ORAL

	
180

	  	
MEGESTROL ACETATE

	
181

	  	
THIOTEPA INJ

	
182

	  	
URACIL MUSTARD ORAL

	
183

	  	
BLEOMYCIN SO4 INJ

	
184

	  	
DACTINOMYCIN INJ

	
185

	  	
DAUNORUBICIN INJ

	
186

	  	
DOXORUBICIN INJ

	
187

	  	
IDARUBICIN INJ

	
188

	  	
MITOMYCIN INJ

	
189

	  	
PLICAMYCIN INJ

	
190

	  	
STREPTOZOCIN INJ

	
191

	  	
CLADRIBINE INJ

	
192

	  	
CYTARABINE INJ

	
193

	  	
FLUDARABINE INJ

	
194

	  	
FLUOROURACIL INJ

	
195

	  	
HYDROXYUREA ORAL

	
196

	  	
MERCAPTOPURINE ORAL

	
197

	  	
METHOTREXATE NA INJ

	
198

	
PA

	
METHOTREXATE NA ORAL

	
199

	  	
THIOGUANINE ORAL

	  	  	  
	
200

	  	
LEVAMISOLE ORAL

	
201

	
PA

	
BORTEZOMIB INJ

	
202

	
PA

	
CAPECITABINE TAB

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
203

	
PA

	
OXALIPLATIN INJ

	
204

	
PA

	
CETUXIMAB INJ

	
205

	
PA

	
BEVACIZUMAB INJ

	
206

	  	  
	
207

	  	
MULTIKINASE INHIBITORS

	
208

	
PA

	
SORAFENIB

	
209

	
PA

	
SUNITINIB

	
210

	  	  
	
211

	  	
MTOR KINASE INHIBITORS

	
212

	  	
EVEROLIMUS

	
213

	  	
TEMSIROLIMUS

	
214

	  	  
	
215

	  	
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF) INHIBITORS

	
216

	
PA

	
BEVACIZUMAB

	
217

	  	  
	
218

	  	
GONADOTROPIN-RELEASING HORMONE ANALOGS

	
219

	
PA

	
GOSERELIN

	
220

	
PA

	
LEUPROLIDE

	
221

	  	  
	
222

	  	
TYROSINE KINASE INHIBITORS

	
223

	
PA

	
IMATINIB MESYLATE ORAL

	
224

	
PA

	
DASATINIB TAB

	
225

	
PA

	
NILOTINIB CAP

	
226

	
PA

	
PAZOPANIB TAB

	
227

	  	  
	
228

	  	
SELECTIVE ESTROGEN RECEPTOR MODULATORS

	
229

	  	
TAMOXIFEN CITRATE ORAL

	
230

	  	  
	
231

	  	
TARGETED AGENTS

	
232

	
PA

	
TRASTUZUMAB

	
233

	
PA

	
LAPATINIB

	
234

	  	  
	
235

	  	
TESTOLACTONE ORAL

	
236

	  	
DEXRAZOXANE INJ

	
237

	  	
ASPARAGINASE INJ

	
238

	  	
BCG,TICE VACCINE

	
239

	  	
CARBOPLATIN INJ

	
240

	  	
CISPLATIN INJ

	
241

	  	
DACARBAZINE INJ

	
242

	  	
ESTRAMUSTINE ORAL

	
243

	  	
ETOPOSIDE INJ

	
244

	  	
ETOPOSIDE ORAL

	
245

	
PA

	
GEMCITABINE INJ

	
246

	
PA

	
IRINOTECAN INJ

	
247

	  	
MITOTANE ORAL

	
248

	
PA

	
MITOXANTRONE INJ

	
249

	  	
PACLITAXEL INJ

	  	  	  
	
250

	
PA

	
DOCETAXEL

	
251

	
PA

	
PENTOSTATIN/MANNITOL INJ

	
252

	  	
PROCARBAZINE ORAL

 

 

 

 

  

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
253

	
PA

	
TEMOZOLOMIDE

	
254

	  	
TENIPOSIDE INJ

	
255

	  	
VINBLASTINE INJ

	
256

	  	
VINCRISTINE INJ

	
257

	  	
VINORELBINE INJ

	
258

	  	
AT LEAST ONE OF THE FOLLOWING

	
259

	  	
FLUTAMIDE

	
260

	  	
BICALUTAMIDE

	
261

	  	  
	
262

	  	
AROMATASE INHIBITORS

	
263

	  	
AT LEAST ONE OF THE FOLLOWING

	
264

	  	
ANASTRAZOLE

	
265

	  	
EXEMESTANE

	
266

	  	
LETROZOLE

	
267

	  	  
	
268

	  	
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

	
269

	
PA

	
DALTEPARIN INJ

	
270

	
PA

	
ENOXAPARIN INJ

	
271

	
PA

	
FONDAPARINUX INJ

	
272

	  	
HEPARIN SODIUM INJ

	
273

	  	
WARFARIN NA ORAL

	
274

	
PA

	
DARBEPOETIN ALFA

	
275

	
PA

	
EPOETIN ALFA, RECOMBINANT HUMAN INJ.

	
276

	
PA

	
FILGRASTIM INJ

	
277

	
PA

	
SARGRAMOSTIM INJ

	
278

	
PA

	
PEGFILGRASTIM

	
279

	  	
CLOPIDOGREL

	
280

	
PA

	
PRASUGREL

	
281

	
PA

	
RIVAROXABAN 10MG TAB

	
281

	  	
ASPIRIN/DIPYRIDAMOLE

	
282

	  	  
	
283

	90-Days Supply with each pad ASPIRIN TAB., EC TAB. 81MG, 325MG
	
284

	  	  
	
285

	  	
INTERMITTENT CLAUDICATION AGENTS

	
286

	  	
CILOSTAZOLE TAB.

	
287

	  	
PENTOXIPHYLLINE

	
288

	  	  
	
289

	
PA

	
ANTIHEMOPHILIC AGENTS

	
290

	  	  
	
291

	  	
AUTONOMIC MEDICATIONS

	
292

	  	
METOCLOPRAMIDE HCL TAB, SYR, INY

	
293

	  	
NEOSTIGMINE BROMIDE ORAL

	
294

	  	
PYRIDOSTIGMINE BROMIDE ORAL

	
295

	  	
BENZTROPINE MESYLATETAB

	
296

	  	
DICYCLOMINE HCL ORAL

	
297

	  	
PROPANTHELINE BR ORAL

	
298

	  	  
	
299

	  	
TRIHEXYPHENIDYL HCL ELIXIR, TAB

	  	  	  
	
300

	  	
BROMOCRIPTINE MESYLATE TAB, CAP

	
301

	  	  
	
302

	  	
CENTRAL NERVOUS SYSTEM AGENTS

 

 

 

 

  

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

	 	 	 
	
303

	  	
OPIOID ANALGESICS

	
304

	  	
CODEINE SO4 ORAL

	
305

	  	
CODEINE/ACETAMINOPHEN ORAL

	
306

	  	
FENTANYL PATCH

	
307

	  	
HYDROCODONE/ACETAMINOPHEN ORAL

	
308

	  	
MEPERIDINE HCL INJ

	
309

	  	
MORPHINE SULFATE ORAL

	
310

	  	
MORPHINE SO4 RTL SUPP

	
311

	  	
OXYCODONE HCL ORAL

	
312

	  	
OXYCODONE HCL/ACETAMINOPHEN ORAL

	
313

	  	
TRAMADOL ORAL

	
314

	  	
HYDROMORPHONE TAB, SUPP, INJ, liq

	
315

	  	
APAP/BUTALBITAL/CAFN ORAL

	
316

	  	
CAFFEINE/ERGOTAMINE ORAL

	
317

	  	  
	
318

	  	
MU-OPIOID RECEPTOR ANTAGONISTS

	
319

	
PA

	
METHYLNALTREXONE BROMIDE INJ

	
320

	  	  
	
321

	  	
THROMBOPOIETIN RECEPTOR AGONIST

	
322

	
PA

	
ROMIPLOSTIM FOR INJ

	
323

	  	  
	
324

	  	
ANTIMIGRAINE AGENTS

	
325

	  	
AT LEAST ONE OF THE FOLLOWINGS:

	
326

	
LC

	
RIZATRIPTAN ORAL

	
327

	
LC

	
SUMATRIPTAN SUCCINATE ORAL, NASAL

	
328

	
LC

	
ZOLMITRIPTAN ORAL,NASAL

	
329

	
LC ALMOTRIPTAN ORAL

	
330

	
LC ELETRIPTAN ORAL

	
331

	  	
ANTIANXIETY AND SEDATIVE/HYPNOTIC AGENTS

	
332

	  	
ANXIOLYTICS

	
333

	  	
ALPRAZOLAM TAB, CONC

	
334

	  	
ALPRAZOLAM XR

	
335

	  	
CHLORDIAZEPOXIDE CAP

	
336

	  	
CLONAZEPAM TAB

	
337

	  	
CLORAZEPATE TAB

	
338

	  	
DIAZEPAM TAB, SOLN ,CONC

	
339

	  	
LORAZEPAM TAB, CONC

	
340

	
LC

	
MIDAZOLAM INJ

	
341

	  	
OXAZEPAM CAP

	
342

	  	
BUSPIRONE

	
343

	  	
SEDATIVES / HYPNOTICS

	
344

	  	
FLURAZEPAM CAP

	
345

	  	
TEMAZEPAM CAP

	
346

	  	
ESTAZOLAM TAB

	
347

	  	
PHENOBARBITAL ORAL

	
348

	  	
SEDATIVES/ HYPNOTICS NO-BENZODIAZEPINES

	
349

	
LC=30 days

	
ZALEPLON

	
350

	  	
ZOLPIDEM

	  	  	  
	
351

	  	  
	
352

	  	
ANTICONVULSANTS

	
353

	  	
CARBAMAZEPINE TAB, CHW TAB, SUSP

 

 

 

 

  

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

	 	 	 
	
354

	  	
CARBAMAZEPINE ER TAB

	
355

	  	
CLONAZEPAM TAB

	
356

	  	
ETHOSUXIMIDE CAP, SYR

	
357

	  	
GABAPENTIN TAB, CAP

	
358

	  	
GABAPENTIN SYR

	
359

	  	
LAMOTRIGINE TAB, ODT

	
360

	  	
OXCARBAZEPINE TAB, SUSP

	
361

	  	
PHENYTOIN CHW TAB, CAP, SUSP

	
362

	  	
PRIMIDONE TAB

	
363

	  	
TIAGABINE TAB

	
364

	  	
TOPIRAMATE CAP, TAB

	
365

	  	
VALPROIC ACID CAP, SYR

	
366

	  	
DIVALPROEX SODIUM EC TAB, CAP

	
367

	  	
DIVALPROEX SODIUM ER TAB

	
368

	  	
LEVETIRACETAM TAB, SOL

	
369

	  	
ZONISAMIDE CAP

	
370

	  	  
	
371

	  	
ANTIPARKINSON AGENTS

	
372

	  	
CARBIDOPA / LEVODOPA CR TAB

	
373

	  	
CARBIDOPA / LEVODOPA IR TAB

	
374

	  	
CARBIDOPA-LEVODOPA-ENTACAPONE TAB

	
375

	  	
SELEGILINE HCL ORAL TAB

	
376

	  	
ANTIPARKINSON AGENTS - DOPAMINE RECEPTOR AGONISTS

	
377

	  	
AT LEAST ONE OF THE FOLLOWING

	
378

	  	
PRAMIPEXOLE ORAL

	
379

	  	
ROPIRINOLE ORAL

	
380

	  	  
	
381

	  	
ANTIDEPRESSANTS

	
382

	  	
TRICYCLIC ANTIDEPRESSANTS

	
383

	  	
AMITRIPTYLINE HCL

	
384

	  	
CLOMIPRAMINE

	
385

	  	
DESIPRAMINE HCL

	
386

	  	
DOXEPIN HCL

	
387

	  	
IMIPRAMINE HCL

	
388

	  	
NORTRIPTYLINE HCL

	
389

	  	
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRI’S)

	
390

	  	
FLUOXETINE (REGULAR RELEASE - 10MG, 20MG, 40MG capsules and 10 mg, 20mg tabs)

	
391

	  	
PAROXETINE HCL REGULAR RELEASE 20MG, 30 MG, 40MG

	
392

	  	
CITALOPRAM

	
393

	  	
AT LEAST TWO OF THE FOLLOWING SSRI’S

	
394

	
PA

	
ESCITALOPRAM

	
395

	  	
SERTRALINE

	
396

	
PA

	
PAROXETINE CR

	
397

	  	
MISCELLANEOUS ANTIDEPRESSANTS

	
398

	  	
BUPROPION REGULAR RELEASE

	
399

	  	
BUPROPION SUSTAINDED RELEASE (SR)

	  	  	  
	
400

	  	
MIRTAZAPINE TAB

	
401

	  	
TRAZODONE 50MG, 100MG, 150MG

	
402

	
PA

	
VENLAFAXINE SUSTAINED RELEASE (SR) TAB, CAP

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
403

	  	
VENLAFAXINE IR TAB

	
404

	
PA (SALUD MENTAL)

	

DULOXETINE

	
405

	  	  
	
406

	  	
ANTIPSYCHOTICS

	
407

	  	
TYPICAL ANTIPSYCHOTICS

	
408

	  	
CHLORPROMAZINE ORAL

	
409

	  	
CHLORPROMAZINE SUPP RTL

	
410

	  	
FLUPHENAZINE ORAL

	
411

	  	
FLUPHENAZINE DECAONATE INJ

	
412

	  	
PERPHENAZINE ORAL

	
413

	  	
THIORIDAZINE ORAL

	
414

	  	
THIOTHIXENE ORAL

	
415

	  	
TRIFLUOPERAZINE ORAL

	
416

	  	
HALOPERIDOL ORAL

	
417

	  	
HALOPERIDOL DECANOATE INJ

	
418

	  	
ATYPICAL ANTIPSHYCOTICS

	
419

	
PA

	
CLOZAPINE ORAL 25 mg, 100 mg

	
420

	  	
AT LEAST THREE OF THE FOLLOWING WITH PRIOR AUTHORIZATION

	
421

	
PA

	
ARIPIPRAZOLE ORAL TAB 5 MG, 10 MG, 15 MG, 20 MG, 30 MG

	
422

	
PA

	
OLANZAPINE ORAL

	
423

	
PA

	
RISPERIDONE ORAL

	
424

	
PA, LC=10 days

	
QUETIAPINE ORAL TAB 25 MG, 50 MG

	
425

	
PA

	
QUETIAPINE ORAL TAB 100 MG, 200 MG, 300 MG, 400 MG

	
426

	
PA, LC= 3 days

	
QUETIAPINE ER ORAL TAB 50MG

	
427

	
PA

	
QUETIAPINE ER ORAL TAB 150MG, 200MG, 300MG, 400MG

	
428

	
PA

	
ZIPRASIDONE ORAL

	
429

	  	  
	
430

	  	
LITHIUM SALTS

	
431

	  	
LITHIUM CARBONATE ORAL

	
432

	  	
LITHIUM CITRATE SYRUP

	
433

	  	  
	
434

	
AL 6-18 y/o, LE, PA

	
ATOMOXETINE

	
435

	  	  
	
436

	  	
CNS STIMULANTS

	
437

	  	
AMPHETAMINES

	
438

	
AL 4-18 y/o

	
DEXTROAMPHETAMINE REGULAR RELEASE TAB

	
439

	
AL 4-18 y/o

	
DEXTROAMPHETAMINE CONTROLLED RELEASE CAP

	
440

	
AL 4-18 y/o

	
DEXTROAMPHETAMINE / AMPHETAMINE TAB

	
441

	 	
AMPHETAMINE - LIKE STIMULANTS

	
442

	
AL 6-18 y/o

	
METHYLPHENIDATE REGULAR RELEASE TAB

	
443

	
AL 6-18 y/o, P

	
METHYLPHENIDATE EXTENDED RELEASE

	
444

	
AL 6-18 y/o

	
DEXMETHYLPHENIDATE REGULAR RELEASE TAB

	
445

	  	
AT LEAST THREE OF THE FOLLOWING MODIFIED RELEASE (DRUG DELIVERY SYSTEM)

	
446

	
AL 6-18 y/o, P, ST

	
METHYLPHENIDATE MR (DIFFUCAP)

	
447

	
AL 6-18 y/o, ST

	
METHYLPHENIDATE MR (OROS)

	
448

	
AL 6-18 y/o, ST

	
METHYLPHENIDATE MR (SODAS)

	  	  	  
	449 AL 6-18 y/o, ST DEXMETHYLPHENIDATE XR
	
450

	  	  
	
451

	  	
CHOLINESTERASE INHIBITORS AGENTS

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
452

	  	
AT LEAST TWO OF THE FOLLOWING

	
453

	  	
DONEPEZIL ORAL

	
454

	  	
RIVASTIGMINE ORAL AND PATCH

	
455

	  	
GALANTAMINE ER

	
456

	  	  
	
457

	  	
NMDA ANTAGONISTS

	
458

	
ST

	
MEMANTINE TAB, ORAL SOLN

	
459

	  	  
	
460

	  	
CNS MEDICATIONS, OTHER

	
461

	  	
ERGOLOID MESYLATES ORAL

	
462

	  	  
	
463

	  	
CARDIOVASCULAR MEDICATIONS

	
464

	  	
DIGITALIS GLYCOSIDES

	
465

	  	
DIGOXIN ORAL

	
466

	  	  
	
467

	  	
BETA-BLOCKERS/RELATED

	
468

	  	
ATENOLOL TAB

	
469

	  	
CARVEDILOL ORAL

	
470

	  	
METOPROLOL TARTRATE TAB

	
471

	  	
METOPROLOL SUCCINATE SR TAB

	
472

	  	
PROPRANOLOL HCL TAB, SOLN, ORAL CONC

	
473

	  	
PINDOLOLTAB

	
474

	  	
LABETALOL TAB

	
475

	  	  
	
476

	  	
BETA-BLOCKERS COMBINATIONS

	
477

	  	
PROPRANOLOL / HYDROCHLOROTHIAZIDE TAB

	
478

	  	
METOPROLOL / HYDROCHLOROTHIAZIDE TAB

	
479

	  	
ATENOLOL / CHLORTHALIDONE TAB

	
480

	  	  
	
481

	  	
ALPHA-BLOCKERS/RELATED

	
482

	  	
DOXAZOSIN TAB

	
483

	  	
TERAZOSIN CAP

	
484

	  	  
	
485

	  	
CALCIUM CHANNEL BLOCKERS

	
486

	  	
DILTIAZEM HCL TAB IR

	
487

	  	
DILTIAZEM SR 12 HR CAP

	
488

	  	
DILTIAZEM SR 24 HR CAP

	
489

	  	
DILTIAZEM HCL COATED BEADS SR 24HR CAP

	
490

	  	
DILTIAZEM HCL EXTENDED RELEASE COATED BEADS 24HR CAPS

	
491

	  	
VERAPAMIL ORAL REGULAR RELEASE Y EXTENDED RELEASE

	
492

	  	
NIFEDIPINE ORAL EXTENDED RELEASE TAB

	
493

	  	  
	
494

	  	
AT LEAST ONE OF THE FOLLOWING

	
495

	  	
AMLODIPINE TAB

	
496

	  	
FELODIPINE TAB

	
497

	  	  
	
498

	  	
ANTIANGINALS

	  	  	  
	
499

	  	
ISOSORBIDE DINITRATE ORAL

	
500

	  	
ISOSORBIDE MONONITRATE

	
501

	  	
NITROGLYCERIN PATCH

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
502

	  	
NITROGLYCERIN SL TAB

	
503

	  	  
	
504

	  	
ANTIARRHYTHMICS

	
505

	  	
AMIODARONE ORAL

	
506

	  	
QUINIDINE ORAL

	
507

	  	
FLECAINIDE ORAL

	
508

	  	
MEXILITINE ORAL

	
509

	  	
PROPAFENONE ORAL

	
510

	  	
SOTALOL ORAL

	
511

	  	  
	
512

	  	
ANTILIPEMIC AGENTS

	
513

	  	
BILE ACID SEQUESTRANTS

	
514

	  	
AT LEAST ONE OF THE FOLLOWING

	
515

	  	
COLESTIPOL TAB, GRANULES

	
516

	  	
CHOLESTYRAMINE RESIN

	
517

	  	  
	
518

	  	
ANTILIPEMIC AGENTS, OTHERS

	
519

	  	
GEMFIBROZIL TAB

	
520

	  	
FENOFIBRATE MICRONIZED (Generic ONLY)

	
521

	  	
NIACIN CR TAB

	
522

	  	  
	
523

	  	
HMG-CoA REDUCTASE INHIBITORS (STATINS)

	
524

	  	
AT LEAST ONE OF THE FOLLOWING HIGH POTENCY AGENTS

	
525

	  	
ATORVASTATIN TAB

	
526

	
ST

	
ROSUVASTATIN TAB

	
527

	  	
SIMVASTATIN TAB

	
528

	  	
LOW POTENCY AGENTS

	
529

	  	
PRAVASTATIN TAB

	
530

	  	  
	
531

	  	
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

	
532

	
PA

	
EZETIMIBE TAB

	
533

	  	  
	
534

	  	
HMG-CoA REDUCTASE INHIBITORS (STATINS)/INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS

	
535

	
ST

	
EZETIMIBE / SIMVASTATIN TAB

	
536

	  	  
	
537

	  	
ANTIHYPERTENSIVES, OTHER

	
538

	
PA

	
CLONIDINE PATCH

	
539

	  	
CLONIDINE HCL ORAL

	
540

	  	
HYDRALAZINE HCL ORAL

	
541

	  	
METHYLDOPA ORAL

	
542

	  	
MINOXIDIL ORAL

	
543

	  	  
	
544

	  	
DIURETICS

	
545

	  	
THIAZIDES/RELATED DIURETICS

	
546

	  	
METOLAZONE ORAL

	
547

	  	
CHLORTHALIDONE ORAL

	
548

	  	
HYDROCHLOROTHIAZIDE ORAL

	  	  	  
	
549

	  	
CHLOROTHIAZIDE ORAL

	
550

	  	
INDAPAMIDE

	
551

	  	  

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
552

	  	
LOOP DIURETICS

	
553

	  	
FUROSEMIDE ORAL

	
554

	  	
BUMETANIDE ORAL

	
555

	  	  
	
556

	  	
CARBONIC ANHYDRASE INHIBITORS DIURETICS

	
557

	  	
ACETAZOLAMIDE ORAL

	
558

	  	  
	
559

	  	
POTASSIUM SPARING/COMBINATION DIURETICS

	
560

	  	
HYDROCHLOROTHYAZIDE / TRIAMTERENE ORAL

	
561

	  	
SPIRONOLACTONE ORAL

	
562

	  	  
	
563

	  	
ACE INHIBITORS

	
564

	  	
CAPTOPRIL TAB

	
565

	  	
ENALAPRIL TAB

	
566

	  	
LISINOPRIL TAB

	
567

	  	
FOSINOPRIL TAB

	
568

	  	
CAPTOPRIL/ HYDROCHLOROTHIAZIDE TAB

	
569

	  	
ENALAPRIL/ HYDROCHLOROTHIAZIDE TAB

	
570

	  	
LISINOPRIL/ HYDROCHLOROTHIAZIDE TAB

	
571

	  	  
	
572

	  	
ANGIOTENSIN II INHIBITORS

	
573

	  	
AT LEAST ONE OF THE FOLLOWING

	
574

	
ST

	
CANDESARTAN

	
575

	
ST

	
IRBESARTAN

	
576

	  	
LOSARTAN

	
577

	
ST

	
VALSARTAN

	
578

	
ST

	
TELMISARTAN

	
579

	  	
AT LEAST ONE OF THE FOLLOWING

	
580

	
ST

	
CANDESARTAN/ HYDROCHLOROTHIAZIDE TAB

	
581

	
ST

	
IRBESARTAN/ HYDROCHLOROTHIAZIDE TAB

	
582

	  	
LOSARTAN/ HYDROCHLOROTHIAZIDE TAB

	
583

	
ST

	
VALSARTAN/ HYDROCHLOROTHIAZIDE TAB

	
584

	
ST

	
TELMISARTAN / HYDROCHLOROTHIAZIDE TAB

	
585

	  	  
	
586

	  	
DERMATOLOGICAL AGENTS

	
587

	  	
ANTIBACTERIAL, TOPICAL

	
588

	  	
GENTAMICIN SULFATE CREAM

	
589

	  	
METRONIDAZOLE TOP GEL 0.75%

	
590

	  	
MUPIROCIN OINT

	
591

	  	
SILVER SULFADIAZINE CREAM

	
592

	  	  
	
593

	  	
ANTIFUNGAL, TOPICAL (ONLY LEGEND DOSAGE FORMS ARE COVERED)

	  	  	  
	
594

	
OTC

	
CLOTRIMAZOLE 1% TOP CREAM

	
595

	
OTC

	
CLOTRIMAZOLE 1% TOP SOLN

	
596

	  	
KETOCONAZOLE 2% SHAMPOO

	
597

	  	
KETOCONAZOLE 2% CREAM

	
598

	
OTC

	
MICONAZOLE NITRATE 2% TOP PWDR

	  	  	  
	  	  	  
	
599

	
OTC

	
MICONAZOLE NITRATE 2% TOP TINCTURE

	
600

	  	
NYSTATIN 100000 UNT/GM TOP OINT

	
601

	  	  

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
602

	  	
ANTI-INFLAMMATORY, TOPICAL

	
603

	  	
AT LEAST ONE OF THE FOLLOWING HIGHEST POTENCY AGENTS

	
604

	  	
AUGMENTED BETAMETHASONE DIPROPIONATE 0.05% OINTMENT

	
605

	  	
CLOBETASOL DIPROPIONATE 0.05% CREAM, OINTMENT, GEL, SOLUTION

	
606

	  	
AT LEAST ONE OF THE FOLLOWING HIGH POTENCY AGENTS

	
607

	  	
BETAMETHASONE DIPROPIONATE 0.05% CREAM, OINTMENT, LOTION

	
608

	  	
FLUOCINONIDE 0.05% CREAM, OINTMENT, GEL, SOLUTION

	
609

	  	
TRIAMCINOLONE ACETONIDE 0.5% CREAM, OINTMENT

	
610

	  	
AT LEAST ONE OF THE FOLLOWING INTERMEDIATE POTENCY AGENTS

	
611

	  	
BETAMETHASONE VALERATE 0.1% LOTION, CREAM, OINTMENT

	
612

	  	
DESOXIMETHASONE 0.05% GEL

	
613

	  	
FLUOCINOLONE ACETONIDE 0.025% CREAM, OINTMENT

	
614

	  	
MOMETASONE FUROATE 0.1% OINTMENT

	
615

	  	
TRIAMCINOLONE ACETONIDE 0.1% CREAM, LOTION, OINTMENT

	
616

	  	
AT LEAST ONE OF THE FOLLOWING LOW POTENCY AGENTS

	
617

	  	
HYDROCORTISONE > 2% CREAM, OINTMENT, LOTION

	
618

	  	
DESONIDE 0.05% CREAM, OINTMENT, LOTION

	
619

	  	
FLUOCINOLONE ACETONIDE 0.01% CREAM, SOLUTION

	
620

	  	  
	
621

	  	
TOPICAL IMMUNOMODULATORS

	
622

	  	
AT LEAST ONE OF THE FOLLOWING

	
623

	  	
PIMECROLIMUS 1% CREAM

	
624

	  	
TACROLIMUS 0.03% OINTMENT

	
625

	  	
TACROLIMUS 0.1% OINTMENT

	
626

	  	  
	
627

	  	
SOAPS/SHAMPOOS/SOAP-FREE CLEANSERS

	
628

	  	
SELENIUM SULFIDE 2.5% SHAMPOO

	
629

	  	  
	
630

	  	
ANTINEOPLASTICS, TOPICAL

	
631

	  	
FLUOROURACIL 2% TOP SOLN

	
632

	  	
FLUOROURACIL 5% CREAM

	
633

	  	
FLUOROURACIL 5% TOP SOLN

	
634

	  	
IMIQUIMOD 5% CREAM

	
635

	  	  
	
636

	  	
ANTIACNE AGENTS

	
637

	  	
ANTIACNE AGENTS, SYSTEMIC

	
638

	  	
ISOTRETINOIN ORAL

	
639

	  	
ANTIACNE AGENTS, TOPICAL

	
640

	  	
CLINDAMYCIN PHOSPHATE 1% TOP SOLN

	
641

	  	
ERYTHROMYCIN 2% TOP GEL

	
642

	  	
ERYTHROMYCIN 2% TOP SOLN

	
643

	  	  
	
644

	
AL 21 < Y/O

	
TRETINOIN 0.025% TOP CREAM

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
645

	
AL 21 < Y/O

	
TRETINOIN 0.1% TOP GEL

	
646

	
AL 21 < Y/O

	
TRETINOIN 0.025% TOP GEL

	
647

	
AL 21 < Y/O

	
TRETINOIN 0.01% TOP GEL

	
648

	
AL 21 < Y/O

	
TRETINOIN 0.05% TOP CREAM

	
649

	
AL 21 < Y/O

	
TRETINOIN 0.1% TOP CREAM

	
650

	  	  
	
651

	  	
ROSACEA AGENTS

	
652

	
AL > 21 Y/O

	
AZELAIC ACID GEL, CREAM

	
653

	  	
METRONIDAZOLE 0.75% TOP CREAM

	
654

	  	
METRONIDAZOLE 0.75% TOP GEL

	
655

	  	
METRONIDAZOLE 0.75% TOP LOTION

	
656

	  	
SULFACETAMIDE/SULFUR 10-5% CREAM

	
657

	  	
SULFACETAMIDE/SULFUR 10-5% SUSP

	
658

	  	
SULFACETAMIDE/SULFUR 10-5% EMULSION

	
659

	  	
SULFACETAMIDE/SULFUR 10-5% LOTION

	
660

	  	  
	
661

	  	
ANTIPSORIATICS

	
662

	  	
ANTIPSORIATICS, SYSTEMIC

	
663

	  	
ACITRETIN ORAL

	
664

	  	
METHOXSALEN ORAL

	
665

	  	
ANTIPSORIATICS, TOPICAL

	
666

	  	
ANTHRALIN 0.25% TOP CREAM

	
667

	  	
ANTHRALIN 0.5% TOP CREAM

	
668

	  	
ANTHRALIN 1% TOP CREAM

	
669

	  	
CALCIPOTRIENE 0.005% OINT

	
670

	  	
CALCIPOTRIENE 0.005% CREAM

	
671

	  	
TAZAROTENE 0.1% CREAM, GEL

	
672

	  	
TAZAROTENE 0.05% CREAM, GEL

	
673

	  	  
	
674

	  	
GASTROINTESTINAL MEDICATIONS

	
675

	  	
ANTIULCER AGENTS

	
676

	  	
HISTAMINE-2 RECEPTOR ANTAGONISTS

	
677

	  	
AT LEAST ONE OF THE FOLLOWING

	
678

	  	
CIMETIDINE ORAL

	
679

	  	
FAMOTIDINE ORAL

	
680

	  	
NIZATIDINE ORAL

	
681

	  	
RANITIDINE ORAL

	
682

	  	  
	
683

	  	
PROTECTANTS, ULCER

	
684

	  	
SUCRALFATE ORAL

	
685

	  	  
	
686

	  	
ANTIULCER AGENTS, OTHER

	
687

	  	
MISOPROSTOL ORAL

	
688

	  	  
	
689

	  	
ANTIDIARRHEAL AGENTS

	
690

	  	
ATROPINE SO4 /DIPHENOXYLATE HCL ORAL

	
691

	
MENTAL

	
LOPERAMIDE ORAL

	
692

	
PA

	
OCTREOTIDE ACETATE INJ

	
693

	  	  
	
694

	  	
DIGESTANTS

	
695

	  	
PANCREATIC ENZYMES

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
696

	  	  
	
697

	  	
ANTIEMETICS

	
698

	  	
PROCHLORPERAZINE TAB, SUPP, INY

	
699

	  	
METOCLOPRAMIDE TAB, SYR, INJ

	
700

	  	
TRIMETHOBENZAMIDE CAP, SUPP, INTRAMUSCULAR INJ

	
701

	
PA

	
APREPITANT CAP

	
702

	  	
AT LEAST ONE OF THE FOLLOWING 5HT3 AGENTS

	
703

	
PA

	
DOLASETRON TAB

	
704

	
PA

	
GRANISETRON TAB

	
705

	
PA

	
ONDANSETRON TAB, ODT

	
706

	  	  
	
707

	  	
GASTRIC MEDICATIONS, OTHER

	
708

	  	
OLSALAZINE

	
709

	  	
MESALAMINE 250MG AND 500MG, 1000mg

	
710

	  	
MESALAMINE DELAYED RELEASE

	
711

	  	
SULFASALAZINE ORAL

	
712

	
PA

	
BUDESONIDE ORAL

	
713

	
PA

	
URSODIOL ORAL

	
714

	  	
PROTOM PUMP INHIBITORS

	
715

	
LC

	
LANSOPRAZOLE CAP PRESENTACIONES GENERICAS

	
716

	
LC

	
OMEPRAZOLE CAP 10 MG , 20 MG, 40 mg

	
717

	  	  
	
718

	  	
GENITOURINARY MEDICATIONS

	
719

	  	
ANALGESICS, URINARY

	
720

	
LC

	
PHENAZOPYRIDINE HCL ORAL

	
721

	  	
METHENAMINE-HYOSCIAMINE-METHYLENE BLUE-DOD-PHEN SALICYLATE

	 	 	 
	
722

	  	
ANTISPASMODICS, URINARY

	
723

	  	
OXYBUTYNIN CHLORIDE IR TAB, SYRUP

	
724

	  	  
	
725

	  	
ANTI-INFECTIVES, VAGINAL

	
726

	  	
CLINDAMYCIN PHOSPHATE VAG CREAM

	
727

	  	
METRONIDAZOLE VAG GEL

	
728

	  	
TERCONAZOLE VAG CREAM AND SUPP

	
729

	  	
ESTROGENS, VAGINAL

	
730

	  	
ESTROGENS CONJUGATED VAG CREAM

	
731

	  	
ESTRADIOL VAG CREAM

	
732

	  	  
	
733

	  	
HORMONES/SYNTHETICS/MODIFIERS

	
734

	  	
SYSTEMIC CORTICOSTEROIDS

	
735

	  	
SYSTEMIC CORTICOSTEROIDS, SHORT ACTING

	
736

	  	
HYDROCORTISONE TAB

	
737

	  	
CORTISONE ACETATE TAB 25MG

	
738

	  	
SYSTEMIC CORTICOSTEROIDS, INTERMEDIATE ACTING

	
739

	  	
METHYLPREDNISOLONE TAB

	
740

	  	
PREDNISOLONE TAB

	
741

	  	
PREDNISOLONE SYRUP

	
742

	  	
PREDNISONE ORAL

	
743

	  	
TRIAMCINOLONE ACETONIDE INJ.

	
744

	  	
TRIAMCINOLONE DIACETATE

	
745

	  	
TRIAMCINOLONE HEXACETONIDE

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
746

	  	
METHYLPREDNISOLONE ACETATE INJ.

	
747

	  	
SYSTEMIC CORTICOSTEROIDS, LONG ACTING

	
748

	  	
DEXAMETHASONE TAB

	
749

	  	
DEXAMETHASONE SYRUP

	
750

	
OB-GYN

	
BETAMETHASONE SODIUM PHOSPHATE AND ACETATE

	
751

	
OB-GYN

	
DEXAMETHASONE SODIUM PHOSPHATE 4MG/ML

	
752

	  	
MINERALOCORTICOID

	
753

	  	
FLUDROCORTISONE ACETATE ORAL

	
754

	  	  
	
755

	  	
ANDROGENS/ANABOLICS

	
756

	  	
NANDROLONE DECANOATE

	
757

	  	
METHYLTESTOSTERONE ORAL

	
758

	  	
AT LEAST ONE OF THE FOLLOWING

	
759

	  	
TESTOSTERONE CYPIONATE

	
760

	  	
TESTOSTERONE ENANTHATE

	
761

	  	  
	
762

	  	
CONTRACEPTIVES, SYSTEMIC (FOR THERAPEUTIC USE ONLY)

	
763

	
PA

	
DESOGESTREL0.15/ETHINYL ESTRADIOL 30 TAB

	
764

	
PA

	
ETHINYL ESTRADIOL 30MCG/NORGESTREL 0.3MG TAB

	
765

	
PA

	
ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB,21

	
766

	
PA

	
ETHINYL ESTRADIOL 35MCG/NORETHINDRONE 1MG TAB,28

	
767

	
PA

	
MESTRANOL 50MCG/NORETHINDRONE 1MG TAB,21

	
768

	
PA

	
MESTRANOL 50MCG/NORETHINDRONE 1MG TAB,28

	
769

	
PA

	
NORGESTREL 0.075 TAB

	
770

	
PA

	
TRIPHASIC ORAL CONTRACEPTIVE(ORTHO-NOVUM 7/7/7/BASED),21

	
771

	
PA

	
TRIPHASIC ORAL CONTRACEPTIVE(ORTHO-NOVUM 7/7/7/BASED),28

	
772

	  	  
	
773

	  	
ESTROGENS

	
774

	  	
DIETHYLSTILBESTROL ORAL

	
775

	  	
ESTRADIOL MICRONIZE TAB

	
776

	  	  
	
777

	  	
BLOOD GLUCOSE REGULATION AGENTS

	
778

	  	
INSULIN

	
779

	  	
INSULIN HUMAN 50/50 (NPH/REG) INJ (OTC)

	
780

	  	
INSULIN HUMAN 70/30 (NPH/REG) INJ (OTC)

	
781

	  	
INSULIN HUMAN NPH 100U/ML INJ (OTC)

	
782

	  	
INSULIN HUMAN REGULAR 100U/ML INJ (OTC)

	
783

	  	
ANALOGS INSULIN

	
784

	  	
AT LEAST ONE OF THE FOLLOWING

	
785

	  	
INSULIN GLARGINE

	
786

	  	
INSULIN DETERMIR

	
787

	  	
AT LEAST ONE OF THE FOLLOWING ULTRA SHORT ACTING AGENTS

	 	 	 
	
788

	  	
INSULIN ASPART VIAL

	
789

	  	
INSULIN GLULISINE VIAL

	
790

	  	
INSULIN LISPRO VIAL

	
791

	  	  
	
792

	  	
HYPOGLYCEMIC AGENTS, ORAL

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
793

	  	
METFORMIN HCL ORAL

	
794

	  	
METFORMIN HCL TAB SR

	
795

	  	  
	
796

	  	
ALPHA-GLUCOSIDASE INHIBITORS

	
797

	  	
AT LEAST ONE OF THE FOLLOWING

	
798

	  	
ACARBOSE ORAL

	
799

	  	
MIGLITOL ORAL

	
800

	  	  
	
801

	  	
SECOND GENERATION SULFONYUREAS

	
802

	  	
GLIMEPIRIDE

	
803

	  	
GLIPIZIDE ORAL

	
804

	  	
GLIPIZIDE TAB SR

	
805

	  	
GLYBURIDE ORAL

	
806

	  	  
	
807

	  	
TIAZOLIDINEDIONES

	
808

	  	
AT LEAST ONE OF THE FOLLOWING

	
809

	  	
PIOGLITAZONE

	
810

	  	
TIAZOLIDINEDIONES COMBINATION

	
811

	  	
PIOGLITAZONE/METFORMIN

	
812

	  	
PIOGLITAZONE/GLIMEPIRIDE

	
813

	  	  
	
814

	  	
DIPEPTIDYL PEPTIDASE-4 INHIBITOR

	
815

	  	
AT LEAST ONE OF THE FOLLOWING

	
816

	
ST

	
SAXAGLIPTIN

	
817

	
ST

	
SITAGLIPTIN TAB

	
818

	
ST

	
SAXAGLIPTIN/METFORMIN TAB

	
819

	
ST

	
SITAGLIPTIN/METFORMIN TAB

	
820

	
ST

	
SITAGLIPTIN/METFORMIN TAB SR

	
821

	  	  
	
822

	  	
GLUCAGON FOR INJECTION (EMERGENCY KIT)

	
823

	
PA

	
HUMAN GROWTH HORMONE (SOMATROPIN)

	
824

	  	  
	
825

	  	
POSTERIOR PITUITARY

	
826

	  	
DesMOPRESSIN ACETATE inj 4mcg/ml

	
827

	  	
DesMOPRESSIN ACETATE tab

	
828

	  	
DESMOPRESSIN ACETATE NASAL SOLN

	
829

	  	  
	
830

	  	
PROGESTINS

	
831

	  	
MEDROXYPROGESTERONE ACETATE ORAL

	
832

	
PA

	
MEDROXYPROGESTERONE ACETATE 150MG INJ, 400MG INJ

	
833

	  	  
	
834

	  	
THYROID MODIFIERS

	
835

	  	
THYROID SUPPLEMENTS

	
836

	  	
LEVOTHYROXINE NA ORAL

	
837

	  	  
	
838

	  	
ANTITHYROID AGENTS

	
839

	  	
METHIMAZOLE ORAL

	
840

	  	
PROPYLTHIOURACIL ORAL

	
841

	  	  
	
842

	  	
HORMONES/SYNTHETICS/MODIFIERS, OTHER

	
843

	  	
ETIDRONATE ORAL

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
844

	  	  
	
845

	  	
5-ALPHA REDUCTASE INHIBITOR

	
846

	  	
FINASTERIDE TAB

	
847

	  	  
	
848

	  	
BIPHOSPHONATES

	
849

	  	
AT LEAST ONE OF THE FOLLOWING

	
850

	  	
ALENDRONATE SODIUM TAB

	
851

	  	
RISEDRONATE TAB

	
852

	  	  
	
853

	  	
PARATHYROID HORMONE

	
854

	
PA

	
TERIPARATIDE INJ

	
855

	  	  
	
856

	  	
IMMUNOLOGICAL AGENTS

	
857

	  	
IMMUNE STIMULANTS

	
858

	
PA

	
INTERFERON ALFA-2A INJ.

	
859

	
PA

	
INTERFERON ALFA-2B INJ.

	
860

	
PA

	
INTERFERON GAMMA-1B INJ

	
861

	  	
IMMUNOLOGICAL AGENTS, OTHER

	
862

	  	
CROMOLYN SODIUM ORAL

	
863

	  	
IMMUNOSUPPRESSANTS

	
864

	
PA

	
AZATHIOPRINE ORAL

	
865

	
PA

	
CYCLOSPORINE ORAL

	
866

	
PA

	
CYCLOSPORINE MODIFIED ORAL

	
867

	
PA

	
MYCOPHENOLATE MOFETIL ORAL

	
868

	
PA

	
MYCOPHENOLATE SODIUM ORAL

	
869

	
PA

	
RAPAMYCIN (SIROLIMUS) ORAL

	
870

	
PA

	
TACROLIMUS ORAL

	
871

	  	  
	
872

	  	
NEURAMINIDASE INHIBITORS

	
873

	
PA

	
OSELTAMIVIR

	
874

	  	  
	
875

	  	
MULTIPLE SCLEROSIS AGENTS

	
876

	  	
IMMUNOLOGICAL AGENTS

	
877

	
PA

	
GLATIRAMER ACETATE INJ

	
878

	
PA

	
NATALIZUMAB INJ

	
879

	  	
AT LEAST ONE OF THE FOLLOWING

	
880

	
PA

	
INTERFERON BETA-1A IM INJ (Avonex)

	
881

	
PA

	
INTERFERON BETA-1A INJ (Rebif)

	
882

	
PA

	
INTERFERON BETA-1B INJ (Extavia)

	
883

	
PA

	
INTERFERON BETA-1B INJ (Betaseron)

	
884

	  	  
	
885

	  	
MUSCULOSKELETAL MEDICATIONS

	
886

	  	
ANTIRHEUMATICS

	
887

	  	
SALICYLATES, ANTIRHEUMATIC

	
888

	  	
AT LEAST ONE OF THE FOLLOWING

	
889

	  	
CHOLINE SALICYLATE

	
890

	  	
MAGNESIUM CHOLINE SALICYLATE

	
891

	  	
DIFLUNISAL

	
892

	  	
MAGNESIUM SALICYLATE

	
893

	  	
SALSALATE ORAL

	
894

	  	
SODIUM SALICYLATE

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
895

	  	  
	
896

	  	
NONSALICYLATE - NSAID’s

	
897

	  	
IBUPROFEN ORAL

	
898

	  	
INDOMETHACIN ORAL

	
899

	  	
NABUMETONE

	
900

	  	
NAPROXEN ORAL

	
901

	  	
SULINDAC ORAL

	
902

	  	  
	
903

	
PA

	
PENICILLAMINE ORAL

	
904

	  	  
	
905

	  	
GOLD COMPOUNDS, ANTIRHEUMATIC

	
906

	
PA

	
AURANOFIN ORAL

	
907

	
PA

	
AUROTHIOGLUCOSE SUSP INJ

	
908

	  	  
	
909

	  	
COX-2 INHIBITORS

	
910

	
ST

	
CELECOXIB CAP.

	
911

	  	  
	
912

	  	
SKELETAL MUSCLE RELAXANTS

	
913

	  	
BACLOFEN ORAL

	
914

	  	
CYCLOBENZAPRINE ORAL

	
915

	  	
DANTROLENE ORAL

	
916

	  	
DIAZEPAM ORAL

	
917

	  	  
	
918

	  	
ANTIGOUT AGENTS

	
919

	  	
ALLOPURINOL ORAL

	
920

	  	
COLCHICINE ORAL (COLCRYS)

	
921

	  	
PROBENECID ORAL

	
922

	  	  
	
923

	  	
NASAL AND THROAT AGENTS, TOPICAL

	
924

	  	
ANTI-INFLAMMATORIES,NASAL

	
925

	  	
FLUTICASONE PROPIONATE (GENERIC)

	
926

	  	  
	
927

	  	
NASAL AND THROAT AGENTS, TOPICAL, OTHER

	
928

	  	
CLOTRIMAZOLE TROCHE

	
929

	  	  
	
930

	  	
OPHTHALMIC AGENTS

	
931

	  	
ANTIGLAUCOMA AGENTS

	
932

	  	
PROSTAGLANDIN / PROSTAMIDE ANALOGS

	
933

	  	
TWO OF THE FOLLOWING

	
934

	  	
LATANOPROST OPH SOLN

	
935

	
ST

	
TRAVAPROST OPH SOLN

	
936

	
ST

	
TRAVAPROST OPH SOLN (BAK-FREE PRESERVATIVE)

	
937

	
ST

	
BIMATROPROST OPH SOLN 0.03%

	
938

	
ST

	
BIMATROPROST OPH SOLN 0.01%

	
939

	  	
CARBONIC ANHYDRASE INHIBITORS

	
940

	  	
TWO OF THE FOLLOWING

	
941

	  	
DORZOLAMIDE OPH SOLN

	
942

	  	
BRINZOLAMIDE OPH SOLN

	
943

	  	
ALPHA-2 ADRENORECEPTOR AGONISTS

	
944

	  	
BRIMONIDINE TARTRATE 0.2%

	
945

	  	
APRACLONIDINE HCL OPH SOLN

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
946

	  	
BETA ADRENERGIC BLOCKERS - OPH

	
947

	  	
TIMOLOL OPH GEL

	
948

	  	
TIMOLOL OPH SOLN

	
949

	  	
BETAXOLOL 0.25% SUSP

	
950

	  	
BETAXOLOL 0.5% SOLN

	
951

	  	
LEVOBUNOLOL OPH SOLN

	
952

	  	  
	
953

	  	
MIOTICS, TOPICAL OPHTHALMIC

	
954

	  	
PILOCARPINE OPH SOLN

	
955

	  	  
	
956

	  	
MYDRIATICS/CYCLOPEGICS, TOPICAL OPHTHALMIC

	
957

	  	
ATROPINE SULFATE OPH OINT

	
958

	  	
ATROPINE SULFATE OPH SOLN

	
959

	  	  
	
960

	  	
ANTI-INFECTIVE, TOPICAL OPHTHALMIC

	
961

	  	
QUINOLONES, TOPICAL OPHTHALMIC

	
962

	  	
AT LEAST ONE OF THE FOLLOWING

	
963

	  	
CIPROFLOXACIN HCL OPH SOLN

	
964

	  	
CIPROFLOXACIN HCL OPH OINT

	
965

	  	
OFLOXACIN OPH SOLN

	
966

	  	
ANTI-BACTERIALS, TOPICAL OPHTHALMIC

	
967

	  	
GENTAMICIN SO4 OPH OINT

	
968

	  	
GENTAMICIN SO4 OPH SOLN

	
969

	  	
TOBRAMYCIN OPH SOLN

	
970

	  	
TOBRAMYCIN OPH OINT

	
971

	  	
BACITRACIN OPH OINT

	
972

	  	
ERYTHROMYCIN OPH OINT

	
973

	  	
SULFACETAMIDE SODIUM OPHTH SOLN 10%

	
974

	  	
ANTI-BACTERIALS COMBINATIONS, TOPICAL OPHTHALMIC

	
975

	  	
POLYMYXIN B / TRIMETHOPRIN OPH SOLN

	
976

	  	  
	
977

	  	
ANTI-VIRALS, TOPICAL OPHTHALMIC

	
978

	  	
AT LEAST ONE OF THE FOLLOWING

	
979

	
PA

	
GANCICLOVIR OPH GEL

	
980

	
PA

	
TRIFLURIDINE OPH SOLN

	
981

	  	  
	
982

	  	
ANTI-INFLAMMATORIES, TOPICAL OPHTHALMIC

	
983

	  	
AT LEAST ONE OF THE FOLLOWING

	
984

	MDL (30 DAYS IN 365 DAYS, MAX 60 DAYS IN 365 DAYS FOR CISTOID MACULAR EDEMA)
	 	  	
DICLOFENAC NA OPH SOLN

	
985

	MDL (30 DAYS IN 365 DAYS, MAX 60 DAYS IN 365 DAYS FOR CISTOID MACULAR EDEMA)
	 	  	
KETOROLAC TROMETHAMINE OPH SOLN 0.4%, 0.5%

	
986

	  	
ANTI-INFLAMMATORIES, TOPICAL OPHTHALMIC, OTHER

	
987

	  	
PREDNISOLONE PHOSPHATE OPH SOLN 1%

	
988

	  	
PREDNISOLONE OPH SUSP

	
989

	  	
FLUOROMETHOLONE ALCOHOL

	
990

	  	
FLUROMETHOLONE ACETATE

	
991

	  	
DEXAMETHASONE/TOBRAMYCIN OPH SUSP

	
992

	  	  
	
993

	  	
ORAL (MOUTH) AGENTS

	
994

	  	
LIDOCAINE HYDROCHLORIDE TOPICAL SOLUTION

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
995

	  	
CHLORHEXIDINE GLUICONATE ORAL RINSE

	
996

	  	  
	
997

	  	
OTIC AGENTS

	
998

	  	
POLYMYXIN B / NEOMYCIN / HC OTIC SOL, SUSP

	
999

	  	
OFLOXACIN OTIC SOLN

	
1000

	  	
ACETIC ACID 2% OTIC SOLN

	
1001

	  	
ACETIC ACID / ALUMINUM ACETATE OTIC SOLN

	
1002

	  	
ACETIC ACID 2% / HC 1% OTIC SOLN

	
1003

	  	  
	
1004

	  	
RESPIRATORY TRACT MEDICATIONS

	
1005

	  	
CROMOLYN SODIUM NEB SOLN

	
1006

	  	
ANTIASTHMA/BRONCHODILATORS

	
1007

	  	
ANTI-INFLAMMATORIES, INHALATION

	
1008

	  	
THREE OF THE FOLLOWING INHALED CORTICOSTEROIDS

	
1009

	  	
BECLOMETHASONE DIPROPIONATE HFA

	
1010

	  	
BUDENOSIDE RESPULES, INHALER

	
1011

	  	
FLUTICASONE HFA INHALER

	
1012

	  	
FLUTICASONE AER POWDER

	
1013

	  	
RESPIRATORY AGENTS - COMIBINATIONS

	
1014

	
ST

	
ALBUTEROL/IPRATROPIUM INHALER

	
1015

	  	
AT LEAST ONE OF THE FOLLOWING

	
1016

	
ST

	
SALMETEROL/FLUTICASONE

	
1017

	
ST

	
BUDESONIDE/ FORMOTEROL

	
1018

	  	  
	
1019

	  	
BRONCHODILATORS, SHORT ACTING

	
1020

	  	
ALBUTEROL INHL SOLN

	
1021

	  	
AT LEAST ONE OF THE FOLLOWING

	
1022

	  	
ALBUTEROL HFA INH

	
1023

	  	
LEVALBUTEROL HFA

	
1024

	  	  
	
1025

	  	
BRONCODILATORS, LONG ACTING

	
1026

	  	
AT LEAST ONE OF THE FOLLOWING

	
1027

	  	
SALMETEROL DISCUS

	
1028

	  	
FORMOTEROL

	
1029

	  	  
	
1030

	  	
BRONCHODILATORS, SYMPATHOMIMETIC, ORAL

	
1031

	  	
ALBUTEROL ORAL

	
1032

	  	
TERBUTALINE ORAL

	
1033

	  	
THEOPHYLLINE ORAL

	
1034

	  	  
	
1035

	  	
ANTICHOLINERGICS

	
1036

	  	
IPRATROPIUM BROMIDE INHL SOLN

	
1037

	  	
IPRATROPIUM BROMIDE HFA INHALER

	
1038

	
PA

	
TIOTROPIUM

	
1039

	  	  
	
1040

	  	
ANTIASTHMA, ANTILEUKOTRIENES

	
1041

	  	
MONTELUKAST TABLETS AND ORAL GRANULES

	
1042

	  	  
	
1043

	  	
ANTITUSSIVES/EXPECTORANTS

	
1044

	  	
OPIOID CONTAINING ANTITUSSIVES/ESPECTORANTS

	
1045

	  	
CODEINE/GUAIFENESIN SYRUP

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
1046

	  	  
	
1047

	  	
RECTAL, LOCAL

	
1049

	  	
ANTI-INFLAMMATORIES, RECTAL

	
1050

	  	
HYDROCORTISONE ENEMA

	
1051

	  	
MESALAMINE ENEMA

	
1052

	  	
MESALAMINE RTL SUPP

	
1053

	  	  
	
1054

	  	
HEMORRHOIDAL PREPARATIONS WITH STEROID

	
1055

	  	
HEMORRHOIDAL/HC RTL OINT

	
1056

	  	
HYDROCORTISONE/PRAMOXINE RTL CREAM

	
1057

	  	
HYDROCORTISONE/PRAMOXINE RTL FOAM

	
1058

	  	
HYDROCORTISONE/PRAMOXINE RTL OINT

	
1059

	  	  
	
1060

	  	
THERAPEUTIC NUTRIENTS/ MINERAL/ELECTROLYTES

	
1061

	  	
IRON INJ

	
1062

	  	
POTASSIUM CHLORIDE ORAL

	
1063

	
PA

	
LEVOCARNITINA

	
1064

	  	  
	
1065

	  	
VITAMINS

	
1066

	  	
LEUCOVORIN CALCIUM INJ

	
1067

	  	
LEUCOVORIN CALCIUM ORAL

	
1068

	  	
CYANOCOBALAMIN 1000MCG INJ

	
1069

	  	
FOLIC ACID ORAL

	
1070

	  	
CALCITRIOL ORAL

	
1071

	  	
ERGOCALCIFEROL INJ

	
1072

	  	
VITAMIN D ORAL

	
1073

	  	
PHYTONADIONE ORAL

	
1074

	
OTC

	
FERROUS SULFATE TAB (325MG)

	
1075

	
OB/GYN ONLY

	
PRENATAL VITAMINS (WITH AT LEAST 1MG FA AND 30 MG ELEMENTAL IRON)

	
1076

	  	  
	
1077

	  	
NUTRITIONALS FOR NEPHROLOGY

	
1078

	
NEPHROLOGY

	
RENAPHRO

	
1079

	
NEPHROLOGY

	
RENAL CAP

	
1080

	
NEPHROLOGY

	
NEPHRONEX

	
1081

	
NEPHROLOGY

	
NEPHROCAP

	
1082

	  	  
	
1083

	  	
HYPERPHOSPHATEMIA AGENTS

	
1084

	  	
CALCIUM ACETATE

	
1085

	  	
ONE OF THE FOLLOWING

	
1086

	
PA

	
SEVELAMER CARBONATE TAB, PACKET

	
1087

	
PA

	
LANTHANUM CARBONATE

	
1088

	  	
CALCIMIMETICS

	
1089

	
PA

	
Cinacalcet

	
1090

	  	  
	
1091

	  	
PROSTHETICS/SUPPLIES/DEVICES

	
1092

	  	
INSULIN SYRINGE 22

	
1093

	  	
INSULIN SYRINGE LOW DOSE

 

 

 

 

 

ASES MASTER FORMULARY  Updated as of:

MAR 21, 2013 (Physical Health)

DEC 13, 2012 (Mental Health)

 

	
1094

	  	  
	
1095

	  	
MISCELLANEOUS PRODUCTS

	
1096

	  	
ANTI-HYPERPROLACTEMIA

	
1097

	  	
CABERGOLINE

	
1098

	  	  
	
1099

	  	
TNF ANTAGONISTS

	
1100

	  	
AT LEAST TWO OF THE FOLLOWINGS

	
1101

	
PA

	
INFLIXIMAB INJ

	
1102

	
PA

	
ADALIMUMAB INJ

	
1103

	
PA E

	
TANERCEPT INJ

	
1104

	  	  
	
1105

	  	
PULMONARY ARTERIAL HYPERTENSION

	
1106

	
PA

	
BOSENTAN

	
1107

	
PA

	
SILDENAFIL (20 MG TAB)

	
1108

	  	  
	
1109

	  	
OPIOID PARTIAL AGONISTS

	
1110

	  	
PA BUPRENORPHINE HCL/ NALOXONE HCL, SL, FILM

	
1111

	  	  
	
1112

	  	
FIBROMYALGIA AGENTS

	
1113

	
PA

	
PREGABALIN

 

ST =           STEP THERAPY

PA =           PRIOR AUTHORIZATION

AL =           AGE LIMITATION

LC =           QUANTITY LIMITATION

 

 

 

 

 

Administration of Health Insurance

of the Commonwealth of Puerto Rico (ASES)

Mi Salud Specialty Drug List (contracted)

2013-2014

 

	
I.

	
Antibiotic

	  	Manufacturer
	  	  	  	  	  
	  	
Linezolid tab.

	
Zyvox

	
PA, P

	
Pfizer

	  	  	  	  	  
	
II.

	
Antineoplasic Agents

	  	  	  
	  	  	  	  	  
	  	
Ixabepilone

	
Ixempra

	
PA, P

	
BMS

	  	  	  	  	  
	
III.

	
Anticonvulsant Agents

	  	  	  
	  	  	  	  	  
	  	
Lacosamide tab. sol.

	
Vimpat

	
PA, P

	
UCB

	  	  	  	  	  
	
IV.

	
Anticoagulant Agents

	  	  	  
	  	  	  	  	  
	  	
Rivaroxaban tab.

	
Xarelto

	
PA, P

	
Janssen

	  	  	  	  	  
	
V.

	
Osteoporosis

	  	  	  
	  	  	  	  	  
	  	
Teriparadide inj.

	
Forteo

	
PA, P

	
Lilly

	  	  	  	  	  
	
VI.

	
Immune Modulators

	  	  	  
	  	  	  	  	  
	  	
Abatacept inj. (SQ & IV)

	
Orencia

	
PA, P

	
BMS

	  	
Certolizumab inj.

	
Cimzia

	
PA, P

	
UCB

	  	
Infliximab inj.

	
Remicade

	
PA, P

	
Janssen

	  	
Golimumab inj.

	
Simponi

	
PA, P

	
Janssen

	  	
Ustekinumab inj.

	
Stelara

	
PA, P

	
Janssen

	  	  	  	  	  
	
VII.

	
Multiple Sclerosis

	  	  	  
	  	  	  	  	  
	  	
Natalizumab inj.

	
Tysabri

	
PA, P

	
Elan

	  	
Dalframpridine tab.

	
Ampyra

	
PA, P

	
Acorda

	  	  	  	  	  
	
IX.

	
Antipsychotics

	  	  	  
	  	  	  	  	  
	  	
Paliperidone inj.

	
Invega Sustenna

	
PA, P

	
Janssen

	  	  	  	  	  
	
PA:

	
Requires preauthorization

	  	  	  
	
P:

	
Contracted brand name product (rebate)

	  	  	  

 

Access to the List of Contracted Specialized Medications:

In the situation in which a provider of medical services prescribes a specialized medication from the List of Contracted Specialized Medications, the MCO, MBHO, TPA or the organization contracted by ASES, shall evaluate the specialized medication requested by means of the exception mechanism.  The evaluation shall take into consideration the specific conditions of each case, which may include, but that is not limited to the following: 1) therapeutical failure with regard to all the alternatives in ASES’s PDL, 2) the lack of availability of therapeutic alternatives in ASES’s PDL for the services or conditions covered, 3) history record of adverse reactions to the medications included in ASES’s PDL, 4) contraindications of use in the medications included in ASES’s PDL.

 

  

  

  

 

PHYSICAL HEALTH

2013-2014

PREFERRED DRUG LIST

 

  

  

  

 

ASES                      

HEALTH INSURANCE ADMINISTRATION

Commonwealth of Puerto Rico

December 19, 2012

Dear provider:

I am pleased to present to you the list of Preferred Drugs (PDL) for Physical Health from the Health Plan of the Commonwealth of Puerto Rico (“Mi Salud”), effective since January 1, 2013.

The medications included herein have been evaluated and approved by a Pharmacy and Therapeutics Committee comprised by primary physicians and clinical pharmacists.

This committee meets periodically to evaluate the therapeutical classifications and issue recommendations based on clinical aspects.  Therefore, this PDL and the specialized PDLs that are included in this guide, may suffer changes, which are notified by means of Normative Letters, in conformity to how they arise.

I exhort you to conserve this Guide for your reference as long as it is necessary.  The same is also available in our electronic page www.asespr.org.

Cordially,

(signed)

Frank R. Díaz Ginés, MHSA

Executive Director

 

	PO Box 195661, San Juan, Puerto Rico  00919-5661	Tel. (787) 474-3300	Fax (787) 474-3346

                                                                                                                               

  

  

  

 

GENERAL ASPECTS OF THE PHARMACY COVERAGE

FROM THE HEALTH PLAN OF THE GOVERNMENT OF PUERTO RICO

	
1.

	
Listing of Drugs

The Administration of Health Insurance (ASES) is the agency responsible for establishing and reviewing the Preferred Drug List (PDL, on the basis of its initials in English) for Physical Health and Mental Health of “Mi Salud” (My Health).  For this purpose, there has been established a Pharmacy and Therapeutics Committee for Physical Health, and another one for Mental Health, both comprised by different health professionals.  These committees meet periodically to evaluate the different therapeutical classifications and issue their recommendations to ASES about the drug lists, based on scientific evidence and clinical aspects.

The Preferred Drug List (PDL) shall serve as a guide in the supplying of drugs under the pharmacy coverage. The PDL has the purpose of improving, putting up to date and attaining the effective cost use of drugs within the coverage of Mi Salud.

In addition, ASES maintains the Uniform Core List (FMU), which is utilized as the official listing from which the PDL is derived.  The drugs in this list which do not appear in the PDL may be utilized the insurance companies, mental health organizations and service providers only as exceptions in the cases in which the drugs in the PDL were not the most clinically effective for the patient in particular.

In like manner, a List of Specialized Drugs (contracted) was created.  In the situation where one provider of medical services prescribes a specialized drug from this list, it should be evaluated by means of the exception process by the MCO, MBHO, TPA or the organization contracted by ASES.

In exceptional cases drugs outside of the aforementioned lists may be utilized by means of an exception procedure.

	
2.

	
Exception Process

In the case of patients who need a drug that does not appear in the PDL or in the FMU, the insurance companies, mental health organizations and health service providers must utilize the process described herein for the approval of the drugs.  This procedure shall consider the particular merits of each case, which may include:

	
  

	
1.

	
Contraindication to the drug(s) that appear in the PDL.

	
  

	
2.

	
History record of adverse reaction to the drug(s) that appear in the PDL.

	
  

	
3.

	
Therapeutical failure with regard to all the alternatives available in the PDL.

	
  

	
4.

	
Non-existence of a therapeutical alternative in the PDL.

This exception process requires the official documentation from the service provider regarding the clinical reasons that justify the use of drugs outside the PDL.

 

  

  

  

 

	
3.

	
Other aspects of the pharmacy coverage

	
  

	
A.

	
The pharmacy coverage of Mi Salud establishes as mandatory the use of bioequivalent products, as long as it is not contraindicated and it is so clinically justified by the provider.

	
  

	
B.

	
The insurance companies, mental health organizations and health service providers shall process their pharmacy claims through the Pharmacy Benefit Managers (PBMs) contracted by the Administration.

	
  

	
C.

	
ASES has an active process to continuously review the drugs that it is required to include in the pharmacy coverage to the insurance companies or TPA, mental health organizations and health service providers.  In addition, it shall evaluate any new drug for inclusion in the same or remove drugs from said listing.  Due to the dynamic nature of this process, ASES may require the inclusion or exclusion of drugs pursuant to changes or advances in standards of practice within an illness or area of treatment.

	
  

	
D.

	
No entity contracted by ASES or the entities contracted by these ( Medical groups, IPAs, independent providers, specialists, etc.) may be ruled by a listing different from the PDL and the Core List, nor can they create an internal drug list that is different from the ones established by ASES.  Neither can they, in any way, limit in a manner contrary to what is established in the contract between ASES and the insurance companies and in this coverage, the drugs that are included in said lists.  The insurance companies shall be responsible for keeping tabs in their providers and employees with regard to the compliance with these provisions.

	
  

	
E.

	
The maximum of dispatch for severe conditions shall be to cover a thirty (30) day therapy.  When medically necessary, additional prescriptions shall be covered.

	
  

	
F.

	
The maximum of dispatch for chronic conditions (maintenance drugs) shall be to cover a thirty (30) day therapy, except at the beginning of the therapy when, on the basis of medical criterion, a minimum of fifteen (15) days may be prescribed for the purpose of reevaluating compliance and tolerance.  On the basis of a recommendation on the part of the physician, the dispatch of each prescription may be refilled up to five (5) times (original prescription plus five (5) refills).  The drugs that require pre-authorization shall be in effect for six months unless there are contraindications or secondary effects.  On or before the ninety (90) days after having prescribed said maintenance drug, the physician must reevaluate the pharmacotherapy for the purpose of compliance, tolerance and classification. Changes in the dosage will not require pre-authorization.  Changes in the drugs utilize may require pre-authorization.

	
  

	
G.

	
The indications in the prescriptions for chronic use drugs, in favor of Children with Special Health Needs, must indicate clearly that they are covering a thirty (30) day therapy and that they may be refilled up to five (5) times (original prescription plus five (5) refills), according to medical criterion.  When it is medically necessary, additional prescriptions shall be refilled.

 

  

  

  

 

	
  

	
H.

	
Coordination with the Department of Health is required for the supplying of birth control methods for family planning.  The contraceptives for the treatment of menstrual dysfunction and for other menstrual conditions shall be covered through your primary physician from Physical Health.

	
  

	
I.

	
The use of bioequivalents approved by the Food and Drug Administration (FDA), classified as AB, is required, as well as authorized by the local regulations as long as it is not contraindicated and it is so consigned by the provider in the medical prescription.

	
  

	
J.

	
The lack of existence in the inventory of bioequivalent drugs does not exempt the dispatch of the prescribed drug nor does it imply any additional payment whatsoever on the part of the beneficiary. As a general rule, bioequivalent drugs should be dispatched as long as there exists a bioequivalent for the drug of the corresponding brand name unless, in spite of the existence of a particular bioequivalent, ASES decides to cover the brand name drug or to cover both.

	
  

	
K.

	
All the prescriptions must be dispatched by a pharmacy contracted by the PBM, duly authorized under the laws of the Commonwealth of Puerto Rico and freely selected by the beneficiary.

	
  

	
L.

	
The right to free selection requires the availability of a determinate number of pharmacies in every municipality to be able to so exercise it.  The PBM is the entity in charge of contracting the network of pharmacies, pursuant to the terms specified by ASES.

	
  

	
M.

	
The prescribed drugs must be delivered concurrently on the date and time when the beneficiary receives the prescription and requires the dispatch of the drug.

For any doubt regarding the pharmacy coverage you may get in touch with the insurance company contracted by ASES in your service region.

 

  

  

  

 

PART I - DESIGN OF THE PREFERRED DRUG LIST, PRESENTATION OF THE PREFERRED DRUG LIST (“PDL”) AND REFERENCE GUIDES

 

In the example that follows we can see the information that is provided for the drugs included in the PDL.

 

	
Indicator of Relative Cost

	
Generic Name (in bold if the drug is available in generic)

	
Brand Name

	
Reference Guides

	
$ sign

	
Nystatin ssp.

	
Mycostatin

	
P, PA

 

For every drug included in the PDL, there appears an Indicator of Cost (Relative Cost), the Generic Name, the Brand Name and Reference Guides as applicable. In the cases in which the generic drug is available, the same appears in bold. Those generic drugs that have an asterisk (*) indicates that not all of the product's presentations have a generic available. As long as the bioequivalent generic of drug exists, the same shall be dispatched. The brand name is mentioned only for reference.

 

We exhort you to utilize the PDL as reference when you are going to prescribe drugs to the beneficiaries of the Health Plan of the Commonwealth of Puerto Rico.

 

INDICATOR OF RELATIVE COST

 

The indicator of relative cost is included in the PDL to offer an estimated value of the cost of a drug therapy including any discount for utilization and comparing the specific product with the other alternatives available in that classification, or to treat the specific disease or condition. In the majority of the cases, the cost per therapy for fifteen or thirty days is compared depending on whether the drug is of acute or of maintenance use, respectively. The comparison of costs and assignment of dollar signs is made on the basis of all the products included within a therapeutical classification, (for example, cardiovascular drugs, gastrointestinal drugs). The dollar signs next to a drug identify its relative cost and must be construed in the following manner:

 

	$                                                                	Less Costly 
	
$$

$$$

$$$$

$$$$$

$$$$$!

$$$$$!!

	Most Costly

 

When several drugs within the same therapeutical classification have the same number of dollar signs, the drug that is mentioned first must be considered as the least costly one.

 

Where there exists an alternative for a number of adequate preparations to treat a particular disease or condition, the indicator of relative cost may be utilized to make a selection on the basis of the cost.

 

  

  

  

 

The designation of the relative costs is effective at the moment of the publication of this edition of the PDL. The cost of the drugs is subject to constant changes.

 

GENERIC DRUGS

 

The bioequivalent generic drugs are identified in bold. Certain bioequivalent generics have a Maximum Allowable Cost (or MAC List) for the payment of the same. This price typically covers the cost of the purchase of the generic products, but not of the brand name ones. The selection of products to be included in the MAC List are those that are prescribed commonly and have been approved by the Food and Drug Administration (FDA, on the basis of its initials in English) to be marketed.

 

REFERENCE GUIDES

 

The drugs which appear in the PDL are those preferred drugs in the coverage of the Health Plan of the Commonwealth of Puerto Rico. These drugs are selected on the basis of their safety, efficacy, high quality, existence of bioequivalents and cost. It is suggested to the physicians that they prescribe and to the pharmacists that they dispense only the drugs which are in the PDL. Ail the drugs included in this document are covered drugs unless they are designated as Unlisted (NF; for example, forms of dosage with prolonged action that are not included in the PDL).

  

  

  

 

KEY FOR THE SYMBOLS AND ABBREVIATIONS

IN THE LIST

	
 

$ up to $$$$$!

	
 

Represents the relative cost of the drug. The smaller the number of dollar signs, the lower is the cost of the drug.  The nigher the number of dollar signs, the higher is the cost.

	
 

PA

	
 

Requires that the pharmacy endeavor a Preauthorization.

	
 

NF

	
 

Unlisted

	
 

P

	
 

Contracted brand name product “Rebates”

	
 

Bold

	
 

Identifies that the drug has generic bioequivalent available in all the presentations.

	
 

Bold*

	
 

Identifies those drugs for which not all the presentations or forms are available in generics; for example, tablets, liquids, injections, etc.

	
 

LC

	
 

Identifies those drugs for which there exists some limitation in the amount that the pharmacy can dispatch

	
 

AL

	
 

Identifies those drugs for which there exists some limitation as to the age for the dispatch of the medication.

	
Cap.

	
Capsule

	
Tab.

	
Tablet

	
Chew tab.

	
Chewable tablet

	
Disp. tab.

	
In English, dispersible tab.

	
Inj.

	
Injectable

	
Susp.

	
Suspension

	
ER, SR, CR

	
Prolonged action (extended release, sustained release, controlled release)

	
SL

	
Sublingual

	
Cr.

	
Creme

	
Oint.

	
Ointment

	
Sol.

	
Solution

	
Syr.

	
Syrup

	
Lot.

	
Lotion

	
Ophth.

	
Ophtalmic

	
Inh.

	
Inhaler

	
SNC

	
Central Nervous System

	
Supp.

	
Suppository

	
TDS

	
Transdermal Patch (transdermal release system)

	
TTS

	
Transdermal Patch (transdermal topic system)

	
OTC

	
Over the counter

	
OTC NF

	
Over the Counter Unlisted

 

  

  

  

 

PHYSICIAL HEALTH

 

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO

PREFERRED DRUG LISTING (PDL)

PHYSICAL HEALTH 

2013-2014

 

	PART II – MEDIATIONS BY THERAPEUTICAL CLASSIFICATION
	 	 	 	 
	1.0 ANTIINFECTIOUS	  	  
	  	  	  	  	  
	1.1 CEPHALOSPORINS	  	  
	  	  	  	  	  
	
1.1.1 FIRST GENERATION

	  	  
	  	  	  	  	  
	  	
$

	
Cephalexin cap.

	
Keflex

	  
	  	
$

	
Cephalexin susp.

	
Keflex

	  
	  	
$$$

	
Cefadroxil* susp.

	
Duricef

	
AL < 12 years

	  	  	  	  	  
	
1.1.2 SECOND GENERATION

	  	  
	  	  	  	  	  
	  	
$

	
Cefaclor cap.

	
Ceclor

	  
	  	  	  	
Ceclor CD

	
NF

	  	
$$$

	
Cefprozil tab., susp.

	
Cefzil

	  
	  	  	  	  	  
	
1.1.3 THIRD GENERATION

	  	  
	  	  	  	  	  
	  	
$$$

	
Cefdinir cap., susp.

	
Omnicef

	  
	  	  	  	  	  
	
1.2 MACROLIDS

	  	  
	  	  	  	  	  
	  	
$

	
EES/Sulfi soxazole susp.

	
Pediazole

	  
	  	
$

	
Erythromycin cap.

	  	  
	  	
$

	
Erythromycin stearate tab.

	
Erythrocin

	  
	  	
$

	
Erythromycin tab.

	  	  
	  	
$

	
Erythromycin EC* tab.

	
E-Mycin,

	  
	  	  	  	
EryTab

	  
	  	
$

	
Erythromycin ethylsuccinate*

	
E.E.S., Eryped

	  
	  	  	
tab., susp.

	  	  
	  	
$$

	
Azithromycin tab.,susp.,

	
Zithromax

	  
	  	  	
powder pack for susp. (1 gm)

	
Zithromax Tri-Pack

	
NF

	  	
$$$

	
Clarithromycin tab., susp.

	
Biaxin

	  
	  	  	  	
Biaxin XL

	
NF

	  	  	  	  	  
	
1.3 PENICILLINS

	  	  
	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  
	  	  	  	
Pen-Vee K

	  
	  	
$

	
Amoxicillin* cap., tab.,

	
Trimox, Amoxil,

	  
	  	  	
chew tab., susp.

	
Wymox

	  
	  	
$

	
Penicillin G Procaine inj.

	  	  
	  	
$$

	
Penicillin G Benzathine inj.

	
Bicillin LA

	  
	  	
$$$

	
Amoxicillin / Clavulanic

	
Augmentin

	  
	  	  	
acid tab., chew tab., susp.

	
Augmentin ES

	
NF

	  	  	  	
Augmentin XR

	
NF

 

  

  

  

 

	
1.4

	
SULFONAMIDES

	  	  
	  	  	  	  	  
	  	
$

	
Trimethoprim /

	
Bactrim, Bactrim DS,

	  
	  	  	
Sulfamethoxazole tab., susp.

	
Septra, Septra DS

	  
	  	
$$$$

	
Sulfadiazine tab.

	  	  
	  	  	  	  	  
	
1.5

	
TETRACYCLINES

	  	  
	  	  	  	  	  
	  	
$

	
Doxycycline hyclate tab., cap.

	
Vibratab, Vibramycin

	  
	  	
$

	
Tetracycline cap.

	
Achromycin

	  
	  	
$

	
Minocycline cap.

	
Minocin

	  
	  	
$$$$

	
Doxycycline syr., susp.

	
Vibramycin

	  
	  	
$$$$$!

	
Demeclocycline tab.

	
Declomycin

	  
	  	  	  	  	  
	
1.6

	
QUINOLONES

	  	  
	  	  	  	  	  
	  	
$

	
Ciprofloxacin tab. (250mg,

	
Cipro

	  
	  	  	
500mg, 750mg)

	  	  
	  	
$

	
Levofloxacin tab.

	
Levaquin

	  
	  	
$$$

	
Moxifloxacin tab.

	
Avelox

	
P

	  	
$$$$

	
Ciprofloxacin susp.

	
Cipro

	  
	  	  	  	  	  
	
1.7 ANTIVIRALS

	  	  
	  	  	  	  	  
	
1.7.1 INFLUENZA

	  	  
	  	  	  	  	  
	  	
$

	
Amantadine cap., syr.

	
Symmetrel

	  
	  	  	  	  	  
	
1.1.2 HERPETIC INFECTIONS

	  	  
	  	  	  	  	  
	  	
$

	
Acyclovir cap.

	
Zovirax

	  
	  	
$$

	
Acyclovir susp.

	
Zovirax

	  
	  	  	  	  	  
	
1.7.3

	
HIV-AIDS THERAPY & HEPATITIS

	  	  
	  	  	  	  	  
	
1.7.3.1

	
NON-NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE

	  
	  	  	  	  	  
	  	
$

	
Nevirapine tab., susp.

	
Viramune

	  
	  	
$$$$$

	
Delavirdine tab.

	
Rescriptor

	  
	  	
$$$$$!

	
Efavirenz tab., cap.

	
Sustiva

	
P

	  	
$$$$$!

	
Nevirapine ER tab.

	
Viramune

	  
	  	  	  	  	  
	
1.7.3.2

	
NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE

	  
	  	  	  	  	  
	  	
$$

	
Stavudine cap., sol. *

	
Zerit

	  
	  	
$$$

	
Zidovudine* tab., cap.,

	
Retrovir

	  
	  	  	
syr., inj.

	  	  
	  	
$$$$

	
Abacavir tab., sol.

	
Ziagen

	  
	  	
$$$$

	
Didanosine delayed

	
Videx EC

	  
	  	  	
release cap.

	  	  
	  	
$$$$

	
Didanosine sol.

	
Videx

	  
	  	
$$$$

	
Lamivudine tab., sol.

	
Epivir

	  
	  	  	  	  	  
	
1.7.3.3

	
NUCLEOSIDES ANALOGOUS TO TRANSCRIPTASE IN COMBINATION

	  	  	  	  	  
	  	
$$$$

	
Lamivudine / Zidovudine tab.

	
Combivir

	  
	  	
$$$$$!!

	
Abacavir/Lamivudine/

	  	  
	  	  	
Zidovudine tab

	
Trizivir

	
P

 

  

  

  

 

	  	  	  	  	  
	
1.7.3.4

	
PROTEASE INHIBITORS

	  	  
	  	  	  	  	  
	  	
Covered via the Transmissible Diseases Prevention and Treatment Centers (CPTETs)

	  	
(Inmunology Clinics)

	  	  
	  	  	  	  	  
	
1.7.3.5

	
ORAL AGENTS FOR HEPATITIS B

	  	  
	  	  	  	  	  
	  	
$$$$$!! Lamivudine tab., sol.

	
Epivir HBV

	
PA

	  	  	  	  	  
	
1.7.4

	
MISCELANEOUS ANTIVIRALS

	  	  
	  	  	  	  	  
	  	
$$

	
Rimantadine tab.

	
Flumadine

	  
	  	
$$$$$!!

	
Palivizumab inj.

	
Synagis

	
PA, P

	  	
$$$$$!!

	
Ganciclovir cap.

	
Cytovene

	  
	  	
$$$$$!!

	
Valganciclovir tab.

	
Valcyte

	  
	  	  	  	  	  
	
1.8

	
ANTIMYCOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Terbinafine tab.

	
Lamisil

	
LC= 84 tab.

	  	
$

	
Ketoconazole tab.

	
Nizoral

	  
	  	
$

	
Nystatin susp.

	
Mycostatin, Nystat

	  
	  	
$

	
Fluconazole tab., susp.

	
Diflucan

	  
	  	
$

	
Griseofulvin microsize tab.

	
Grifulvin V

	  
	  	
$$$

	
Griseofulvin

	
Gris-PEG

	  
	  	  	
ultramicrosize * tab.

	  	  
	  	
$$$

	
Clotrimazole troche

	
Mycelex

	  
	  	
$$$

	
Itraconazole* cap., sol.

	
Sporanox

	
VIH-SIDA

	  	
$$$$$

	
Flucytosine cap. Ancobon

	  	  
	  	  	  	  	  
	
1.9

	
ANTITUBERCULOUS

	  	  
	  	  	  	  	  
	  	
$

	
Isoniazid tab.

	  	  
	  	
$$

	
Isoniazid syr.

	  	  
	  	
$$$$

	
Ethambutol tab.

	
Myambutol

	  
	  	
$$$$

	
Pyrazinamide tab.

	  	  
	  	
$$$$

	
Rifampin cap.

	
Rifadin

	  
	  	
$$$$

	
Isoniazid/Rifampin cap.

	
Rifamate

	  
	  	
$$$$$

	
Ethionamide tab.

	
Trecator

	  
	  	
$$$$$!

	
Rifabutin cap.

	
Mycobutin

	  
	  	
$$$$$!

	
Cycloserine cap.

	
Seromycin

	  
	  	
$$$$$!

	
Capreomycin inj.

	
Capastat

	  
	  	  	  	  	  
	
1.10

	
ANTIPARASITICS

	  	  
	  	  	  	  	  
	  	
$$$

	
Iodoquinol tab.

	
Yodoxin

	  
	  	
$$$

	
Albendazole tab.

	
Albenza

	  
	  	  	  	  	  
	
1.11

	
ANTIMALARIALS

	  	  
	  	  	  	  	  
	  	
$

	
Pyrimethamine tab.

	
Daraprim

	  
	  	
$

	
Hydroxychloroquine tab.

	
Plaquenil

	  
	  	
$

	
Quinine sulfate* tab., cap.

	  	  
	  	
$

	
Primaquine phosphate tab.

	
Primaquine

	  
	  	
$

	
Chloroquine phosphate tab.

	
Aralen

	  
	  	
$$$

	
Mefl oquine tab.

	
Lariam

	  

 

  

  

  

 

	
1.12

	
MISCELANEOUS ANTIINFECTIOUS

	  	  
	  	  	  	  	  
	  	
$

	
Metronidazole tab.

	
Flagyl

	  
	  	  	  	
Flagyl ER

	
NF

	  	
$

	
Metronidazole Extemporaneous

	
Giardia lamblia

	  	  
	  	  	
Preparation

	  	  	  
	  	
$

	
Dapsone tab.

	
Dapsone

	  	  
	  	
$

	
Nitrofurantoin monohydrate

	
Macrobid

	  	  
	  	  	
macrocrystalline cap.

	  	  	  
	  	
$

	
Clindamycin cap.

	
Cleocin

	  	  
	  	  	
(150mg, 300mg)

	  	  	  
	  	
$$

	
Nitrofurantoin

	
Macrodantin

	  	  
	  	  	
macrocrystals* cap.

	  	  	  
	  	
$$$

	
Clindamycin cap. (75mg), sol.

	
Cleocin

	  	  
	  	
$$$

	
Pentamidine inh.

	
NebuPent

	  	  
	  	
$$$$

	
Streptomycin inj.

	  	  	  
	  	
$$$$$!

	
Atovaquone susp.

	
Mepron

	  	  
	  	
$$$$$!!

	
Vancomycin cap., oral sol.

	
Vancocin

	  	  
	  	
$$$$$!!

	
Tobramycin inh.

	
Tobi

	
PA

	  
	  	  	  	  	  	  
	
2.0

	
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPIDS

	  	  
	  	  	  	  	  	  
	
2.1

	
GLYCOSIDES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Digoxin* tab.

	
Lanoxin

	  	  
	  	
$$

	
Digoxin elixir

	
Lanoxin

	  	  
	  	  	  	  	  	  
	
2.2

	
ANTIHYPERTENSIVE THERAPY

	  	  	  
	  	  	  	  	  	  
	
2.2.1

	
DIURETICS

	  	  	  
	  	  	  	  	  	  
	
2.2.1.1

	
THIAZYDES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Indapamide tab.

	
Lozol

	  	  
	  	
$

	
Hydrochlorothiazide* tab.

	
Microzide

	  	  
	  	
$

	
Chlorothiazide* tab., susp.

	
Diuril

	  	  
	  	
$

	
Chlorthalidone tab.

	
Hygroton

	  	  
	  	
$$

	
Metolazone tab.

	
Zaroxolyn

	  	  
	  	  	  	  	  	  
	
2.2.1.2

	
ANHIDRASE INHIBITORS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Acetazolamide tab.

	
Diamox

	  	  
	  	  	  	
Diamox sequels

	  	
NF

	  	  	  	  	  	  
	
2.2.1.3

	
LOOP DIURETICS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Furosemide tab., sol.

	
Lasix

	  	  
	  	
$

	
Bumetanide tab.

	
Bumex

	  	  
	  	  	  	  	  	  
	
2.2.1.4

	
MISCELLANEUOS DIURETICS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Triamterene/HCTZ tab.

	
Maxzide

	  	  
	  	
$

	
Triamterene/HCTZ cap.

	
Dyazide

	  	  
	  	
$$

	
Spironolactone tab.

	
Aldactone

	  	  
	  	  	  	  	  	  
	
2.2.2

	
BETA BLOCKERS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Atenolol tab.

	
Tenormin

	  	  
	  	
$

	
Atenolol/ Chlortalidone tab.

	
Tenoretic

	  	  
	  	
$

	
Metoprolol tartrate tab.

	
Lopressor

	  	  
	  	
$

	
Propranolol tab.

	
Inderal

	  	  
	  	
$

	
Propranolol/ HCTZ tab.

	
Inderide

	  	  
	  	
$

	
Labetalol tab.

	
Normodyne

	  	  

  

  

  

 

	 	  	  	  	 	  
	 	
$

	
Pindolol tab.

	
Visken

	 	  
	 	
$$

	
Metoprolol tartrate / HCTZ tab.

	
Lopressor HCT

	 	  
	 	
$$

	
Propranolol sol., conc.

	  	 	  
	 	
$$

	
Metoprolol succinate SR* tab.

	
Toprol XL

	 	
PA

	 	
$$

	
Carvedilol tab.

	
Coreg

	 	  
	 	  	  	  	 	  
	2.2.3 CALCIUM CHANNEL ANTAGONISTS
	 	  	  	  	 	  
	 	
$

	
Amlodipine tab.

	
Norvasc

	 	  
	 	
$

	
Verapamil tab.

	
Isoptin,

	 	  
	 	  	  	
Calan

	 	  
	 	
$

	
Diltiazem tab.

	
Cardizem

	 	  
	 	  	  	
Cardizem LA

	 	
NF

	 	
$

	
Verapamil ER tab.

	
Calan SR,

	 	  
	 	  	  	
Isoptin SR

	 	  
	 	  	  	
Verelan

	 	
NF

	 	  	  	
Verelan PM

	 	
NF

	 	  	  	
Covera HS

	 	
NF

	 	  	  	  	 	  
	 	
$

	
Diltiazem SR 24hr cap.

	
Dilacor XR

	 	  
	 	
$$

	
Diltiazem HCl Extended

	
Tiazac

	 	  
	 	  	
Release Beads SR 24hr

	  	 	  
	 	  	
cap. (120mg, 180mg,

	  	 	  
	 	  	
240mg, 300mg, 360mg)

	  	 	  
	 	
$$

	
Diltiazem SR 12hr cap.

	
Cardizem SR

	 	  
	 	
$$$

	
Nifedipine SR tab., CR tab.

	
Generic only

	 	  
	 	  	  	
Adalat CC

	 	
NF

	 	  	  	
Procardia XL

	 	
NF

	 	
$$$

	
Diltiazem HCl coated

	  	 	  
	 	  	
beads SR 24hr cap.

	
Generic only

	 	  
	 	  	  	  	 	  
	2.2.4 ANGIOTENSINE INHIBITORS (ACE)	  	 	  
	 	  	  	  	 	  
	 	
$

	
Captopril tab.

	
Capoten

	 	  
	 	
$

	
Enalapril tab.

	
Vasotec

	 	  
	 	
$

	
Lisinopril tab.

	
Privinil, Zestril

	 	  
	 	
$

	
Lisinopril/HCTZ tab.

	
Prinzide, Zestoretic

	 	  
	 	
$

	
Enalapril/HCTZ tab.

	
Vaseretic

	 	  
	 	
$

	
Captopril/HCTZ tab.

	
Capozide

	 	  
	 	
$$

	
Fosinopril tab.

	
Monopril

	 	  
	 	  	  	  	 	  
	2.2.5 ANGIOTENSINE RECEPTOR BLOCKERS (ARB)	  	 	  
	 	  	  	  	 	  
	 	
$

	
Losartan tab.

	
Cozaar

	 	  
	 	
$

	
Losartan HCT tab.

	
Hyzaar

	 	  
	 	
$

	
Irbesartan tab.

	
Avapro

	 	  
	 	
$

	
Irbesartan/ HCTZ tab.

	
Avalide

	 	  
	 	  	  	  	 	  
	2.2.6 ANTIHYPERTENSIVES WITH CENTRAL ACTION	 	  
	 	  	  	  	 	  
	 	
$

	
Clonidine tab.

	
Catapress

	 	  
	 	
$

	
Methyldopa tab.

	
Aldomet

	 	  
	 	
$$$$

	
Clonidine TTS

	
Catapress TTS

	 	  
	 	  	  	  	 	  
	2.2.7 VASODILATORS	  	 	  
	 	
$

	
Isosorbide dinitrate SL tab.

	
Isordil

	 	  
	 	
$

	
Isosorbide mononitrate ER tab.

	
Imdur

	 	  
	 	
$

	
Nitroglycerin SL tab.

	
Nitrostat

	 	  
	 	
$

	
Isosorbide dinitrate* tab.

	
Isordil

	 	  
	 	
$

	
Isosorbide mononitrate tab.

	
Ismo, Monoket

	 	  

 

  

  

  

 

	  	  	  	  	  	  
	  	
$

	
Hydralazine tab.

	
Apresoline

	  	  
	  	
$$

	
Minoxidil tab.

	
Loniten

	  	  
	  	
$$

	
Isosorbide dinitrate* ER

	  	  	  
	  	  	
tab., cap.

	  	  	  
	  	
$$$

	
Nitroglycerin Film ER TD

	
Generic only

	  	  
	  	  	  	
NitroDur

	  	
NF

	  	  	  	
Minitran

	  	
NF

	  	  	  	  	  	  
	
2.2.8

	
ALPHA RECEPTOR BLOCKERS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Doxazosin tab.

	
Cardura

	  	  
	  	
$

	
Terazosin cap.

	
Hytrin

	  	  
	  	  	  	  	  	  
	
2.3

	
ANTIARRHYTHMICS

	  	  	  
	  	  	  	  	  	  
	  	
$$

	
Quinidine sulfate tab.

	  	  	  
	  	
$$$

	
Quinidine gluconate tab.

	
Quinaglute

	  	  
	  	
$$$

	
Mexiletine cap.

	
Mexitil

	  	  
	  	
$$$

	
Sotalol tab.

	
Betapace,

	  	  
	  	  	  	
Betapace AF

	  	  
	  	
$$$

	
Quinidine sulfate CR tab.

	  	  	  
	  	
$$$

	
Flecainide tab.

	
Tambocor

	  	  
	  	
$$$$

	
Amiodarone tab. (200mg,

	
Cordarone

	  	  
	  	  	
400mg)

	  	  	  
	  	
$$$$

	
Propafenone tab.

	
Rythmol

	  	  
	  	  	  	  	  	  
	
2.4

	
CHOLESTEROL AND LIPID REDUCING AGENTS

	  	  
	  	  	  	  	  	  
	  	
$

	
Simvastatin tab.

	
Zocor

	  	  
	  	
$

	
Atorvastatin tab.

	
Lipitor

	  	  
	  	
$

	
Gemfi brozil tab.

	
Lopid tab.

	  	  
	  	
$

	
Pravastatin

	
Pravachol

	  	  
	  	
$$

	
Cholestyramine powder packs

	
Questran

	  	  
	  	
$$

	
Niacin CR tab.

	
Niaspan

	
P

	  
	  	  	  	  	  	  
	
3.0

	
AUTONOMIC MEDICATIONS AND FOR THE CENTRAL NERVOUS SYSTEM,

	  	
NEUROLOGY AND PHYCHIATRY

	  	  	  
	  	  	  	  	  	  
	
3.1

	
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION

	  	  
	  	  	  	  	  	  
	  	
$

	
Meperidine inj. Demerol

	  	  	  
	  	
$

	
APAP/Codeine* tab., cap.,

	  	  	  
	  	  	
elixir, sol., susp.

	  	  	  
	  	
$

	
Tramadol tab.

	
Ultram

	  	  
	  	
$

	
Methadone* tab., disp. tab., sol., conc.

	
ASSMCA

	  	  
	  	
$

	
Morphine sulfate tab., sol.

	  	  	  
	  	
$$

	
APAP/Hydrocodone* tab.,

	  	  	  
	  	  	
cap., elixir

	  	  	  
	  	
$$

	
Oxycodone tab., cap., sol.

	
Roxicodone

	  	  
	  	
$$

	
APAP/Butalbital/Caffeine

	  	  	  
	  	  	
tab., cap.

	
Fioricet

	  	  
	  	
$$

	
Hydromorphone tab., liq., inj.

	
Dilaudid

	  	  
	  	
$$

	
Codeine sulfate tab.

	  	  	  
	  	
$$

	
Oxycodone/APAP* tab.,

	  	  	  
	  	  	
cap., sol.

	  	  	  
	  	
$$$$

	
Morphine sulfate SR tab., supp.

	  	  	  
	  	
$$$$

	
Fentanyl TDS

	
Duragesic

	  	  
	  	
$$$$$

	
Hydromorphone supp.

	
Dilaudid

	  	  

  

  

  

 

	
3.2 MIGRAINE

	  	  
	  	  	  	  	  
	  	
$

	
Divalproex sodium ER

	
Depakote ER

	  
	  	  	
tab. (500 mg)

	  	  
	  	
$

	
Ergotamine tartrate/

	
Cafergot

	  
	  	  	
Caffeine tab.

	  	  
	  	
$

	
Sumatriptan tab.

	
Imitrex

	
LC=6 tab.

	  	
$$

	
APAP/Butalbital/Caffeine

	  	  
	  	  	
tab., cap.

	
Fioricet

	  
	  	
$$$

	
Divalproex sodium ER

	
Depakote ER

	
P

	  	  	
tab. (500 mg)

	  	  
	  	
$$$

	
Ergotamine tartrate/

	
Cafergot

	  
	  	  	
Caffeine supp.

	  	  
	  	
$$$$

	
Sumatriptan Nasal Spray

	
Imitrex Nasal

	
LC=6

	  	  	  	
Spray

	
inhalers

	
3.3

	
ANTICONVULSIVES

	  	  
	  	  	  	  	  
	  	
$

	
Phenobarbital tab., elixir

	  	  
	  	
$

	
Clonazepam tab.

	
Klonopin

	  
	  	
$

	
Carbamazepine tab.

	
Tegretol

	  
	  	
$

	
Carbamazepine chew tab.

	
Tegretol

	  
	  	
$

	
Phenytoin* chew tab.,

	
Dilantin

	  
	  	  	
cap, susp.

	  	  
	  	
$

	
Valproic acid cap., syr.

	
Depakene

	  
	  	
$

	
Divalproex sodium EC tab.,

	  	  
	  	  	
sprinkle cap.

	
Depakote

	  
	  	
$

	
Divalproex sodium ER

	
Depakote ER

	  
	  	  	
tab. (500 mg)

	  	  
	  	
$$

	
Primidone tab.

	
Mysoline

	  
	  	
$$

	
Carbamazepine susp.

	
Tegretol

	  
	  	
$$

	
Divalproex sodium EC tab.,

	  	  
	  	  	
cap. sprinkle cap.

	
Depakote

	
P

	  	
$$

	
Zonisamide cap.

	
Zonegran

	  
	  	
$$

	
Carbamazepine ER tab.*

	
Tegretol XR

	  
	  	
$$

	
Gabapentin cap., tab.

	
Neurontin

	  
	  	
$$

	
Ethosuximide cap., syr.

	
Zarontin

	  
	  	
$$

	
Oxcarbazepine tab., susp.

	
Trileptal

	  
	  	
$$

	
Lamotrigine tab.,

	
Lamictal, Lamictal CD

	  
	  	  	
chew disp. tab.

	  	  
	  	
$$

	
Topiramate tab., cap.

	
Topamax

	  
	  	
$$

	
Levetiracetam tab., sol.

	
Keppra

	  
	  	
$$$

	
Divalproex sodium ER

	
Depakote ER

	
P

	  	  	
tab. (500 mg)

	  	  
	  	
$$$

	
Gabapentin sol. Neurontin

	  	  
	  	
$$$$

	
Tiagabine tab. Gabitril

	  	  
	  	  	  	  	  
	
3.4

	
ANTIVERTIGO AND ANTIEMETICS

	  	  
	  	  	  	  	  
	  	
$

	
Promethazine inj.

	
Phenergan

	  
	  	
$

	
Metoclopramide syr., inj.

	
Reglan

	  
	  	
$

	
Trimethobenzamide inj.

	
Tigan

	  
	  	
$

	
Promethazine syr.

	
Phenergan

	  
	  	
$

	
Prochlorperazine tab.

	
Compazine

	  
	  	
$

	
Prochlorperazine inj.

	
Compazine inj.

	  
	  	
$

	
Metoclopramide tab.

	
Reglan

	  
	  	
$

	
Promethazine* tab.

	
Phenergan

	  
	  	
$

	
Ondansetron tab., ODT

	
Zofran

	  
	  	  	
tab.

	  	  
	  	
$$

	
Trimethobenzamide cap.,

	  	  
	  	  	
supp.

	
Tigan

	  

 

  

  

  

 

	  	
$$

	
Promethazine supp.

	
Phenergan

	 	  
	  	
$$$

	
Prochlorperazine* supp.

	
Compazine

	 	  
	  	  	  	  	 	  
	
3.5

	
ANTIPARKINSON

	  	 	  
	  	  	  	  	 	  
	
3.5.1

	
ANTICHOLINERGIC

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Benztropine tab.

	
Cogentin

	 	  
	  	
$

	
Trihexyphenidyl HCl tab.

	
Artane

	 	  
	  	
$

	
Trihexyphenidyl HCl elixir

	
Artane

	 	  
	  	  	  	  	 	  
	
3.5.2

	
DOPAMINERGICS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Selegiline tab.

	
Carbex

	 	  
	  	
$

	
Carbidopa/Levodopa tab.

	
Sinemet

	 	  
	  	
$

	
Carbidopa/Levodopa ER tab.

	
Sinemet CR

	 	  
	  	
$$$

	
Bromocriptine tab., cap.

	
Parlodel

	 	  
	  	  	  	  	 	  
	
3.5.3

	
DOPAMINE RECEPTOR AGONISTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Pramipexole tab.

	
Mirapex

	 	  
	  	
$

	
Ropinirole tab.

	
Requip

	 	  
	  	  	  	  	 	  
	
3.5.4

	
MISCELLANEOUS AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Amantadine cap., syr.

	
Symmetrel

	 	  
	  	
$$$

	
Carbidopa/ Levodopa/

	
Stalevo

	 	
P

	  	  	
Entacapone tab.

	  	 	  
	  	  	  	  	 	  
	
3.6 PSYCHOTROPIC AGENTS

	  	 	  
	  	  	  	  	 	  
	
3.6.1

	
ANTIDEPRESSIVES

	  	 	  
	  	  	  	  	 	  
	
3.6.1.1

	
TRICYCLICS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Amitriptyline tab.

	
Elavil

	 	  
	  	
$

	
Nortriptyline cap., sol.

	
Pamelor, Aventyl

	  	
$

	
Doxepin cap., conc.

	
Sinequan

	 	  
	  	
$

	
Clomipramine cap.

	
Anafranil

	 	  
	  	
$

	
Imipramine HCl tab.

	
Tofranil

	 	  
	  	
$

	
Desipramine tab.

	
Norpramin

	 	  
	  	  	  	  	 	  
	
3.7

	
ANTIANXIETY/HYPNOTICS

	  	 	  
	  	  	  	  	 	  
	
3.7.1

	
BENZODIAZEPINES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Clonazepam tab.

	
Klonopin

	 	  
	  	
$

	
Flurazepam cap.

	
Dalmane

	 	  
	  	
$

	
Temazepam* cap.

	
Restoril

	 	  
	  	
$

	
Chlordiazepoxide cap.

	
Librium

	 	  
	  	
$

	
Estazolam tab.

	
ProSom

	 	  
	  	
$

	
Clorazepate tab. T

	
ranxene

	 	  
	  	
$

	
Lorazepam tab.

	
Ativan

	 	  
	  	
$

	
Alprazolam tab.

	
Xanax

	 	  
	  	
$

	
Diazepam tab.

	
Valium

	 	  
	  	
$$

	
Oxazepam cap.

	
Serax

	 	  
	  	
$$

	
Midazolam inj.

	
Versed

	LC=5mg/30días

  

  

  

 

	
3.8

	
SNC AGENTS AND MISCELLANEOUS

	 	 	 
	 	 	 	 	 	 
	  	
$

	
Ergoloid mesylate cap.

	
Hydergine LC

	 	  
	  	
$$

	
Disulfi ram tab.

	
Antabuse

	 	
PA

	  	
$$$

	
Ergoloid mesylate liq.

	
Hydergine

	 	  
	  	
$$$

	
Pyridostigmine tab.

	
Mestinon

	 	  
	  	
$$$

	
Pyridostigmine CR tab.

	
Mestinon Timespan

	 	  
	  	
$$$

	
Ergoloid mesylate tab.

	
Hydergine

	 	  
	  	
$$$

	
Ergoloid mesylate SL tab.

	
Hydergine SL

	 	  
	  	
$$$$

	
Neostigmine tab.

	
Prostigmin

	 	  
	  	
$$$$

	
Pyridostigmine syr.

	
Mestinon

	 	  
	  	  	  	  	 	  
	
3.9

	
ALZHEIMER

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Rivastigmine cap., sol.

	
Exelon

	 	  
	  	
$$$

	
Donepezil tab., ODT

	
Aricept

	 	  
	  	
$$$$

	
Memantine tab., sol.

	
Namenda

	 	
ST

	  	
$$$$

	
Rivastigmine patch

	
Exelon patch

	 	
P

	  	  	  	  	 	  
	
4.0

	
DERMATOLOGICAL AGENTS

	  	 	  
	  	  	  	  	 	  
	
4.1

	
TOPICAL CORTICOSTEROIDS

	  	 	  
	  	  	  	  	 	  
	
4.1.1

	
TOPICAL CORTICOSTEROIDS OF VERY HIGH POTENCY

	 	  
	  	  	  	  	 	  
	  	
$

	
Clobetasol cr., oint. (0.05%)

	
Temovate

	 	  
	  	
$

	
Augmented betamethasone

	
Diprolene

	 	  
	  	  	
dipropionate oint. (0.05%)

	  	 	  
	  	
$

	
Clobetasol gel (0.05%)

	
Temovate

	 	  
	  	
$$

	
Clobetasol sol. (0.05%)

	
Temovate

	 	  
	  	  	  	  	 	  
	
4.1.2

	
TOPICAL CORTICOSTEROIDS OF HIGH POTENCY

	 	  
	  	  	  	  	 	  
	  	
$

	
Betamethasone dipropionate

	
Diprosone

	 	  
	  	  	
cr., oint., lot. (0.05%)

	  	 	  
	  	
$

	
Triamcinolone acetonide

	
Kenalog

	 	  
	  	  	
cr., oint. (0.5%)

	  	 	  
	  	
$

	
Fluocinonide cr., oint., gel,

	
Lidex

	 	  
	  	  	
sol. (0.05%)

	  	 	  
	  	  	  	  	 	  
	
4.1.3

	
TOPICAL CORTICOSTEROIDS OF MEDIUM POTENCY

	 	  
	  	  	  	  	 	  
	  	
$

	
Triamcinolone acetonide

	
Kenalog

	 	  
	  	  	
cr., oint. (0.1%)

	  	 	  
	  	
$

	
Fluocinolone acetonide

	
Synalar

	 	  
	  	  	
cr., oint. (0.025%)

	  	 	  
	  	
$

	
Betamethasone valerate

	
Valisone

	 	  
	  	  	
cr., oint., lot. (0.1%)

	  	 	  
	  	
$

	
Mometasone furoate oint.(0.1%)

	
Elocon

	 	  
	  	
$

	
Desoximetasone gel (0.05%)

	
Topicort

	 	  
	  	
$$

	
Triamcinolone acetonide lot. (0.1%)

	
Kenalog

	 	  
	  	  	  	  	 	  
	
4.1.4

	
TOPICAL CORTICOSTEROIDS OF LOW POTENCY

	 	  
	  	  	  	  	 	  
	  	
$

	
Desonide cr., oint, lot. (0.05%)

	
Desowen

	 	  
	  	
$

	
Hydrocortisone cr., oint. (≥ 2%)

	  	 	  
	  	
$

	
Fluocinolone acetonide

	
Synalar

	 	  
	  	  	
cr., sol. (0.01%)

	  	 	  
	  	
$$

	
Hydrocortisone lot. (≥ 2%)

	  	 	  

  

  

  

 

	 	 	 	 	 	 	 
	
4.2

	
THERAPY FOR ACNE

	 	 	 	  
	  	  	  	  	 	  
	  	
$

	
Erythromycin topical sol. (2%)

	  	 	  
	  	
$

	
Clindamycin sol. (1%)

	
Cleocin T sol.

	 	  
	  	
$

	
Erythromycin gel (2%)

	
EryGel

	 	  
	  	
$$

	
Tretinoin gel (0.01%, 0.025%)

	
Retin A

	AL<21 años
	  	
$$

	
Tretinoin cr. (0.025%, 0.05%, 0.1%)

	
Retin A

	AL<21 años
	  	
$$$

	
Isotretinoin cap. (10mg, 20mg,

	
Accutane, Sotret,

	 	  
	  	  	
40mg)

	
Claravis, Amnesteem

	 	  
	  	  	  	  	 	  
	
4.3

	
TOPICAL ANTIPSORIATICS

	  	 	  
	  	  	  	  	 	  
	  	
$$$$

	
Tazarotene cr., gel

	
Tazorac

	P
	  	  	  	  	 	  
	
4.4

	
TOPICAL ANTIMYCOTICS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Nystatin oint.

	
Mycostatin

	 	  
	  	
$

	
Clotrimazole cr., sol. (1%)

	
Various

	OTC
	  	
$

	
Miconazole nitrate powder,

	
Various

	OTC
	  	  	
tincture (2%)

	  	 	  
	  	
$

	
Ketoconazole cr.,

	
Nizoral

	 	  
	  	  	
shampoo (2%)

	  	 	  
	  	  	  	  	 	  
	
4.5

	
TOPICAL ANTIBACTERIALS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Gentamicin cr., oint.

	
Garamycin

	 	  
	  	
$

	
Silver sulfadiazine cr.

	
Silvadene

	 	  
	  	
$$

	
Mupirocin oint.

	
Bactroban

	 	  
	  	  	  	  	 	  
	
4.6

	
SCABIES DRUGS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Permethrin cr. (5%)

	
Elimite

	LC = 60gm
	  	  	  	
Acticin

	NF
	  	
$$$$

	
Lindane lot. (1%)

	
 

	ST, LC=60cc	
 

	  	  	  	  	 	  
	
4.7

	
MISC. TOPICAL AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Selenium sulfide

	
Selsun

	 	  
	  	  	
shampoo 2.5%

	  	 	  
	  	
$$$

	
Anthralin cr. (0.5%)

	
Drithocream

	 	  
	  	
$$$

	
Fluorouracil sol. (2%, 5%)

	
Efudex

	 	  
	  	
$$$$

	
Fluorouracil cr. (5%)

	
Efudex

	 	  
	  	
$$$$

	
Calcipotriene cr. (0.005%)

	
Dovonex

	 	  
	  	  	  	  	 	  
	
4.8

	
THERAPY FOR ROSACEA

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Sulfacetamide/Sulfur cr.,

	  	 	  
	  	  	
lot., emulsion

	
Sulfacet – R

	 	  
	  	
$$$

	
Metronidazole cr., gel, lot.

	
MetroCream, MetroGel,

	  	  	
(0.75%)

	
MetroLotion

	 	  
	  	
$$$

	
Sulfacetamide/Sulfur susp.

	
Sulfacet-R

	 	  
	 	 	 	 	 
	
4.9

	
ORAL DERMATOLOGICAL AGENTS

	  	 	  
	  	
$$$$

	
Methoxsalen cap.

	
Oxsoralen

	 	  
	  	
$$$$$

	
Acitretin cap.

	
Soriatane

	
P

	
 

  

  

  

 

	 	 	 	 	 	 	 	 
	
4.10

	
MISCELLANEOUS ANTIPSORIATICS

	 	 	  	  
	  	  	  	  	 	 	  	  
	
4.10.1

	
TNF ANTAGONISTS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$$$$$! Adalimumab inj.

	
Humira,

	 	 	
PA, P

	  
	  	  	  	
Humira Pen

	 	 	
PA, P

	  
	  	
$$$$$! Etanercept inj.

	
Enbrel

	 	 	
PA, P

	  
	  	  	  	  	 	 	  	  
	
5.0

	
MEDICATIONS FOR THE EAR, NOSE AND THROAT

	 	 	  	  
	 	 	 	 	 	 	 
	
5.1

	
OTIC PREPARATIONS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Hydrocortisone/Neomycin/

	  	 	 	  	  
	  	  	
Polymixin B otic sol., susp.

	  	 	
Cortisporin

	
 

	  
	  	
$

	
Burrow’s (Acetic acid 2%/

	  	 	 	  	  
	  	  	
Aluminum acetate) otic sol.

	  	 	
Domeboro

	
 

	  
	  	
$$

	
Ofloxacin otic sol.

	  	 	
Floxin Otic

	
 

	  
	  	  	  	  	 	
Floxin Otic Singles

	
NF

	  	
$$

	
Acetic acid otic sol.

	  	 	
Vosol

	
 

	  
	  	
$$

	
Acetic acid/

	  	 	
Vosol-HC

	
 

	  
	  	  	
Hydrocortisone otic sol.

	  	 	 	  	  
	 	 	 	 	 
	
5.2 AGENTS FOR THE MOUTH AND THROAT

	 	 	  	  
	  	
$

	
Chlorhexidine gluconate sol. (0.12%)

	 	
Peridex

	
 

	  
	  	
$

	
Lidocaine viscous sol.

	  	 	
Xylocaine

	
 

	  
	  	
$

	
Hydrocortisone acetate

	  	 	
Orabase

	
 

	  
	  	  	
dental paste

	  	 	 	  	  
	  	
$$

	
Clotrimazole troche

	  	 	
Mycelex

	
 

	  
	  	  	  	  	 	 	  	  
	
6.0

	
GASTROENTEROLOGY

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	
6.1

	
AGENTS FOR ULCERS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	
6.1.1

	
H2 ANTAGONISTS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Ranitidine tab. (300mg)

	
 

	
Zantac

	 	  	  
	  	
$

	
Cimetidine tab., sol.

	 	
Tagamet

	  
	  	
$$

	
Ranitidine syr.

	
 

	
Zantac

	 	  	  
	  	  	  	  	 	 	  	  
	
6.1.2 PROTON PUMP INHIBITORS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Omeprazole cap. (10mg, 20mg)

	
 

	
Prilosec

	 	  	  
	  	  	  	  	 	 	  	  
	
6.1.3 MISCELLANEUOUS ULCER AGENTS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Sucralfate tab.

	
 

	
Carafate

	 	  	  
	  	
$$$

	
Sucralfate susp.

	
 

	
Carafate

	 	  	  
	  	
$$$$

	
Misoprostol tab.

	
 

	
Cytotec

	 	  	  
	  	  	  	  	 	 	  	  
	
6.2 ANTIDIARRHEA DRUGS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Diphenoxylate/ Atropine

	
 

	
Lomotil

	 	  	  
	  	  	
tab., liq.

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	
6.3 ANTIPASMODICS

	  	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
$

	
Dicyclomine tab., cap.

	
 

	
Bentyl

	 	  	  
	  	
$

	
Dicyclomine syr.

	
 

	
Bentyl

	 	  	  

  

  

  

 

	  	  	  	  	  	  
	
6.4 MISCELLANEOUS GASTROINTESTINAL AGENTS

	  	  
	  	  	  	  	  	  
	
6.4.1 GASTROINTESTINAL AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Sulfasalazine tab.

	
Azulfi dine

	  	  
	  	
$$

	
Sulfasalazine EC tab.

	
Azulfi dine EN

	  	  
	  	
$$$$

	
HC retention enema

	
Colocort, Hydrocort

	  	  
	  	
$$$$

	
Mesalamine EC tab.

	
Asacol, Asacol HD

	  	
P

	  	
$$$$

	
Olsalazine cap.

	
Dipentum

	  	  
	  	
$$$$$

	
Mesalamine supp.

	
Canasa

	  	  
	  	
$$$$$

	
Mesalamine CR cap.

	
Pentasa

	  	
P

	  	
$$$$$

	
Budesonide cap.

	
Entocort EC

	  	
PA

	  	
$$$$$

	
Mesalamine enema

	
Rowasa

	  	  
	  	  	  	  	  	  
	
6.4.2 BILIARY ACIDS

	  	  	  
	  	  	  	  	  	  
	  	
$$$ Ursodiol cap. (300 mg)

	
Actigall

	  	  
	  	  	  	  	  	  
	
6.4.3 DIGESTIVES

	  	  	  
	  	  	  	  	  	  
	  	
$$

	
Pancreatic enzymes

	
Creon

	  	
P

	  	
$$

	
Pancreatic enzymes*

	  	  	  
	  	  	  	  	  	  
	
6.4.4 OTHERS

	  	  	  	  
	  	  	  	  	  	  
	  	
$

	
Hydrocortisone rectal cr.

	
Anusol-HC

	  	  
	  	  	
(2.5%)

	  	  	  
	  	
$$

	
Hydrocortisone acetate/

	
Analpram-HC

	  	  
	  	  	
Pramoxine rectal cr.

	  	  	  
	  	
$$$

	
Hydrocortisone acetate/

	
Proctofoam HC

	  	  
	  	  	
Pramoxine rectal foam

	  	  	  
	  	
$$$$$

	
Cromolyn conc.

	
Gastrocrom

	  	  
	  	  	  	  	  	  
	
7.0

	
ENDOCRINOLOGY AGENTS

	  	  	  
	  	  	  	  	  	  
	
7.1

	
DIABETES THERAPY

	  	  	  
	  	  	  	  	  	  
	
7.1.1

	
HYPOGLYCEMIC AGENTS

	  	  	  
	  	  	  	  	  	  
	
7.1.1.1

	
SULPHONILUREA

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Glyburide micronized tab.

	
Generic Only

	  	  
	  	
$

	
Glipizide tab.

	
Glucotrol

	  	  
	  	
$

	
Glipizide XL tab.

	
Glucotrol XL

	  	  
	  	
$

	
Glyburide tab.

	
Generic Only

	  	  
	  	
$

	
Glimepiride tab.

	
Amaryl

	  	  
	  	  	  	  	  	  
	
7.1.1.2

	
ALFA GLUCOSIDASE INHIBITORS

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Acarbose tab.

	
Precose

	  	  
	  	  	  	  	  	  
	
7.1.1.3

	
TIAZOLIDINEDIONAS

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Pioglitazone tab.

	
Actos

	  	  
	  	  	  	  	  	  
	
7.1.1.4

	
DPP IV INHIBITOR

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Saxagliptin tab.

	
Onglyza

	
ST, P

	  
	  	
$$$

	
Saxagliptin/Metformin tab.

	
Kombiglyze

	
ST, P

	  
	  	  	  	  	  	  
	  	  	  	  	  	  

  

  

  

 

	  	  	  	  	 	  
	
7.1.1.5

	
INSULIN

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Human insulin (regular, NPH,

	
Humulin

	 	
P

	  	  	
70/30, lente) vial

	
Humulin Pen

	 	
NF

	  	
$$$

	
Insulin lispro vial

	
HumaLog

	 	
P

	  	  	  	
HumaLog Mix

	 	
NF

	  	  	  	
HumaLog Pen

	 	
NF

	  	
$$$

	
Insulin glargine vial

	
Lantus

	 	
P

	  	  	  	
Lantus Solostar

	 	
P

	  	  	  	  	 	  
	
7.1.1.6

	
OTHERS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Insulin syringe & needle

	
Several

	 	  
	  	
$

	
Metformin tab.

	
Glucophage

	 	  
	  	
$

	
Metformin tab.

	
Glucophage XR

	 	  
	  	  	  	  	 	  
	
7.1.2

	
HIPERGLYCEMIC AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Glucagon inj.

	  	 	  
	  	  	  	  	 	  
	
7.2

	
THYROID

	  	 	  
	  	  	  	  	 	  
	
7.2.1

	
ANTITHYROID AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Propylthiouracil tab.

	  	 	  
	  	
$$

	
Methimazole tab.

	
Tapazole

	 	  
	  	  	  	  	 	  
	
7.2.2

	
THYROID HORMONES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Levo-thyroxine tab.

	
Several

	 	  
	  	
$

	
Levo-thyroxine tab.

	
Synthroid

	 	
P

	  	
$

	
Levo-thyroxine tab.

	
Levoxyl

	 	
P

	  	  	  	  	 	  
	
7.3

	
CORTICOSTEROIDS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Dexamethasone sodium phosphate inj.

	  	OB-GYN
	  	
$

	
Prednisone tab.

	
Deltasone

	 	  
	  	
$

	
Dexamethasone tab.

	
Decadron

	 	  
	  	
$

	
Methylprednisolone* tab.

	
Medrol

	 	  
	  	
$

	
Prednisolone syrup

	
Prelone

	 	  
	  	
$

	
Triamcinolone acetonide inj.

	
Kenalog,

	 	  
	  	  	  	
Aristocort Forte

	 	  
	  	  	  	
Aristospan

	 	
NF

	  	
$

	
Hydrocortisone* tab., sol.

	
Cortef

	 	  
	  	
$

	
Cortisone acetate tab.

	  	 	  
	  	
$

	
Fludrocortisone acetate tab.

	
Florinef

	 	  
	  	
$

	
Dexamethasone elixir,

	
Decadron

	 	  
	  	  	
syrup, sol.

	  	 	  
	  	
$$

	
Betamethasone acetate &

	
Celestone

	OB-GYN
	  	  	
sodium phosphate inj.

	
Soluspan

	 	  
	  	  	  	  	 	  
	
7.4

	
GROWTH HORMONES

	  	 	  
	  	  	  	  	 	  
	  	
$$$$$

	
Somatropin inj.

	
Omnitrope

	PA, P
	  	  	  	  	 	  
	
7.5

	
MISCELLANEOUS ENDOCRINOLOGICAL AGENTS

	 	  
	  	  	  	  	 	  
	
7.5.1

	
ANDROGENS

	  	 	  
	  	  	  	  	 	  
	  	
$$$ Testosterone cypionate* in oil inj.

	
Depo-Testosterone

	 	  

  

  

  

 

	  	  	  	  	 	  
	
7.5.2

	
ANTIHYPERPROLACTINEMIA AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$$$$$ Cabergoline tab.

	
Dostinex

	 	  
	  	  	  	  	 	  
	
7.5.3 OTHERS

	  	  	 	  
	  	  	  	  	 	  
	  	
$$$

	
Desmopressin acetate

	
DDAVP

	 	  
	  	  	
nasal sol. (0.01%)

	  	 	  
	  	
$$$

	
Etidronate disodium tab.

	
Didronel

	 	
PA

	  	
$$$$

	
Desmopressin acetate

	
DDAVP

	 	  
	  	  	
nasal spray sol. (0.01%)

	  	 	  
	  	
$$$$

	
Desmopressin acetate tab.

	
DDAVP

	 	  
	  	
$$$$$

	
Desmopressin acetate inj.

	
DDAVP

	 	  
	  	  	
(4mcg/ml vial, small vial)

	  	 	  
	  	
$$$$$!

	
Desmopressin acetate nasal

	
Stimate

	 	  
	  	  	
spray sol. 1.5 mg/ml

	  	 	  
	  	
$$$$$!!

	
Octreotide acetate* inj.

	
Sandostatin

	 	
PA

	  	  	  	
Sandostatin LAR

	 	
PA

	  	  	  	  	 	  
	
8.0

	
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY

	 	  
	  	  	  	  	 	  
	
8.1

	
NONSTEROID ANTIINFLAMATORIES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Ibuprofen tab. (≥ 400mg)

	
Motrin (≥ 400mg)

	OTC are NF
	  	
$

	
Naproxen tab.

	
Naprosyn

	 	  
	  	
$

	
Indomethacin cap.

	
Indocin

	 	  
	  	
$

	
Salsalate tab.

	
Disalcid

	 	  
	  	
$

	
Sulindac tab.

	
Clinoril

	 	  
	  	
$$

	
Naproxen EC tab.

	
EC-Naprosyn

	 	  
	  	
$$

	
Naproxen sodium tab.

	
Anaprox, Anaprox DS

	 	  
	  	  	  	
Naprelan

	 	
NF

	  	
$$

	
Nabumetone tab.

	
Relafen

	 	  
	  	
$$$$

	
Indomethacin ER cap.

	
Indocin SR

	 	  
	  	
$$$$

	
Celecoxib cap.

	
Celebrex

	ST, P
	  	  	  	  	 	  
	
8.2

	
GOUT

	  	  	 	  
	  	  	  	  	 	  
	  	
$

	
Colchicine tab.

	  	 	  
	  	
$

	
Allopurinol tab.

	
Zyloprim

	 	  
	  	
$

	
Probenecid tab.

	
Benemid

	 	  
	  	  	  	  	 	  
	
8.3 MUSCLE RELAXANTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Cyclobenzaprine tab. (10mg)

	
Flexeril

	 	  
	  	
$

	
Diazepam* tab., sol., conc.

	
Valium

	 	  
	  	
$

	
Baclofen tab.

	
Lioresal

	 	  
	  	
$$

	
Dantrolene cap.

	
Dantrium

	 	  
	  	  	  	  	 	  
	
8.4 TNF ANTAGONISTS

	  	 	  
	  	  	  	  	 	  
	  	
$$$$$! Adalimumab inj.

	
Humira,

	PA, P
	  	  	  	
Humira Pen

	PA, P
	  	
$$$$$! Etanercept inj.

	
Enbrel

	PA, P
	  	  	  	  	 	  
	
8.5 MISC. RHEUMATOLOGICAL AGENTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Methotrexate* tab.

	
Rheumatrex

	 	  
	  	
$

	
Penicillamine cap.

	
Cuprimine

	 	  
	  	
$$$

	
Azathioprine tab.

	
Imuran

	 	  

  

  

  

 

	  	  	  	  	 	  
	  	
$$$$

	
Aurothioglucose inj.

	
Solganal

	PA
	  	
$$$$$

	
Auranofin cap.

	
Ridaura

	PA
	  	  	  	  	 	  
	
9.0

	
OBSTETRICS AND GYNECOLOGY

	  	 	  
	  	  	  	  	 	  
	
9.1

	
PRENATAL VITAMINS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Prental Vitamins with iron and

	
Generic only

	OB-GYN
	  	  	
folic acid

	  	 	  
	  	  	  	  	 	  
	
9.2

	
BIOLOGICAL AGENTS

	  	 	  
	  	  	  	  	 	  
	
Rho Gam- Second dose (post partum).

	  	 	  
	
(The Department of Health covers the first dose at selected Pharmacies – Mothers and Children Program.)

	  	  	  	  	 	  
	
9.3

	
ESTROGEN AND PROGESTIN

	  	 	  
	  	  	  	  	 	  
	
9.3.1

	
ESTROGEN

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Estradiol tab.

	  	 	  
	  	
$

	
Estropipate tab.

	  	 	  
	  	
$$

	
Conjugated estrogens tab.

	
Premarin

	P
	  	  	
(0.3mg, 0.625mg, 0.9mg, 1.25mg, 2.5mg)

	  	 	  
	  	  	  	  	 	  
	
9.3.2

	
ESTROGENS IN COMBINATION

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Conjugated estrogen/

	
PremPro

	 	
P

	  	  	
Medroxyprogesterone tab.

	
PremPro Low Dose

	 	
NF

	  	  	
(0.625/2.5mg; 0.625/5mg)

	  	 	  
	  	
$$$

	
Estradiol/Norethindrone

	
Activella

	 	  
	  	  	
acetate tab.

	  	 	  
	  	  	  	  	 	  
	
9.3.3

	
PROGESTERONE

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Medroxyprogesterone

	
Provera

	 	  
	  	  	
acetate tab.

	  	 	  
	  	  	  	  	 	  
	
9.3.4

	
BIRTH CONTROL PILLS

	  	 	  
	  	  	  	  	 	  
	  	
Available through the Department of Health

	  	PA-AUB
	  	  	  	  	 	  
	
9.4

	
TOPICAL AGENTS

	  	 	  
	  	  	  	  	 	  
	
9.4.1

	
VAGINAL ESTROGENS

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Conjugated estrogen vaginal cr.

	
Premarin

	P
	  	  	  	
Vaginal cream

	 	  
	  	
$$

	
Estradiol vaginal tab.

	
Vagifem

	 	  
	  	  	  	  	 	  
	
9.4.2

	
VAGINAL ANTIINFECTIOUS

	  	 	  
	  	  	  	  	 	  
	  	
$$

	
Terconazole* vaginal cr., supp.

	
Terazol - 3,

	 	  
	  	  	  	
Terazol - 7

	 	  
	  	
$$$

	
Clindamycin phosphate

	  	 	  
	  	  	
vaginal* cr., supp.

	
Cleocin

	 	  
	  	
$$$

	
Metronidazole vaginal gel

	
Vandazole

	 	  
	  	  	
(0.75%)

	  	 	  

 

  

  

  

 

	  	  	  	  	  	  
	
9.5

	
MISCELANEOUS AGENTS

	  	  	  
	  	  	  	  	  	  
	
9.5.1

	
OSTEOPOROSIS

	  	  	  
	  	  	  	  	  	  
	  	
$$ Alendronate tab. (includes

	
Fosamax

	  	  
	  	
weekly dose)

	  	  	  
	  	
$$$ Risedronate tab.

	
Actonel

	
P

	  
	  	  	  	  	  	  
	
10.0

	
NUTRIENTS, VITAMINS AND CLOTTING THERAPY

	  	  
	  	  	  	  	  	  
	
10.1

	
NUTRIENTS AND VITAMINS

	  	  	  
	  	  	  	  	  	  
	
10.1.1

	
NUTRIENTS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Potassium chloride CR tab.

	
Klor-Con

	  	  
	  	
$

	
Potassium chloride* CR cap.

	
Kay-Ciel/ Kaon Cl

	  	  
	  	
$

	
Potassium chloride* packs

	
Klor-Con

	  	  
	  	
$$

	
Potassium chloride* sol.

	
Kay-Ciel/ Kaon Cl

	  	  
	  	
$$

	
Levocarnitine tab. (330mg), sol.

	
Carnitor

	  	  
	  	
$$

	
Iron dextran inj.

	
Infed

	  	  
	  	  	  	  	  	  
	
10.1.2 VITAMINS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Phytonadione tab.

	
Mephytoin

	  	  
	  	
$

	
Vitamin D tab., cap.

	  	
OTC

	  
	  	
$

	
Ferrous sulfate tab. (325 mg)

	
Several

	
OTC

	  
	  	
$

	
Acido fólico tab. (1 mg)

	  	  	  
	  	
$

	
Cyanocobalamin inj.

	
Vit B-12 inj.

	  	  
	  	
$

	
Leucovorin inj.

	  	  	  
	  	
$$

	
Ergocalciferol inj.

	
Calciferol

	  	  
	  	
$$

	
Calcitriol cap.

	
Rocaltrol

	  	  
	  	
$$

	
Leucovorin tab.

	  	  	  
	  	  	  	  	  	  
	
10.2

	
CLOTTING THERAPY

	  	  	  
	  	  	  	  	  	  
	
10.2.1

	
ANTICOAGULANTS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Heparin* inj.

	  	  	  
	  	
$

	
Warfarin tab.

	
Coumadin

	  	  
	  	
$$$

	
Prasugrel tab.

	
Effient

	
PA, P

	  
	  	
$$$$

	
Enoxaparin inj.

	
Lovenox

	
PA

	  
	  	  	  	  	  	  
	
10.2.2

	
ANTIPLATELETS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Aspirin tab., EC tab.

	
Several

	  	
OTC

	  	  	
(81mg, 325mg)

	
(90 days’ supply per prescription)

	  
	  	
$$$$

	
Clopidogrel tab.

	
Plavix

	  	  
	  	
$$$$

	
Dipyridamole/ ASA cap.

	
Aggrenox

	  	  
	  	  	  	  	  	  
	
10.2.3 ANTIHEMOPHILIC AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$$$$$!!

	
Factor IX

	
Complex for inj.

	
PA

	  
	  	
$$$$$!!

	
Antihemophilic factor VIII

	
Hemofil M

	
PA, P

	  
	  	  	
(human) for inj.

	  	  	  
	  	
$$$$$!!

	
Antihemophilic factor VIII

	
Kogenate

	
PA, P

	  
	  	  	
recombinant inj.

	
Recombinate

	
PA, P

	  
	  	  	  	
Advate

	
PA, P

	  
	  	  	  	
Xyntha

	
PA, P

	  
	  	
$$$$$!!

	
Coagulation factor IX inj. PA

	  	  	  
	  	
$$$$$!!

	
Antihemophilic factor VWF PA

	  	  	  
	 	 	
(human) inj.

	 	 	 

  

  

  

 

	  	
$$$$$!!

	
Coagulation factor IX

	
Benefix

	
PA, P

	 
	  	  	
recombinant inj.

	  	  	 
	  	
$$$$$!!

	
Coagulant factor VIIA

	  	
PA

	 
	  	  	
recombinant inj.

	  	  	 
	  	
$$$$$!!

	
Antiinhibitor coagulant

	  	
PA

	 
	  	  	
complex inj.

	  	  	 
	  	  	  	  	  	 
	
10.2.4 AGENTS FOR INTERMITENT CLAUDICATION

	  	 
	  	  	  	  	  	 
	  	
$

	
Pentoxifylline tab.

	
Trental

	  	 
	  	
$

	
Cilostazol tab.

	
Pletal

	  	 
	  	  	  	  	  	 
	
11.0 ANTIDOTES

	  	  	 
	  	  	  	  	  	 
	  	
$$

	
Sodium polystyrene/

	
Kayexalate

	  	 
	  	  	
sulfonate powder, susp.

	
Kionex

	  	 
	  	
$$

	
Calcium acetate cap.

	
Phoslo

	  	 
	  	
$$$$

	
Sevelamer carbonate tab.,

	
Renvela

	
PA, P

	 
	  	  	
powder

	  	  	 
	  	
$$$$

	
Cinacalcet tab.

	
Sensipar

	
PA, P

	 
	  	  	  	  	  	 
	
12.0

	
RESPIRATORY AGENTS

	  	  	 
	  	  	  	  	  	 
	
12.1

	
ANTIHISTAMINES

	  	  	 
	  	  	  	  	  	 
	
12.1.1

	
ANTIHISTAMINES

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Diphenhydramine cap. (50mg)

	
Benadryl

	
OTC are NF

	  	
$

	
Hydroxyzine pamoate cap.

	
Vistaril

	  	 
	  	
$

	
Hydroxyzine* HCl tab., syr.

	
Atarax

	  	 
	  	  	  	  	  	 
	
12.1.2

	
NON-SEDATIVE ANTIHISTAMINES

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Loratadine OTC tab., syr.

	
Claritin

	
 

	
OTC

	  	  	  	  	  	 
	
12.2

	
INTRANASAL STEROIDS

	  	  	 
	  	  	  	  	  	 
	  	
$$

	
Fluticasone nasal susp.

	
Flonase

	  	 
	  	  	  	  	  	 
	
12.3

	
OTHERS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Cromolyn nasal sol.

	
Nasalcrom

	
 

	
OTC

	  	  	  	  	  	 
	
12.4

	
ASTHMA AGENTS

	  	  	 
	  	  	  	  	  	 
	
12.4.1

	
BRONCHIODILATORS

	  	  	 
	  	  	  	  	  	 
	12.4.1.1    XANTINES	  	  	 
	  	  	  	  	  	 
	  	
$

	
Theophylline sol.

	  	  	 
	  	
$

	
Theophylline SR 12hr tab.

	
Theo-Dur

	  	 
	  	
$

	
Theophylline elixir

	
Aerolate,

	  	 
	  	  	  	
Elixophylline

	  	 
	  	
$

	
Theophylline* SR cap., CR cap.

	
Slo-BID Gyro,

	  	 
	  	  	  	
Theo – 24, Theocap,

	  	 
	  	  	  	
Theo-Dur SPR

	  	 
	  	
$$

	
Theophylline* SR 24hr tab.

	
Uniphyl

	  	 
	  	
$$$

	
Theophylline tab.

	
Theolair

	  	 

  

  

  

 

	  	  	  	  	  	 
	
12.4.1.2 ORAL BETA AGONISTS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Albuterol tab., syr.

	
Ventolin, Proventil

	  	 
	  	  	
Albuterol CR tab.

	
Volmax

	
NF

	 
	  	  	  	
Proventil Repetabs

	
NF

	 
	  	
$

	
Terbutaline tab.

	
Brethine

	  	 
	  	  	  	  	  	 
	
12.4.1.3 INHALED BETA AGONISTS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Albuterol inh. sol.

	  	
Generic Only

	  	
$$

	
Albuterol HFA inh.

	
ProAir HFA

	
P

	 
	  	  	  	
Ventolin HFA

	
P

	 
	  	  	  	
Proventil HFA

	
NF

	 
	  	
$$

	
Levalbuterol inh.

	
Xopenex HFA

	
P

	 
	  	
$$$

	
Formoterol inh.

	
Foradil

	
P

	 
	  	
$$$$

	
Salmeterol inh., diskus

	
Serevent

	  	 
	  	  	  	  	  	 
	
12.4.1.4 ANTICHOLINERGICS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Ipratropium Br inh. sol.

	
Atrovent

	  	 
	  	
$$$

	
Ipratropium Br inh.

	
Atrovent HFA

	  	 
	  	
$$$

	
Tiotropium inhalation powder

	
Spiriva

	
PA

	 
	  	  	  	  	  	 
	
12.4.1.5 INHALED CORTICOSTEROIDS

	  	  	 
	  	  	  	  	  	 
	  	
$$

	
Beclomethasone inh.

	
Qvar

	
P

	 
	  	
$$$

	
Fluticasone inhalation powder

	
Flovent HFA

	
P

	 
	  	  	  	
Flovent Diskus

	
P

	 
	  	
$$$$

	
Budesonide inh. susp.

	
Pulmicort

	  	 
	  	
(respules)

	  	  	 
	  	  	  	  	  	 
	12.4.1.6 AGENTS IN COMBINATION	  	  	 
	  	  	  	  	  	 
	  	
$$$

	
Albuterol / Ipratropium

	
Combivent

	
ST

	 
	  	  	
bromide inh.

	  	  	 
	  	
$$$$

	
Fluticasone / Salmeterol powder

	
Advair Diskus

	
ST, P

	 
	  	  	  	
Advair HFA

	
ST, P

	 
	
12.4.1.7

	
MISCELLANEOUS AGENTS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Montelukast tab., chew tab.

	
Singulair

	  	 
	  	
$

	
Cromolyn sodium inh. sol.

	
Intal

	  	 
	  	
$$$

	
Cromolyn inh.

	
Intal inh.

	  	 
	  	  	  	  	  	 
	
12.5

	
ANTITUSSIVES AND EXPECTORANTS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Codeine / Guaifenesin

	  	
Generic Only

	  	  	
liq., syr.

	  	  	 
	  	  	  	  	  	 
	
13.0

	
OPHTALMIC AGENTS

	  	  	 
	  	  	  	  	  	 
	
13.1

	
OPHTALMIC ANTIBIOTICS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Gentamicin ophth. sol.

	
Garamycin

	  	 
	  	
$

	
Erythromycin ophth. oint.

	  	  	 
	  	
$

	
Tobramycin ophth. sol.

	
Tobrex

	  	 
	  	
$

	
Bacitracin ophth. oint.

	
Bacitracin

	  	 
	  	
$

	
Sodium sulfacetamide

	
Bleph 10

	  	 
	  	  	
ophth. sol. (10%)

	  	  	 
	  	
$

	
Trimethoprim/Polymyxin B

	
Polytrim

	  	 
	  	  	
ophth. sol.

	  	  	 

  

  

  

 

	  	  	  	  	  
	  	
$

	
Sodium sulfacetamide ophth.

	  	  
	  	  	
oint. (10%)

	  	  
	  	
$

	
Ofloxacin ophth. sol.

	
Ocuflox

	  
	  	
$

	
Gentamicin ophth. oint.

	
Garamycin

	  
	  	
$

	
Ciprofloxacin ophth. sol.

	
Ciloxan

	  
	  	
$$

	
Tobramycin ophth. oint.

	
Tobrex

	  
	  	
$$

	
Ciprofloxacin ophth. oint.

	
Ciloxan

	  
	  	
$$$

	
Trifluridine ophth. sol.

	
Viroptic

	
PA

	  	  	  	  	  
	
13.2

	
OPHTALMIC ANTIINFLAMATORIES

	  	  
	  	  	  	  	  
	
13.2.1

	
CORTICOSTEROIDS

	  	  
	  	  	  	  	  
	  	
$

	
Prednisolone acetate ophth.

	  	  
	  	  	
susp. (1%)

	
Pred Forte

	  
	  	
$

	
Fluorometholone ophth.

	  	  
	  	  	
susp. (0.1%) FML

	
Liquifi lm

	  
	  	
$$

	
Prednisolone phosphate

	  	  
	  	  	
ophth. sol. (1%)

	
Inflamase

	  
	  	
$$

	
Fluorometholone acetate

	
Efl one

	  
	  	  	
ophth. susp. (0.1%)

	
Flarex

	
NF

	  	  	  	  	  
	
13.2.2

	
NON STEROIDAL ANTIINFLAMMATORIES

	  	  
	  	  	  	  	  
	  	
$$$ Ketorolac ophth. sol.

	
Acular

	  
	  	  	  	
(max 30 days in 365 days)

	  	  	  	
Acular LS

	  
	  	  	  	
Acular PF

	
NF

	  	
$$$ Diclofenac ophth. sol.

	
Voltaren

	  
	  	  	  	
(max 30 days in 365 days)

	  	  	  	  	  
	
13.3

	
PRODUCTS IN COMBINATION

	  	  
	  	  	  	  	  
	
$$$

	
Tobramycin/Dexamethasone

	
Tobradex

	  
	  	
ophth. susp.

	
Tobradex oint.

	
NF

	  	  	  	  	  
	
13.4

	
AGENTS FOR GLAUCOMA

	  	  
	  	  	  	  	  
	
13.4.1

	
MYOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Pilocarpine ophth. sol.

	  	  
	  	  	  	  	  
	
13.4.2

	
SELECTIVE ADRENERGIC AGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Brimonidine ophth. sol. (0.2%)

	
Alphagan

	  
	  	  	  	
Alphagan P

	
NF

	  	  	  	  	  
	
13.4.3

	
BETA BLOCKERS

	  	  
	  	  	  	  	  
	  	
$

	
Timolol* ophth. sol.

	
Timoptic

	  
	  	
$

	
Levobunolol ophth. sol.

	
Betagan

	  
	  	
$

	
Betaxolol* ophth. sol. (0.5%)

	
Betoptic

	  
	  	  	  	
Betopic S

	
NF

	  	
$

	
Timolol XE ophth. gel

	
Timoptic-XE

	  
	  	  	  	  	  
	
13.4.4

	
ANHIDRASE INHIBITORS

	  	  
	  	  	  	  	  
	  	
$

	
Dorzolamide ophth. sol.

	
Trusopt Plus

	  
	  	
$

	
Brinzolamide ophth. susp.

	
Azopt

	
P

  

  

  

 

	  	  	  	  	  	  
	
13.4.5

	
PROSTAGLANDINES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Latanoprost ophth. sol.

	
Xalatan

	  	  
	  	
$$

	
Bimatoprost ophth. sol.

	
Lumigan

	
ST, P

	  
	  	
$$

	
Travaprost ophth. sol.

	
Travatan Z

	
ST, P

	  
	  	  	  	  	  	  
	
13.5

	
MISCELLANEOUS OPHTALMIC AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Atropine ophth. sol., oint.

	
Iso-Atropine

	  	  
	  	  	  	  	  	  
	
14.0

	
UROLOGY

	  	  	  
	  	  	  	  	  	  
	
14.1

	
ANTISPASMODICS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Oxybutinin tab.

	
Ditropan

	  	  
	  	  	  	
Ditropan XL

	  	
NF

	  	
$$

	
Oxybutynin syr.

	
Ditropan

	  	  
	  	  	  	  	  	  
	
14.2

	
ANESTHESICS

	  	  	  
	  	  	  	  	  	  
	  	
$ Phenazopyridine tab.

	
Pyridium

	
LC= 6 tab.

	  	
(100 mg, 200 mg)

	  	  	  
	  	  	  	  	  	  
	
14.3

	
MISCELLANEOUS UROLOGICAL AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Methenamine-hyosciaminemethylene

	  	  	  
	  	  	
blue-sod biphosphenyl

	
Urin D/S,

	  	  
	  	  	
salicilate tab. 81.6 mg

	
Uretron D/S

	  	  
	  	
$$

	
Finasteride tab. (5 mg)

	
Proscar

	  	  
	  	  	  	  	  	  
	
15.0

	
CANCER

	  	  	  
	  	  	  	  	  	  
	   There shall be covered under the pharmacy coverage only the oral presentations of the cancer products which are detailed as follows. Other presentations shall be covered through the ambulatory chemotherapy clinics.
	  	  	  	  	  	  
	
15.1 ANTIMETABOLITS

	  	  	  
	  	  	  	  	  	  
	  	
$$

	
Methotrexate tab.

	  	  	  
	  	
$$$

	
Mercaptopurine tab.

	
Purinethol

	  	  
	  	
$$$

	
Thioguanine tab.

	  	  	  
	  	
$$$$$!

	
Capecitabine tab.

	
Xeloda

	  	
PA

	  	  	  	  	  	  
	
15.2 ALKALATING AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$$

	
Lomustine cap.

	
CEENU

	  	  
	  	
$$$$

	
Busulfan tab.

	
Myleran

	  	  
	  	
$$$$$

	
Melphalan tab.

	
Alkeran

	  	  
	  	
$$$$$!

	
Cyclophosphamide tab.

	
Cytoxan

	  	  
	  	
$$$$$!

	
Chlorambucil tab.

	
Leukeran

	  	  
	  	
$$$$$!!

	
Temozolamide cap.

	
Temodar

	  	
PA

	  	
$$$$$!!

	
Procarbazine cap.

	
Matulane

	  	  
	  	  	  	  	  	  
	
15.3 ANDROGENS, ESTROGENS, PROGESTINS

	  	  	  
	  	  	  	  	  	  
	
15.3.1 PROGESTINS

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Megestrol acetate tab., susp.

	
Megace

	  	  
	  	
$$$$

	
Medroxyprogesterone acetate

	
Depo-Provera

	  	
PA

	  	  	
inj. (400 mg)

	  	  	  

  

  

  

 

	  	  	  	  	  	 
	  	  	  	  	  	 
	
15.3.2

	
ANTIANDROGENS

	  	  	 
	  	  	  	  	  	 
	  	
$$ Bicalutamide tab.

	
Casodex

	
PA

	 
	  	
$$ Flutamide cap.

	
Eulexin

	
PA

	 
	  	  	  	  	  	 
	
15.3.3

	
BREAST CANCER

	  	  	 
	  	  	  	  	  	 
	
15.3.3.1

	
ANTISTROGENS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Tamoxifen tab.

	
Nolvadex

	  	 
	  	  	  	  	  	 
	
15.3.3.2 AROMATASE INHIBITORS

	  	  	 
	  	  	  	  	  	 
	  	
$

	
Letrozole tab.

	
Femara

	  	 
	  	
$

	
Anastrozole tab.

	
Arimidex

	  	 
	  	
$

	
Exemestane tab.

	
Aromasin

	  	 
	  	  	  	  	  	 
	
15.3.4 HORMONAS

	  	  	 
	  	  	  	  	  	 
	  	
$$$$$!!

	
Estramustine cap.

	
Emcyt

	  	 
	  	  	  	  	  	 
	
15.4 MISCELANEOUS CANCER AGENTS

	  	  	 
	  	  	  	  	  	 
	  	
$$$

	
Hydroxyurea cap.

	
Hydrea

	  	 
	  	
$$$$

	
Leuprolide inj.

	
Eligard

	
PA, P

	 
	  	  	
(all the presentations)

	  	  	 
	  	
$$$$$

	
Leuprolide inj.

	
Lupron Depot

	
PA, P

	 
	  	  	
(all the presentations)

	  	  	 
	  	
$$$$$!

	
Etoposide cap.

	
Vepesid

	  	 
	  	
$$$$$!

	
Dasatinib tab.

	
Sprycel

	
PA, P

	 
	  	
$$$$$!

	
Sunitinib cap.

	
Sutent

	
PA, P

	 
	  	
$$$$$!

	
Sorafenib tab.

	
Nexavar

	
PA, P

	 
	  	
$$$$$!

	
Nilotinib

	
Tasigna

	
PA, P

	 
	  	
$$$$$!

	
Everolimus tab. Afinitor PA, P

	  	  	 
	  	
$$$$$!!

	
Goserelin implant

	
Zoladex

	
PA

	 
	  	
$$$$$!!

	
Mitotane tab.

	
Lysodren

	  	 
	  	
$$$$$!!

	
Imatinib tab., cap.

	
Gleevec

	
PA

	 
	  	  	  	  	  	 
	
15.5 INMUNOSUPRESSORS

	  	  	 
	  	  	  	  	  	 
	  	
$$$$

	
Azathioprine tab.

	
Imuran

	  	 
	  	
$$$$

	
Cyclosporine modifi ed cap., sol.

	
Neoral

	
PA, P

	 
	  	
$$$$

	
Cyclosporine modifi ed cap., sol.

	
Generic only

	
PA

	 
	  	  	  	
Gengraf

	
NF

	 
	  	
$$$$$

	
Cyclosporine* cap., sol.

	
Sandimmune

	
PA

	 
	  	
$$$$$

	
Cyclosporine cap., sol.

	
Sandimmune

	
PA, P

	 
	  	
$$$$$!

	
Sirolimus tab., sol.

	
Rapamune

	
PA

	 
	  	
$$$$$!

	
Mycophenolate sodium tab.

	
Myfortic

	
PA, P

	 
	  	
$$$$$!

	
Mycophenolate mofetil tab.,

	
CellCept

	
PA

	 
	  	  	
cap., liq.

	  	  	 
	  	
$$$$$!

	
Tacrolimus cap.

	
Prograf

	
PA

	 
	  	  	  	  	  	 
	
16.0 BIOTECHNOLOGY

	  	  	 
	  	  	  	  	  	 
	
16.1 MULTIPLE SCLEROSIS

	  	  	 
	  	  	  	  	  	 
	  	
$$$$$!!

	
Glatiramer acetate inj.

	
Copaxone

	
PA, P

	 
	  	
$$$$$!!

	
Interferon beta-1A inj.

	
Avonex

	
PA, P

	 

  

  

  

 

	 	  	  	  	  	 
	 	
$$$$$!!

	
Interferon beta-1B inj.

	
Extavia

	
PA, P

	 
	 	
$$$$$!!

	
Mitoxantrone inj.

	
Novantrone

	
PA

	 
	 	  	  	  	  	 
	 	16.2 ERYTHROID STIMULANTS	 	 	 
	 	  	  	  	  	 
	 	
$$$$$

	
Darbepoetin alfa inj.

	
Aranesp

	
PA, P

	 
	 	
$$$$$

	
Epoetin alfa inj.

	
Procrit

	
PA, P

	 
	 	  	  	  	  	 
	 	
16.3 MYELOID STIMULANTS

	  	  	 
	 	  	  	  	  	 
	 	
$$$$$!

	
Sargramostim inj.

	
Leukine

	
PA, P

	 
	 	
$$$$$!!

	
Filgrastim inj.

	
Neupogen

	
PA, P

	 
	 	
$$$$$!!

	
Pegfi lgrastim inj.

	
Neulasta

	
PA, P

	 
	 	  	  	  	  	 
	 	
16.4 INTERFERONS

	  	  	 
	 	  	  	  	  	 
	 	
$$$$$!!

	
Interferon alfa-2B inj.

	
Intron A

	
PA

	 
	 	
$$$$$!!

	
Interferon Gamma-1B inj.

	
Actimmune

	
PA

	 
	 	  	  	  	  	 
	 	
Revised 12/26/2012

	  	  	 
	 	  	  	  	  	 
	 	NF Unlisted	  	  	  	 
	 	PA Requires preauthorization	  	  	 
	 	P Contracted brand name product (rebate)	  	  	 
	 	Bold Generic bioequivalent available in all the presentations	  	 
	 	Bold* Some presentations of the medications are not available in generic	  	 
	 	LC Limit as to the amount to be dispatched	  	  	 
	 	ST: Step therapy, Clinical protocol for its use	  	  	 
	 	AL Age limit	  	  	 
	 	OB-GYN Only in Obstetrics-Gynecology listing	  	  	 
	 	VIH-AIDS Only in HIV-AIDS listing	  	  	 
	 	OTC-Over the Counter	  	  	 
	 	OTC-Over the Counter-Unlisted	  	  	 

 

  

  

  

PART III - APPENDIX I

PRODUCTS WITH A LIMITATION 

AS TO THE AMOUNT TO BE DISPATCHED

 

	
1.

	
Antimycotics

 

	  	  	  
	
Product

	
Generic

	
Limitation

	  	
Name

	  
	
Lamisil

	
Terbinafine

	
Maximum 12 weeks

	  	
tab.

	
(lifetime) - 84 tablets

 

	
2.

	
Triptanes (Agents for migraine)

 

	
Product

	
Generic Name

	
Limitation

	
Imitrex

	
Sumatriptan nasal spray

	
Maximum amount within a 30 day

	  	  	
period = 6 inhalers

	
Imitrex

	
Sumatriptan tab.

	
Maximum amount within a 30 day

	  	  	
period = 6 tablets

 

	
3.

	
Antianxiety/Hypnotic

 

	
Product

	
Generic Name

	
Limitation

	
Versed

	
Midazolam inj.

	
Maximum amount within a 30 day

	  	  	
period = 5 mg.

 

	
4.

	
Scabicides

	
Product

	
Generic Name

	
Limitation

	
Elimite

	
Permethrin cr. (5%)

	
Maximum amount within a 30 day

	  	  	
period = 60 gm.

	
Lindane

	
Lindane lot. (1%)

	
Maximum amount within a 30 day

	  	  	
period = 60 cc

 

	
5.

	
Anesthesics

 

	
Product

	
Generic Name

	
Limitation

	
Pyridium

	
Phenazopyridine tab.

	
Maximum treatment for three days

	  	  	
= 6 tablets

 

  

  

  

 

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO

PREFERRED DRUG LIST DENTAL 2013-2014

	  	  	  	
 

	  	
1.0

	
ANTIINFECTIOUS

	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
1.1

	
CEPHALOSPORINES

	 	 	  	  
	  	  	  	  	 	 	  	  
	  	
1.1.1

	
FIRST GENERATION

	 	 	  	  
	  	  	
$

	
Cephalexin cap.

	 	 	
Keflex

	  
	  	  	
$

	
Cephalexin susp.

	 	 	
Keflex

	  
	  	  	
$$$

	
Cefadroxil* susp.

	 	 	
Duricef

	
AL < 12 years

	 	 	 	 	 	 
	  	1.2     MACROLIDS	 	 	  	  
	  	  	  	  	 	 	  	  
	  	  	
$

	
Erythromycin cap.

	 	 	  	  
	  	  	
$

	
Erythromycin stearate tab.

	 	 	
Erythrocin

	  
	  	  	
$

	
Erythromycin tab.

	 	 	  	  
	  	  	
$

	
Erythromycin EC* tab.

	 	 	
E-Mycin,

	  
	  	  	  	  	 	 	
EryTab

	  
	  	  	
$

	
Erythromycin

	 	 	  	  
	  	  	  	
ethylsuccinate* tab., chew

	 	 	
E.E.S.,

	  
	  	  	  	
tab., susp.

	 	 	
Eryped

	  
	  	  	  	  	 	 	  	  
	  	
1.3

	
PENICILLINS

	 	 	  	  
	  	  	  	  	 	 	  	  
	  	  	
$

	
Ampicillin cap., susp.

	 	Principen	  
	  	  	
$

	
Penicillin VK tab., sol.

	 	Veetids,	  
	  	  	  	  	 	Pen-Vee K	  
	  	  	
$

	
Amoxicillin* cap., tab., Trimox,

	 	 	  	  
	  	  	  	
chew tab., susp.

	 	Amoxil,
	  	  	  	  	 	Wymox	  
	  	  	  	  	 	 	  	  
	
1.4

	
ANTIINFECTIOUS MISCELLANEOUS

	 	 	  	  
	  	  	  	  	 	 	  	  
	  	  	
$

	
Clindamycin cap.

	 	Cleocin	  
	  	  	  	
(150mg, 300mg)

	 	 	  	  
	  	  	
$$$

	
Clindamycin cap. (75mg), sol.

	 	Cleocin
	  	  	  	  	 	 	  	  
	  	  	  	  	 	 	  	  
	
2.0

	
NARCOTIC ANALGESICS AND AGENTS IN COMBINATION

	  
	  	  	  	  	 	 	  	  
	  	
$

	  	
APAP/ Codeine* tab., cap.,

	 	 	  	  
	  	  	  	
elixir, sol., susp.

	 	 	  	  
	  	
$

	  	
APAP/ Hydrocodone tab.,

	 	 	  	  
	  	  	  	
cap., elixir

	 	 	  	  
	 	 	 	 	 
	
3.0 NON-STEROID ANTIINFLAMMATORIES

	 	 	  	  
	  	
$

	  	
Ibuprofen tab. (≥400mg)

	Motrin (≥400mg)	
OTC are NF

	  	
$

	  	
Naproxen tab.

	Naprosyn	  
	  	
$$

	
Naproxen EC tab.

	EC-Naprosyn	  
	  	
$$

	
Naproxen sodium tab.

	Anaprox, Anaprox DS	  
	  	  	  	  	Naprelan	
NF

	  	  	  	  	 	 	  	  
	
Revided 12/26/12

	 	 	  	  

 

  

  

  

 

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO

 

PREFERRED DRUG LIST

EMERGENCY ROOMS

2013-2014

	  	  	  	  	  	  
	
1.0

	
ANTIINFECTIOUS

	  	  	  
	  	  	  	  	  	  
	
1.1.1

	
CHEPHALOSPORINES

	  	  	  
	  	  	  	  	  	  
	
1.1.1

	
FIRST GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Cephalexin cap.

	
Keflex

	  	  
	  	
$

	
Cephalexin susp.

	
Keflex

	  	  
	  	
$$$

	
Cefadroxil* susp.

	
Duricef AL « 12 years

	
 

	  
	  	  	  	  	  	  
	
1.1.2

	
SECOND GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$$

	
Cefaclor cap.

	
Ceclor

	  	  
	  	  	  	
Ceclor CD

	
NF

	  
	  	
$$$

	
Cefprozil tab., susp.

	
Cefzil

	  	  
	  	  	  	  	  	  
	
1.1.3

	
THIRD GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Defdninir cap., susp.

	
Omnicef

	  	  
	  	  	  	  	  	  
	
1.1.2

	
MACROLIDS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
EES/Sulfisoxasole susp.

	
Pediazole

	  	  
	  	
$

	
Erythromycin cap.

	  	  	  
	  	
$

	
Erythroycim stearate tab.

	
Erythrocin

	  	  
	  	
$

	
Erythromycin tab.

	  	  	  
	  	
$

	
Erythromycin EC*tab.

	
E-Mycin,

	  	  
	  	  	  	
Ery Tab

	  	  
	  	
$

	
Erythromycin ethylsuccinate*

	
E.E.S.,

	  	  
	  	  	
Tab., susp.

	
Eryped

	  	  
	  	
$$$

	
Azithromycin tab.,susp.,

	
Zithromax

	  	  
	  	  	
powder pack for susp. (1 gm)

	
Zithromax Tri-Pack

	
NF

	  	
$$$

	
Clarithromycin tab., susp.

	
Biaxin

	  	  
	  	  	  	  	  	  
	
1.3

	
PENICILINS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  	  
	  	  	  	
Pen-Vee K

	  	  
	  	
$

	
Amoxicillin* cap., tab.,

	
Trimox,

	  	  
	  	  	
Chew tab., susp.,

	
Amoxil

	  	  
	  	  	  	
Wymox

	  	  
	  	
$$$

	
Amoxicillin / Clavulanic

	
Augmentin

	  	  
	  	  	
acid tab., chew tab., susp.

	
Augmentin ES

	
NF

	 	 	 	
Augmentin XR

	
NF

  

  

  

 

	  	  	  	  	  	  
	
1.4

	
SULFONAMIDES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Trimethoprim /

	
Bactrim, Bactrim DS,

	  
	  	  	
Sulfamethoxazole tab., susp.

	
Septra, Septra DS

	  
	  	  	  	  	  	  
	
1.5

	
TETRACYICLINES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Doxycycline hyclate tab.,

	
Vibratab,

	  	  
	  	  	
cap.

	
Vibramycin

	  	  
	  	
$

	
Tetracycline cap.

	
Achromycin

	  	  
	  	
$$$$

	
Doxycycline syr., susp.

	
Vibramycin

	  	  
	  	  	  	  	  	  
	
1.6

	
ANTIMYCOTICS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Nystatin susp.

	
Mycostatin, Nystat

	  
	  	  	  	  	  	  
	
1.7

	
ANTIVIRALS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Acyclovir tab., cap.

	
Zovirax

	  	  
	  	
$$

	
Acyclovir susp.

	
Zovirax

	  	  
	  	  	  	  	  	  
	
1.8.

	
QUNINOLONES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ciprofloxacin tab. (250mg,

	
Cipro

	  	  
	  	  	
500mg, 750mg)

	  	  	  
	  	
$

	
Levofloxacin tab.

	
Levaquin

	  	  
	  	
$$$$

	
Ciprofloxacin susp.

	
Cipro

	  	  
	  	  	  	  	  	  
	
1.9

	
MISCELLANEOUS ANTIINFECTIOUS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Metronidazole tab.

	
Flagyl

	  	  
	  	  	  	
Flagyl ER

	
NF

	  
	  	
$

	
Nitrofurantoin/monohydrate Macrobid

	  	  	  
	  	  	
Macrocrystals* cap.

	  	  	  
	  	
$

	
Clindamycin cap.

	
Cleocin

	  	  
	  	  	
(150mg, 300mg)

	  	  	  
	  	
$$

	
Nitrofurantoin

	
Macrodantin

	  	  
	  	  	
macrocrystals* cap.

	  	  	  
	  	
$$$

	
Clindamycin cap. (75mg), susp.

	
Cleocin

	  	  
	  	  	  	  	  	  
	
2.0

	
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPDS

	  
	  	  	  	  	  	  
	
2.1

	
GLYCOSIDES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Digoxin* tab.

	
Lanoxin

	  	  
	  	
$$

	
Digoxin elixir

	
Lanoxin

	  	  
	  	  	  	  	  	  
	
2.2

	
ANTIHYPERTENSIVE THERAPY

	  	  	  
	  	  	  	  	  	  
	
2.2.1

	
DIURETICS

	  	  	  

  

  

  

 

	  	  	  	  	  
	
2.2.1.1

	
THIAZIDES

	  	  
	  	  	  	  	  
	  	
$

	
Hydrochlorothiazide* tab.

	
Microzide

	  
	  	  	  	  	  
	
2.2.1.2

	
LOOP

	
DIURETICS

	  	  
	  	  	  	  	  
	  	
$

	
Furosemide tab., sol.

	
Lasix

	  
	  	  	  	  	  
	
2.2.2

	
BETA BLOCKERS

	  	  
	  	  	  	  	  
	  	
$

	
Atenolol tab.

	
Tenormin

	  
	  	
$

	
Atenolol/ HCTZ

	
Tenoretic

	  
	  	
$

	
Metoprolol tartrate tab.

	
Lopressor

	  
	  	
$

	
Metroprolol/HCTZ

	
Lopressor HCT

	  
	  	  	  	  	  
	
2.2.3

	
CALCIUM CHANNEL ANTAGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Verapamil tab.

	
Isoptin, Calan

	  
	  	  	  	  	  
	
2.2.4

	
ANGIOTENSINE INHIBITORS (ACE)

	  	  
	  	  	  	  	  
	  	
$

	
Captopril tab.

	
Capoten

	  
	  	
$

	
Captopril/HCTZ

	
Capozide

	  
	  	
$

	
Enalapril tab.

	
Vasotec

	  
	  	
$

	
Enalapril/HCTZ

	
Vaseretic

	  
	  	  	  	  	  
	
2.2.5

	
ANGIOTESINE RECEPTOR BLOCKER (ARB)

	  	  
	  	  	  	  	  
	  	
$

	
Losartan tab.

	
Cozaar

	  
	  	  	  	  	  
	
2.2.6

	
ANTIHYPTERTENSIVES WITH CENTRAL ACTION

	  
	  	  	  	  	  
	  	
$

	
Clonidine tab.

	
Catapress

	  
	  	  	  	  	  
	
2.2.7

	
VASODILATORS

	  	  
	  	  	  	  	  
	  	
$

	
Nitroglycerin SL tab.

	
Nitrostat

	  
	  	  	  	  	  
	
3.0

	
AUTONOMIC DRUGS FOR THE CENTRAL NERVOUS SYSTEM, NEUROLOGY

	  
	  	
AND PSYCHIATRY

	  	  
	  	  	  	  	  
	
3.1

	
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION

	  
	  	  	  	  	  
	  	
$

	
APAP/Codeine* tab.,

	  	  
	  	  	
elixir, sol., susp.

	  	  
	  	
$

	
Tramadol tab.

	
Ultram

	  
	  	
$$

	
APAP/Butalbital/Caffeine

	
Fioricet

	  
	  	  	
tab., cap.

	  	  

  

  

  

 

	  	  	  	  	  
	
3.2

	
ANTICONVULSIVES

	  	  
	  	  	  	  	  
	  	
$

	
Phenobarbital tab., elixir

	  	  
	  	
$

	
Phenytoin* chew tab.,

	
Dilantin

	  
	  	  	
cap, susp.

	  	  
	  	
$$

	
Levetiracetam tab., sol. Keppra

	  	  
	  	  	  	  	  
	
3.3

	
ANTIVERTIGO AND ANTIEMETICS

	  	  
	  	  	  	  	  
	  	
$

	
Promethazine Syr.

	
Phenergan

	  
	  	
$

	
Prochlorperazine tab.

	
Compazine

	  
	  	
$

	
Metoclopramide tab., syr., inj.

	
Reglan

	  
	  	
$

	
Promethazine* tab.

	
Phenergan

	  
	  	
$$

	
Trimethobenzamide cap., supp.

	
Tigan

	  
	  	
$$

	
Promethazine supp.

	
Phenergan

	  
	  	
$$$

	
Prochlorperazine* supp.

	
Compazine

	  
	  	  	  	  	  
	  	  	  	  	  
	
4.0

	
DERMATOLOGICAL AGENTS/ TOPICAL THERAPY

	  
	  	  	  	  	  
	
4.1

	
TOPICAL ANTIBATERIAL

	  	  
	  	  	  	  	  
	  	
$

	
Gentamicin cr., oint.

	
Garamycin

	  
	  	
$

	
Silver sulfadiazine cr.

	
Silvadene

	  
	  	
$$

	
Mupirocin oint.

	
Bactroban

	  
	  	  	  	  	  
	
4.2

	
ESCABIDES

	  	  
	  	  	  	  	  
	  	
$$$$

	
Lindane lot. (1%)

	  	
ST, LC = 60cc

	  	  	  	  	  
	
5.0

	
DRUGS FOR THE EARS AND THROAT

	  	  
	  	  	  	  	  
	
5.1

	
OTIC PREPARATIONS

	  	  
	  	  	  	  	  
	  	
$

	
Burrow’s (Acetic acid 2%/

	  	  
	  	  	
Aluminum acetate) otic sol.

	
Domeboro

	  
	  	
$

	
Acetic acid/ Hydrocortisone

	
Vosol-HC

	  
	  	  	
Otic sol.

	  	  
	  	
$

	
Hydrocortisone/Neomycin/

	  	  
	  	  	
Polymixin B otic sol., susp.

	
Cortisporin

	  
	  	
$$

	
Acetic acid otic sol.

	
Vosol

	  
	  	
$$

	
Ofloxacin otic sol. Floxin Otic

	  	  
	  	  	  	  	  
	
5.2

	
AGENTS FOR THE MOUTH AND THROAT

	  	  
	  	  	  	  	  
	  	
$

	
Lidocaine viscous sol.

	
Xylocaine

	  
	  	
$$$

	
Clotrimazole troche

	
Mycelex

	  
	  	  	  	  	  
	
6.0

	
GASTROENTEROLOGY

	  	  

	  	  	  	  	  
	
6.1

	
AGENTS FOR ULCERS

	  	  

 

  

  

  

 

	  	  	  	  	  
	
6.1.1

	
H2 ANTAGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Ranitidine tab. (300mg)

	
Zantac

	  
	  	
$

	
Cimetidine tab., sol.

	
Tagamet

	  
	  	
$$

	
Ranitidine syr.

	
Zantac

	  
	  	  	  	  	  
	
6.1.2

	
PROTON PUMP INHIBITOR

	  	  
	  	  	  	  	  
	  	
$

	
Omeprazole cap. Prilosec

	  	  
	  	  	
(10mg, 20mg)

	  	  
	  	  	  	  	  
	
6.2

	
ANTIDIARRHEICS

	  	  
	  	  	  	  	  
	  	
$

	
Diphenoxylate/

	
Lomotil

	  
	  	  	
Atropine Tab., liq.

	  	  
	  	  	  	  	  
	
7.0

	
ENDOCRINOLOGICAL AGENTS

	  	  
	  	  	  	  	  
	
7.1

	
DIABETES THERAPY

	  	  
	  	  	  	  	  
	
7.1.1.

	
HIPOGLYCEMIC AGENTS

	  	  
	  	  	  	  	  
	
7.1.1.1

	
SULFONILUREANS

	  	  
	  	  	  	  	  
	  	
$

	
Glipizide tab.

	
Glucotrol

	  
	  	
$

	
Glipizide XL tab.

	
Glucotrol XL

	  
	  	
$

	
Glimepiride tab.

	
Amaryl

	  
	  	  	  	  	  
	
7.1.1.2

	
INSULIN

	  	  
	  	  	  	  	  
	  	
$

	
Human insulin (regular) vial

	
Humulin R

	
P

	  	  	  	  	  
	
7.1.1.3.

	
OTHERS

	  	  
	  	  	  	  	  
	  	
$

	
Insulin syringe & needle

	
Varios

	  
	  	
$

	
Metformin tab.

	
Glucophage

	  
	  	  	  	  	  
	
7.2

	
CORTICOSTEROIDS

	  	  
	  	  	  	  	  
	  	
$

	
Prednisone tab.

	
Deltasone

	  
	  	
$

	
Dexamethasone tab.

	
Decadron

	  
	  	
$

	
Dexamethasone elixir,

	
Decadron

	  
	  	  	
syrup, sol.

	  	  
	  	
$

	
Methylprednisolone* tab.

	
Medrol

	  
	  	
$

	
Prednisolone syrup

	
Prelone

	  
	  	  	  	  	  
	
8.0

	
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY

	  
	  	  	  	  	  
	
8.1

	
NON-STEROIDAL ANIINFLAMMATORIES

	  	  
	  	  	  	  	  
	  	
$

	
Ibuprofen tab. (≥400mg)

	
Motrin (≥400mg) OTC are NF

	  
	  	
$

	
Naproxen tab.

	
Naprosyn

	  
	 	
$

	
Indomethacin cap.

	
Indocin

	 

 

  

  

  

 

	  	
$

	
Salsalate tab.

	
Disalcid

	  
	  	
$$

	
Naproxen sodium tab.

	
Anaprox,

	  
	  	  	  	
Anaprox DS

	  
	  	  	  	
Naprelan

	
NF

	  	
$$ Nabumetone tab. Relafen

	  	  
	  	  	  	  	  
	
8.2

	
GOUT

	  	  	  
	  	  	  	  	  
	  	
$

	
Colchicine tab.

	
Colcrys

	  
	  	  	  	  	  
	
8.3

	
MUSCLE RELAXANTS

	  	  
	  	  	  	  	  
	  	
$

	
Cyclobenzaprine tab. (10mg)

	
Flexeril

	  
	  	  	  	  	  
	
9.0

	
COAGULATION THERAPHY

	  	  
	  	  	  	  	  
	
9.1

	
ANTICOAGULANTS

	  	  
	  	  	  	  	  
	  	
$

	
Warfarin tab.

	
Coumadin

	  
	  	  	  	  	  
	
9.2

	
ANTIPLATELETS

	  	  
	  	  	  	  	  
	  	
$

	
Clopidogrel tab.

	
Plavix

	  
	  	  	  	  	  
	
10.0

	
RESPIRATORY AGENTS

	  	  
	  	  	  	  	  
	
10.1

	
ANTIHISTAMINES

	  	  
	  	  	  	  	  
	  	
$

	
Diphenhydramine cap. (50mg)

	
Benadryl cap.

	
OTC are NF

	  	
$

	
Hydroxyzine pamoate cap.

	
Vistaril

	  
	  	
$

	
Hydroxyzine* HCl tab., syr.

	
Atarax

	  
	  	  	  	  	  
	
10.2

	
ASTHMA AGENTS

	  	  
	  	  	  	  	  
	
10.2.1

	
BRONCODILATORS

	  	  
	  	  	  	  	  
	
10.2.1.1

	
BETA ORAL AGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Albuterol tabl, syr.

	
Ventolin

	  
	  	  	
Albuterol CR tab.

	
Volmax

	
NF

	  	  	  	
Proventil Repetab

	
NF

	  	
$$

	
Terbutaline tab.

	
Brethine

	  
	  	  	  	  	  
	
10.2.1.2

	
INHALED BETA AGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Albuterol inh. sol.

	  	
Generic only

	  	
$$

	
Albuterol HFA

	
ProAir HFA

	
P

	  	  	  	
Ventolin HFA

	
P

	  	  	  	
Proventil HFA

	
NF

	  	
$$

	
Levalbuterol inh.

	
Xopenex HFA

	
P

  

  

  

 

	  	  	  	  	  
	
10.2.1.3

	
ANTICHOLINERGICS

	  	  
	  	  	  	  	  
	  	
$

	
Ipratropium Br inh. sol.

	
Atrovent

	  
	  	
$$$

	
Ipratropium Br inh.

	
Atrovent HFA

	  
	  	  	  	  	  
	
10.3

	
ANTITUSSIVES AND EXPECTORANTS

	  	  
	  	  	  	  	  
	  	
$

	
Codeine / Guaifenesin liq.

	
Generic only

	  
	  	  	  	  	  
	
11.0

	
OPHTHALMIC AGENTS

	  	  
	  	  	  	  	  
	
11.1

	
OPHTHALMIC ANTIBIOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Gentamicin ophth. sol.

	
Garamycin

	  
	  	
$

	
Gentamicin ophth. oint.

	
Garamycin

	  
	  	
$

	
Trimethoprim/Polymyxin B

	
Polytrim

	  
	  	  	
ophth. sol.

	  	  
	  	
$

	
Tobramycin ophth. sol.

	
Tobrex

	  
	  	  	  	  	  
	
11.2

	
OPHTHALMIC ANTIINFLAMMATORIES

	  	  
	  	  	  	  	  
	  	
$

	
Prednisolone acetate ophth.

	
Pred Forte

	  
	  	  	
susp. (1%)

	  	  
	  	  	  	  	  
	
12.0

	
UROLOGY

	  	  
	  	  	  	  	  
	
12.1

	
ANESTHESICS

	  	  
	  	  	  	  	  
	  	
$

	
Phenazopyridine tab.

	
Pyridium

	
LC=6 tab.

	  	  	
(100mg, 200mg)

	  	  
	  	  	  	  	  
	
12.2

	
MISCELLANEOUS UROLOGICAL AGENTS

	  	  
	  	  	  	  	  
	  	
$

	
Methenamine-hyosciaminemethylene

	  	  
	  	  	
blue-sod biphosphenyl

	
Urin D/S,

	  
	  	  	
salicilate tab. 81.6 mg

	
Uretron D/S

	  
	  	  	  	  	  
	
Revised 12/23/2012

	  	  
	  	  	  	  	  
	  	  	  	  	  

 

  

  

  

NEPHROLOGY

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO 

PREFERRED DRUG LIST 

NEPHROLOGY 

2013-2014

	  	  	  	  	  	  
	
1.0

	
ANTIINFECTIOUS

	  	  	  
	  	  	  	  	  	  
	
1.1

	
CEPHALOSPORINES

	  	  	  
	  	  	  	  	  	  
	
1.1.1

	
FIRST GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Cephalexin cap.

	
Keflex

	  	  
	  	
$

	
Cephalexin susp.

	
Keflex

	  	  
	  	
$$$

	
Cefadroxil* susp.

	
Duricef

	
AL less than 12 years

	  	  	  	  	  	  
	
1.1.2

	
SECOND GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Cefaclor cap.

	
Ceclor

	  	  
	  	  	  	
Ceclor CD

	
NF

	  
	  	
$$$

	
Cefprozil tab., susp.

	
Cefzil

	  	  
	  	  	  	  	  	  
	
1.1.3

	
THIRD GENERATION

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Cefdinir cap., susp.

	
Omnicef

	  	  
	  	  	  	  	  	  
	
1.2

	
MACROLIDS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
EES/Sulfisoxazole susp.

	
Pediazole

	  	  
	  	
$

	
Erythromycin cap.

	  	  	  
	  	
$

	
Erythromycin stearate tab.

	
Erythrocin

	  	  
	  	
$

	
Erythromycin tab.

	  	  	  
	  	
$

	
Erythromycin EC* tab.

	
E-Mycin,

	  	  
	  	  	  	
EryTab

	  	  
	  	
$

	
Erythromycin

	
E.E.S., Eryped

	  	  
	  	  	
ethylsuccinate* tab., susp.

	  	  	  
	  	
$$

	
Azithromycin tab., susp.,

	
Zithromax

	  	  
	  	  	
powder pack for susp. (1 gm)

	
Zithromax Tri-Pack

	
NF

	  	
$$$

	
Clarithromycin tab., susp.

	
Biaxin

	  	  
	  	  	  	
Biaxin XL

	  	
NF

	
1.3

	
PENICILLINS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  	  
	  	  	  	
Pen-Vee K

	  	  
	  	
$

	
Amoxicillin* cap., tab.

	
Trimox,

	  	  
	  	  	
chew tab., susp.

	
Amoxil,

	  	  
	  	  	  	
Wymox

	  	  
	  	
$

	
Penicillin G Procaine inj.

	  	  	  
	  	
$$

	
Penicillin G Benzathine inj.

	
Bicillin LA

	  	  
	  	
$$$

	
Amoxicillin/Clavulanic

	
Augmentin

	  	  
	  	  	
acid tab., susp.

	
Augmentin ES

	
 

	
NF

	  	  	  	
Augmentin XR

	
 

	
NF

 

  

  

  

 

	  	  	  	  	 	  
	
1.4

	
SULFONAMIDES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Trimethoprim/

	
Bactrim, Bactrim DS,

	 	  
	  	  	
Sulfamethoxazole tab., susp.

	
Septra, Septra DS

	 	  
	  	  	  	  	 	  
	
1.5

	
QUINOLONES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Ciprofloxacin tab. (250 mg,

	
Cipro

	 	  
	  	  	
500 mg, 750 mg)

	  	 	  
	  	
$

	
Levofloxacin tab. Levaquin

	  	 	  
	  	
$$$

	
Moxifloxacin tab.

	
Avelox

	 	
P

	  	
$$$$

	
Ciprofloxacin susp.

	
Cipro

	 	  
	  	  	  	  	 	  
	
2.0

	
CARDIOVASCULAR AGENTS FOR HYPERTENSION AND LIPIDS

	 	  
	  	  	  	  	 	  
	
2.1

	
ANTIHYPERTENSIVE THERAPY

	  	 	  
	  	  	  	  	 	  
	
2.1.1

	
DIURETICS

	  	 	  
	  	  	  	  	 	  
	
2.1.1.1

	
THIAZIDES

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Hydrochlorothiazide* tab.

	
Microzide

	 	  
	  	
$

	
Chlorothiazide* tab., susp.

	
Diuril

	 	  
	  	
$

	
Chlorthalidone tab.

	
Hygroton

	 	  
	  	
$$

	
Metolazone tab.

	
Zaroxolyn

	 	  
	  	  	  	  	 	  
	
2.1.1.2  LOOP DIURETICS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Furosemide tab., sol.

	
Lasix

	 	  
	  	
$

	
Bumetanide tab.

	
Bumex

	 	  
	  	  	  	  	 	  
	
2.1.2

	
BETA BLOCKERS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Atenolol tab.

	
Tenormin

	 	  
	  	
$

	
Atenolol/Chlortalidone tab.

	
Tenoretic

	 	  
	  	
$

	
Metoprolol tartrate tab.

	
Lopressor

	 	  
	  	
$

	
Propranolol tab.

	
Inderal

	 	  
	  	
$

	
Propranolol/HCTZ tab.

	
Inderide

	 	  
	  	
$

	
Labetalol tab.

	
Normodyne

	 	  
	  	
$$

	
Metoprolol tartrate/HCTZ tab.

	
Lopressor HCT

	 	  
	  	
$$

	
Propranolol sol., conc.

	  	 	  
	  	
$$

	
Metoprolol succinate SR* tab.

	
Toprol XL

	 	  
	  	
$$

	
Carvedilol tab.

	
Coreg

	 	  
	  	  	  	  	 	  
	
2.1.3

	
CALCIUM CHANNEL ANTAGONISTS

	  	 	  
	  	  	  	  	 	  
	  	
$

	
Amlodipine tab.

	
Norvasc

	 	  
	  	
$

	
Verapamil tab.

	
Isoptin,

	 	  
	  	  	  	
Calan

	 	  
	  	
$

	
Ditiazem tab.

	
Cardizem

	 	  
	  	  	  	
Cardizem LA

	
NF

	  
	  	
$

	
Verapamil ER tab.

	
Calan SR,

	 	  
	  	  	
Isoptin SR

	  	 	  

 

  

  

  

 

	  	  	  	  	  
	  	  	  	
Verelan

	
NF

	  	  	  	
Verelan PM

	
NF

	  	  	  	
Covera HS

	
NF

	  	
$

	
Diltiazem SR 24 hr cap.

	
Dilacor XR

	  
	  	
$$

	
Diltiazem HCL Extended

	
Tiazac

	  
	  	  	
Release Beads SR 24 hr

	  	  
	  	  	
cap. (120mg, 180mg,

	  	  
	  	  	
240mg, 300mg, 360mg)

	  	  
	  	
$$

	
Diltiazem SR 12 hr cap.

	
Cardizem SR

	  
	  	
$$$

	
Nifedipine SR tab., CR tab.

	  	
Generic only

	  	  	  	
Adalat CC

	
NF

	  	  	  	
Procardia XL

	
NF

	  	
$$$

	
Diltiazem HCI coated

	  	
Generic only

	  	  	
beads SR 24hr cap.

	  	  
	  	  	  	  	  
	
2.1.4

	
ANGIOTENSINE INHIBITORS (ACE)

	  	  
	  	  	  	  	  
	  	
$

	
Captopril tab.

	
Capoten

	  
	  	
$

	
Enalapril tab.

	
Vasotec

	  
	  	
$

	
Lisinopril tab.

	
Privinil,

	  
	  	  	  	
Zestril

	  
	  	
$

	
Captopril HCTZ

	
Capozide

	  
	  	
$

	
Enalapril HCTZ

	
Vaseretic

	  
	  	
$

	
Lisinopril HCTZ

	
Prinzide,

	  
	  	  	  	
Zestoretic

	  
	  	
$$

	
Fosinopril tab.

	
Monopril

	  
	  	  	  	  	  
	
2.1.5

	
ANGIOTENSINE RECEPTOR BLOCKERS (ARB)

	  	  
	  	  	  	  	  
	  	
$

	
Losartan tab.

	
Cozaar

	  
	  	
$

	
Losartan HCT tab.

	
Hyzaar

	  
	  	
$

	
Irbesartan tab.

	
Avapro ST, P

	  
	  	
$

	
Irbesartan/HCTZ tab.

	
Avalide ST, P

	  
	  	  	  	  	  
	
2.1.6

	
VASODILATORS

	  	  
	  	  	  	  	  
	
2.1.6.1

	
ALPHA RECEPTOR BLOCKERS

	  	  
	  	  	  	  	  
	  	
$

	
Doxazosin tab.

	
Cardura

	  
	  	
$

	
Terazosin cap.

	
Hytrin

	  
	  	  	  	  	  
	
2.2

	
CHOLESTEROL AND LIPID REDUCING AGENTS

	  
	  	  	  	  	  
	  	
$

	
Simvastatin tab.

	
Zocor

	  
	  	
$

	
Atorvastatin tab.

	
Lipitor

	  
	  	
$

	
Gemfibrozil tab.

	
Lopid tab.

	  
	  	  	  	
Lopid cap.

	  
	  	
$

	
Pravastatin

	
Pravachol

	  
	  	
$$$

	
Cholestyramine powder packs

	
Questran

	  
	  	
$$$

	
Niacin CR tab.

	
Niaspan

	
P

 

  

  

  

 

	  	  	  	  	  
	
3.0

	
ANTIVERTIGO AND ANTIEMETICS

	  	  
	  	  	  	  	  
	  	
$

	
Metoclopramide syr., inj.

	
Reglan

	  
	  	
$

	
Metoclopramide tab.

	
Reglan

	  
	  	  	  	  	  
	
4.0

	
GASTROENTEROLOGY

	  	  
	  	  	  	  	  
	
4.1

	
AGENTS FOR ULCERS

	  	  
	  	  	  	  	  
	
4.1.1

	
H2

	
ANTAGONISTS

	  	  
	  	  	  	  	  
	  	
$

	
Ranitidine tab. (300 mg)

	
Zantac

	  
	  	
$

	
Cimetidine tab., sol.

	
Tagamet

	  
	  	
$

	
Ranitidine syr.

	
Zantac

	  
	  	  	  	  	  
	
4.2

	
ANTIDIARRHEA

	  	  
	  	  	  	  	  
	  	
$

	
Diphenoxylate/

	
Lomotil

	  
	  	  	
Atropine tab., liq.

	  	  
	  	  	  	  	  
	
5.0

	
ENDOCRINOLOGIC AGENTS

	  	  
	  	  	  	  	  
	
5.1

	
DIABETES THERAPY

	  	  
	  	  	  	  	  
	
5.1.1

	
HYPOGLYCEMIC AGENTS

	  	  
	  	  	  	  	  
	
5.1.1.1.1 SULFONILUREAS

	  	  
	  	  	  	  	  
	  	
$

	
Glyburide micronized tab.

	
Generic Only

	  
	  	
$

	
Glipizide tab.

	
Glucotrol

	  
	  	
$

	
Glipizide XL tab. G

	
lucotrol XL

	  
	  	
$

	
Glyburide tab.

	
Generic Only

	  
	  	
$

	
Glimepiride

	
Amaryl

	  
	  	  	  	  	  
	
5.1.1.2  ALPHA GLUCOSIDASE INHIBITORS

	  	  
	  	  	  	  	  
	  	
$$$

	
Acarbose tab.

	
Precose

	  
	  	  	  	  	  
	
5.1.1.3  THIAZOLIDINEDIONES

	  	  
	  	  	  	  	  
	 	
$$$$  

	Pioglitazone tab.	
Actos

	 
	  	  	  	  	  
	
5.1.1.4  DPP IV INHIBITOR

	  	  
	  	  	  	  	  
	  	
$$$ Saxagliptin tab.

	
Onglyza

	
ST, P

	  	
$$$ Saxagliptin/Metformin tab.

	
Kombiglyze

	
ST, P

	  	  	  	  	  
	
5.1.1.5  INSULIN

	  	  
	  	  	  	  	  
	  	
$

	
Human insulin (regular, NPH,

	
Humulin

	
P

	  	  	
70/30, lens) vial

	
Humulin Pen

	
NF

	  	
$$$

	
Insulin lispro vial

	
Humalog

	
P

	  	  	  	
Humalog Mix

	
NF

 

  

  

  

 

	  	  	  	  	  
	  	  	  	
Humalog Pen

	
NF

	  	
$$$

	
Insulin glargine vial

	
Lantus

	
P

	  	  	  	
Lantus Solostar

	
P

	  	  	  	  	  
	
5.1.1.6 OTHERS

	  	  
	  	  	  	  	  
	  	
$

	
Insulin syringe & needles

	
Several

	  
	  	
$

	
Metformin tab.

	
Glucophage

	  
	  	
$

	
Metformin XR tab

	
Glucophage XR

	  
	  	  	  	  	  
	
5.2

	
CORTICOSTEROIDS

	  	  
	  	  	  	  	  
	  	
$

	
Prednisone tab.

	
Deltasone

	  
	  	
$

	
Dexamethasone tab.

	
Decadron

	  
	  	
$

	
Methylprednisolone* tab.

	
Medrol

	  
	  	
$

	
Prednisolone syrup

	
Prelone

	  
	  	
$

	
Hydrocortisone* tab., sol.

	
Cortef

	  
	  	
$

	
Fludrocortisone acetate tab.

	
Florinef

	  
	  	
$

	
Dexamethasone elixir,

	
Decadron

	  
	  	  	
syrup, sol.

	  	  
	  	  	  	  	  
	
5.3

	
MISCELLANEOUS ENDOCRINOLOGIC AGENTS

	  
	  	  	  	  	  
	  	
$$$

	
Desmopressin acetate

	
DDAVP

	  
	  	  	
nasal sol. (0.01%)

	  	  
	  	
$$$$

	
Desmopressin acetate

	
DDAVP

	  
	  	  	
nasal spray sol. (0.01%)

	  	  
	  	
$$$$$!

	
Desmopressin acetate nasal

	
Stimate

	  
	  	  	
spray sol. 1.5 mg/ml

	  	  
	  	  	  	  	  
	
6.0

	
NUTRIENTS AND VITAMINS

	  	  
	  	  	  	  	  
	
6.1

	
NUTRIENTS

	  	  
	  	  	  	  	  
	  	
$

	
Potassium chloride CR tab.

	
Klor-Con

	  
	  	
$

	
Potassium chloride* CR cap.

	
Kay-Ciel, Kaon Cl

	  
	  	
$

	
Potassium chloride* packs

	
Klor-Con

	  
	  	
$$

	
Potassium chloride* sol.

	
Kay-Ciel, Kaon CI

	  
	  	
$$

	
Iron dextran inj.

	
INFed

	  
	  	  	  	  	  
	
6.2

	
VITAMINS

	  	  
	  	  	  	  	  
	  	
$

	
Vitamin D tab., cap.

	  	
OTC

	  	
$

	
Ferrous sulfate tab. (325 mg)

	
Several

	
OTC

	  	
$

	
Folic acid tab. (1 mg)

	  	  
	  	
$

	
Cyanocobalamin inj.

	
Vit. B-12 inj.

	  
	  	
$$

	
Ergocalciferol inj.

	
Calciferol

	  
	  	
$$

	
Calcitriol cap.

	
Rocaltrol

	  

 

  

  

  

 

	  	  	  	  	  
	
7.0

	
ANTIDOTES

	  	  
	  	  	  	  	  
	  	
$$

	
Sodium polystyrene/

	
Kayexalate

	  
	  	  	
sulfonate powder, susp.

	
Kionex

	  
	  	
$$

	
Calcium acetate cap.

	
Phoslo

	  
	  	
$$$$

	
Sevelamer carbonate tab.

	
Renvela

	
PA, P

	  	
$$$$

	
Cinacalcet tab.

	
Sensipar

	
PA, P

	  	  	  	  	  
	
8.0

	
IMMUNOSUPPRESSORS

	  	  
	  	  	  	  	  
	  	
$$$$

	
Azathioprine tab.

	
Imuran

	  
	  	
$$$$

	
Cyclosporine modified cap., sol.

	
Neoral

	
PA, P

	  	
$$$$

	
Cyclosporine modified

	
Generic only

	
PA

	  	  	
cap., sol.

	  	  
	  	  	  	
Gengraf

	
NF

	  	
$$$$$

	
Cyclosporine* cap., sol.

	
Sandimmune

	
PA

	  	
$$$$$

	
Cyclosporine cap., sol.

	
Sandimmune

	
PA, P

	  	
$$$$$!

	
Sirolimus tab., sol.

	
Rapamune

	
PA

	  	
$$$$$!

	
Mycophenolate sodium tab.

	
Myfortic

	
PA, P

	  	
$$$$$!!

	
Mycophenolate mofetil tab.,

	
CellCept

	
PA

	  	  	
cap., liq.

	  	  
	 	
$$$$$!! 

	Tacrolimus cap.	
Prograf

	
PA

	  	  	  	  	  
	
9.0

	
BIOTECHNOLOGY

	  	  
	  	  	  	  	  
	
9.1

	
ERYTHROID STIMULANTS

	  	  
	  	  	  	  	  
	  	
$$$$$

	
Darbepoetin alpha inj.

	
Aranesp

	
PA, P

	  	
$$$$$

	
Epoetin alpha inj.

	
Procrit

	
PA, P

	  	  	  	  	  
	
10.0

	
MISCELLANEOUS AGENTS

	  	  
	  	  	  	  	  
	  	
$

	
Indomethacin cap.

	
Indocin

	  
	  	
$$$

	
Megestrol acetate tab., susp.

	
Megace

	  
	  	
$$$

	
Indomethacin ER cap.

	
Indocin

	  
	  	  	  	  	  
	
Revised

	
12/26/2012

	  	  

Code  (for all the pages): 

NF - Unlisted

P - Contracted brand name product (rebate)

Bold - Bioequivalent generic available in all presentations

Bold* - Some presentations of the drugs are not available in generic 

ST - Step Therapy, Clinical protocol for its use 

AL - Age Limitation

 

  

  

  

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO 

PREFERRED DRUG LIST 

OBSTETRICS-GYNECOLOGY 

2013-2014

	  	  	  	  	  
	
1.0

	
ANTIINFECTIOUS

	  	  
	  	  	  	  	  
	
1.1

	
CEPHALOSPORINES

	  	  
	  	  	  	  	  
	
1.1.1

	
FIRST GENERATION

	  	  
	  	  	  	  	  
	  	
$

	
Cephalexin cap.

	
Keflex

	  
	  	
$

	
Cephalexin susp.

	
Keflex

	  
	  	  	  	  	  
	
1.1.2

	
SECOND GENERATION

	  	  
	  	  	  	  	  
	  	
$

	
Cefaclor cap.

	
Ceclor

	  
	  	  	  	
Ceclor CD

	
NF

	  	
$$$

	
Cefprozil tab., susp.

	
Cefzil

	  
	  	  	  	  	  
	
1.1.3

	
THIRD GENERATION

	  	  
	  	  	  	  	  
	  	
$$$

	
Cefdinir cap., susp.

	
Omnicef

	  
	  	  	  	  	  
	
1.2

	
MACROLIDS

	  	  
	  	  	  	  	  
	  	
$

	
Erythromycin cap.

	  	  
	  	
$

	
Erythromycin stearate tab.

	
Erythromycin

	  
	  	
$

	
Erythromycin tab.

	  	  
	  	
$

	
Erythromycin EC* tab.

	
E-Mycin

	  
	  	  	  	
EryTab

	  
	  	
$

	
Erythromycin

	  	  
	  	  	
ethylsuccinate* tab susp.

	
E.E.S., Eryped

	  
	  	
$$

	
Azithromycin susp., powder

	
Zithromax

	  
	  	  	
pack for susp. (1 gm)

	
Zithromax

	  
	  	  	  	
Zithromax Tri-Pack

	
NF

	
1.3

	
PENICILLINS

	  	  
	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  
	  	  	  	
Pen-Vee K

	  
	  	
$

	
Amoxicillin* cap., tab.

	
Trimox,

	  
	  	  	
chew tab., susp.

	
Amoxil,

	  
	  	  	  	
Wymox

	  
	  	
$

	
Penicillin G Procaine inj.

	  	  
	  	
$$

	
Penicillin G Benzathine inj.

	
Bicillin LA

	  
	  	
$$$

	
Amoxicillin, Clavulanic

	
Augmentin

	  
	  	  	
acid tab., susp.

	
Augmentin ES

	
NF

	  	  	  	
Augmentin XR

	
NF

	
1.4

	
SULFONAMIDES

	  	  
	  	  	  	  	  
	  	
$

	
Trimethoprim/

	
Bactrim, Bactrim DS

	  
	  	  	
Sulfamethoxazole tab.

	
Septra, Septra DS

	  
	  	  	
susp.

	  	  
	  	  	  	  	  
	
1.5

	
ANTIVIRALS

	  	  
	  	  	  	  	  
	
1.5.1

	
HERPETIC INFECTIONS

	  	  
	 	 	 	 	 
	  	
$

	
Acyclovir tab., cap.

	
Zovirax

	  
	  	
$$

	
Acyclovir susp.

	
Zovirax

	  

 

  

  

  

 

	  	  	  	 	  	  
	
1.5.2

	
HIV-AIDS THERAPY

	 	  	  
	  	  	  	 	  	  
	
1.5.2.1

	
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE

	 	  	  
	  	  	  	 	  	  
	  	
$$$$$

	
Zidovudine* tab., cap.,

	
Retrovir

	 	  
	  	  	
syr., inj.

	 	  	  
	  	  	  	 	  	  
	
1.5.2.2

	
PROTEASE INHIBITORS

	 	  	  
	  	  	  	 	  	  
	  	
Covered through the Prevention and Treatment Centers for Transmissible Diseases (CPTETs)

	  	
(Immunology Clinics)

	 	  	  
	  	  	  	 	  	  
	
1.6

	
ANTITUBERCULOUS

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Isoniazid tab.

	 	  	  
	  	
$$

	
Isoniazid syr.

	 	  	  
	  	
$$$$

	
Ethambutol tab.

	 	
Myambutol

	  
	  	
$$$$

	
Rifampin cap.

	 	
Rifadin

	  
	  	
$$$$

	
Isoniazid/Rifampin cap.

	 	
Rifamate

	  
	  	
$$$$$

	
Ethionamide tab.

	 	
Trecator

	  
	  	
$$$$$!

	
Rifabutin cap.

	 	
Mycobutin

	  
	  	  	  	 	  	  
	
1.7

	
MISCELLANEOUS ANTIINFECTIOUS

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Metronidazole tab.

	 	
Flagyl

	  
	  	  	  	 	
Flagyl ER

	
NF

	  	
$

	
Dapsone tab.

	 	
Dapsone

	  
	  	
$

	
Clindamycin cap.

	 	
Cleocin

	  
	  	  	
(150mg, 300mg)

	 	  	  
	  	
$$

	
Nitrofurantoin

	 	
Macrodantin

	  
	  	  	
macrocystals* cap.

	 	  	  
	  	
$$$

	
Clindamycin cap. (75mg)

	 	
Cleocin

	  
	  	
$$$

	
Pentamidine inh.

	 	
NebuPent

	  
	  	  	  	 	  	  
	
2.0

	
ANTIHYPERTENSIVE THERAPY

	 	  	  
	  	  	  	 	  	  
	
2.1

	
BETA BLOCKERS

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Atenolol tab.

	 	
Tenormin

	  
	  	
$

	
Atenolol/HCTZ

	 	
Tenoretic

	  
	  	
$

	
Metoprolol tartrate tab.

	 	
Lopressor

	  
	  	
$

	
Propranolol tab.

	 	
Inderal

	  
	  	
$

	
Propranolol/HCTZ

	 	
Inderide

	  
	  	
$

	
Labetalol tab.

	 	
Normodyne

	  
	  	
$

	
Metoprolol/HCTZ

	 	
Lopressor HCT

	  
	  	
$$

	
Metoprolol succinate SR*

	 	
Toprol XL

	  
	  	  	
tab.

	 	  	  
	  	
$$

	
Carvedilol tab.

	 	
Coreg

	
ST

	  	  	  	 	  	  
	
2.2

	
CALCIUM CHANNEL ANTAGONISTS

	 	  	  
	  	  	  	 	  	  
	  	
$$$

	
Nifedipine SR tab., CR tab

	Generic only	  
	  	  	  	Adalat CC	
NF

	  	  	  	Procardia XL	
NF

  

  

  

 

	  	  	  	  	  
	
3.3

	
ANTIHYPERTENSIVES WITH CENTRAL ACTION

	  	  
	  	  	  	  	  
	  	
$

	
Methyldopa tab.

	
Aldomet

	  	  	  	  	  
	
3.4

	
VASODILATORS

	  	  
	  	  	  	  	  
	  	
$

	
Hydralazine tab.

	
Apresoline

	  	  	  	  	  
	
3.0

	
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION

	  
	  	  	  	  	  
	  	
$

	
Oxycodone/APAP cap.

	  	  
	  	
$

	
Oxycodone/APAP sol.

	  	  
	  	
$$$

	
Oxycodone/APAP tab.

	  	  
	  	  	  	  	  
	
4.0

	
ANTIVERTIGO AND ANTIEMETICS

	  	  
	  	  	  	  	  
	  	
$

	
Metoclopramide syr., inj.

	  	
Reglan

	  	
$

	
Trimethobenzamide inj.

	  	
Tigan

	  	
$

	
Promethazine syr.

	  	
Phenergan

	  	
$

	
Prochlorperazine tab.

	  	
Compazine

	  	
$

	
Prochlorperazine inj.

	  	
Compazine inj.

	  	
$

	
Metoclopramide tab.

	  	
Reglan

	  	
$

	
Promethazine* tab.

	  	
Phenergan

	  	
$$

	
Trimethobenzamide cap., supp.Tigan

	  	  
	  	
$$

	
Promethazine supp.

	  	
Phenergan

	  	
$$$

	
Prochlorperazine* supp.

	  	
Compazine

	  	  	  	  	  
	
5.0

	
DEMALOTOGIC AGENTS/TOPICAL THERAPY

	  	  
	  	  	  	  	  
	
5.1

	
TOPICAL ANTIMYCOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Nystain oint.

	  	
Mycostatin

	  	
$

	
Ketoconazole cr.,

	  	
Nizoral

	  	  	
shampoo (2%)

	  	  
	  	  	  	  	  
	
5.2

	
TOPICAL ANTIBACTERIALS

	  	  
	  	  	  	  	  
	  	
$

	
Gentamicin cr., oint.

	  	
Garamycin

	  	  	  	  	  
	
6.0

	
GASTROENTEROLOGY

	  	  
	  	  	  	  	  
	
6.1

	H2 ANTAGONISTS	  	  
	  	  	  	  	  
	  	
$

	
Ranitidine tab. (300mg)

	  	
Zantac

	  	
$

	
Cimetidine tab., sol.

	  	
Tagamet

	  	
$$

	
Ranitidine syr.

	  	
Zantac

	  	  	  	  	  
	
6.2

	
MISCELLANEOUS ANTIULCER AGENTS

	  	  
	  	  	  	  	  
	  	
$

	
Sucralfate tab.

	  	
Carafate

	  	
$$$

	
Sucralfate susp.

	
Carafate

	  	  	  	  	  
	
6.3

	MISC. GASTROINTESTINAL AGENTS	  	  
	  	  	  	  	  
	  	
$

	
Hydrocortisone rectal cr.

	
Anusol-HC

	  	  	
(2.5%)

	  	  
	  	
$$

	
Hydrocortisone acetate/

	
Analpram-HC

	  	  	
Pramoxine rectal cr.

	  	  
	  	
$$$

	
Hydrocortisone acetate/

	
Proctofoam HC

	  	  	
Pramoxine rectal foam

	  	  

 

  

  

  

 

	  	  	  	 	  	  
	
7.0

	
ENDOCRINOLOGICAL AGENTS

	 	  	  
	  	  	  	 	  	  
	
7.1

	
DIABETES THERAPY

	 	  	  
	  	  	  	 	  	  
	
7.1.1

	
HYPOGLYCEMIC AGENTS

	 	  	  
	  	  	  	 	  	  
	
7.1.1.1

	
INSULIN

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Human insulin (regular,

	 	
Humulin

	
P

	  	  	
NPH, 70/30, lens)vial

	 	  	  
	  	  	  	 	
Humulin Pen

	
NF

	  	
$$$

	
Insulin lispro vial

	 	
Humalog

	
P

	  	  	  	 	
Humalog Mix

	
NF

	  	  	  	 	
Humalog Pen

	
NF

	  	
$$$

	
Insulin glargine vial

	 	
Lantus

	
P

	  	  	  	 	
Lantus Solostar

	
P

	  	  	  	 	  	  
	
7.1.1.2

	OTHERS 	 	 	 	 
	  	  	  	 	  	  
	  	
$

	
Insulin syringe & needles

	 	
Several

	  
	  	  	  	 	  	  
	
7.2

	
THYROID

	 	  	  
	  	  	  	 	  	  
	
7.2.1

	
THYROID HORMONES

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Levo-thyroxine tab.

	 	
Several

	  
	  	
$

	
Levo-thyroxine tab.

	 	
Synthroid

	
P

	  	
$

	
Levo-thyroxine tab.

	 	
Levoxyl

	
P

	  	  	  	 	  	  
	
7.3

	
CORTICOSTEROIDS

	 	  	  
	  	  	  	 	  	  
	
$

	
Dexmethasone sodium

	 	  	
OB-GYN

	  	
phosphate inj.

	 	  	  
	
$

	
Prednisone tab.

	 	
Deltasone

	  
	
$

	
Dexamethasone tab.

	 	
Decadron

	  
	
$

	
Methylprednisolone* tab.

	 	
Medrol

	  
	
$

	
Prednisolone tab., syrup

	 	
Prelone

	  
	
$

	
Hydrocortisone* tab., sol.

	 	
Cortef

	  
	
$

	
Fludrocortisone acetate tab.

	 	
Florinef

	  
	
$

	
Dexamethasone elixir,

	 	
Decadron

	  
	  	
syrup, sol.

	 	  	  
	
$$

	
Betamethasone acetate &

	 	
Celestone

	
OB-GYN

	  	
sodium phosphate inj.

	 	
Soluspan

	  
	  	  	  	 	  	  
	  	  	  	 	  	  
	
8.0

	
OBSTETRICS AND GYNECOLOGY

	 	  	  
	  	  	  	 	  	  
	
8.1

	
PRENATAL VITAMINS

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Prenatal vitamins with

	  Generic only	
OB-GYN

	  	  	
iron and folic acid

	 	  	  
	  	  	  	 	  	  
	
8.2

	
BIOLOGICAL AGENTS

	 	  	  
	  	  	  	 	  	  
	  	
Rho Gam- Second dose (post-partum)

	 	  	  
	  	
(The Department of Health covers the first dose at selected pharmacies - Mothers and Children Program.)

 

  

  

  

 

	  	  	  	 	  	  
	
8.3

	
ESTROGEN AND PROGESTIN

	 	  	  
	  	  	  	 	  	  
	
8.3.1

	
ESTROGEN

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Estradiol tab.

	 	  	  
	  	
$

	
Estropipate tab.

	 	  	  
	  	
$$

	
Conjugated estrogens tab.

	 	
Premarin

	
P

	  	  	
(0.3mg, 0.625mg, 0.9mg,

	 	  	  
	  	  	
1.25mg, 2.5mg)

	 	  	  
	  	  	  	 	  	  
	
8.3.2

	
ESTROGENS IN COMBINATION

	 	  	  
	  	  	  	 	  	  
	  	
$$

	
Conjugated estrogen/

	 	
PremPro

	
P

	  	  	
Medroxyprogesterone tab.

	 	
PremPro Low Dose

	
NF

	  	  	
(O.625/2.5mg; 0.625/5mg)

	 	  	  
	  	
$$$

	
Estradiol/Norethindrone

	 	
Activella

	  
	  	  	
acetate tab.

	 	  	  
	  	  	  	 	  	  
	
8.3.3

	
PROGESTERONE

	 	  	  
	  	  	  	 	  	  
	  	
$

	
Medroxyprogesterone

	 	
Provera

	  
	  	  	
acetate tab.

	 	  	  
	  	  	  	 	  	  
	
8.3.4

	
BIRTH CONTROL PILLS

	 	  	  
	  	  	  	 	  	  
	  	
Available through the Department of Health

	 	  	
PA-AUB

	  	  	  	 	  	  
	
8.4

	
TOPICAL AGENTS

	 	  	  
	  	  	  	 	  	  
	
8.4.1

	
VAGINAL ESTROGENS

	 	  	  
	  	  	  	 	  	  
	  	
$$

	
Conjugated estrogen vaginal cr.

	 	
Premarin

	
P

	  	  	  	 	
Vaginal

	  
	  	
$$

	
Estradiol vaginal tab.

	 	
Vagifem

	  
	  	  	  	 	  	  
	
8.4.2

	
VAGINAL ANTIINFECTIVES

	 	  	  
	  	  	  	 	  	  
	  	
$$

	
Terconazole* vaginal cr., supp.

	 	
Terazol - 3,

	  
	  	  	  	 	
Terazol - 7

	  
	  	
$$$

	
Clindamycin phosphate

	 	
Cleocin

	  
	  	  	
vaginal* cr., supp.

	 	  	  
	  	
$$$

	
Metronidazole vaginal gel

	 	
Vandazole

	  
	  	  	
(0.75%)

	 	  	  
	
8.5

	
MISCELLANEOUS AGENTS

	 	  	  
	  	  	  	 	  	  
	
8.5.1

	
OSTEOPOROSIS

	 	  	  
	  	  	  	 	  	  
	  	
$$

	
Alendronate tab. (includes

	 	
Fosamax

	  
	  	  	
weekly dosage)

	 	  	  
	  	
$$$

	
Risedronate tab.

	 	
Actonel

	
P

	  	  	  	 	  	  
	
9.0

	
NUTRIENTS AND VITAMINS

	 	  	  
	  	  	  	 	  	  
	
9.1

	
NUTRIENTS

	 	  	  
	  	  	  	 	  	  
	  	
$$

	
Iron dextran inj.

	 	
Infed

	  

 

  

  

  

 

	  	  	  	  	  	  
	
1.1

	
VITAMINS

	  	  	  
	 	 	 	 	 
	  	
$

	
Ferrous sulfate tab. (325 mg)

	  	
Several

	
OTC

	  	
$

	
Folic acid tab. (1 mg)

	  	  	  
	  	
$

	
Cyanocobalamin inj.

	  	
Vit.B-12 inj.

	  
	  	
$

	
Leucovorin inj.

	  	  	  
	  	
$$$$$

	
Leucovorin tab.

	  	  	  
	  	  	  	  	  	  
	
10.0

	
ANTICLOTTING

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Heparin* inj.

	  	  	  
	  	  	  	  	  	  
	
11.0

	
RESPIRATORY AGENTS

	  	  	  
	  	  	  	  	  	  
	
11.1

	
LOW SEDATION ANTIHISTAMINES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Diphenhydramine cap. (50 mg)

	  	
Benadryl

	
OTC are NF

	  	
$

	
Hydroxyzine pamoate cap.

	  	
Vistaril

	  
	  	
$$

	
Hydroxyzine* HCI tab., syr.

	  	
Atarax

	  
	  	  	  	  	  	  
	
11.2

	
NON-SEDATING ANTIHISTAMINES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Loratadine OTC tab., syr.

	  	
Claritin

	
OTC

	  	  	  	  	  	  
	
11.3

	
ASTHMA AGENTS

	  	  	  
	  	  	  	  	  	  
	11.3.1 	
ORAL BETA AGONISTS

	 	 	 
	  	  	  	  	  	  
	  	
$$

	
Terbutaline tab.

	  	
Brethine

	  
	  	  	  	  	  
	11.3.2	
INHALED BETA AGONISTS

	 	 	 
	  	  	  	  	  	  
	  	
$

	
Albuterol inh., inh. sol.

	  	
Generic only

	  
	  	
$$

	
Albuterol HFA inh.

	
P

	
roAir HFA

	
P

	  	  	  	  	
Ventolin HFA

	
P

	  	  	  	  	
Proventil

	
NF

	  	
$$

	
Levalbuterol inh.

	  	
Xopenex HFA

	
P

	  	
$$$

	
Formoterol inh.

	  	
Foradil

	
P

	  	
$$$$

	
Salmeterol inh., diskus

	  	
Serevent

	  
	  	  	  	  	  	  
	
11.3.3

	
ANTICHOLINERGICS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ipratropium Br inh. sol.

	  	
Atrovent

	  
	  	
$$$

	
Ipratropium Br Inh.

	  	
Atrovent HFA

	  
	  	
$$$

	
Tiotropium inh.

	  	
Spiriva

	
PA

	  	  	  	  	  	  
	11.3.4	
INHALED CORTICOSTEROIDS

	 	 	 
	  	  	  	  	  	  
	  	
$$

	
Beclomethasone inh.

	  	
Qvar

	
P

	  	
$$$

	
Fluticasone inh., powder

	  	
Flovent HFA

	
P

	  	  	  	  	
Flovent Diskus

	
P

	  	
$$$$

	
Budesonide inh. Susp.

	  	
Pulmicort

	  
	  	  	
(respules)

	  	  	  
	  	  	  	  	  	  
	11.3.5	
AGENTS IN COMBINATION

	 	 	 
	  	  	  	  	  	  
	  	
$$$$

	
Fluticasone/Salmeterol

	  	
Advair Diskus

	
ST, P

	  	  	
powder

	  	
Advair HFA

	
ST, P

 

  

  

  

 

	 	 	 	 	 	 
	12.0 	
CANCER

	 	 	 	 
	 	 	 	 	 	 
	
12.1 

	PROGESTINS	  	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Megestrol acetate tab., susp.

	  	
Megace

	  
	  	
$$$$

	
Medroxyprogesterone acetate

	  	
Depo-Provera

	  
	  	  	
inj. (400 mg)

	  	  	  

 

	
Revised 12/26/2012

	  
	
Code (for all the pages):

	
NF - Unlisted

	
P - Contracted brand name product

	
Bold - Bioequivalent generic available in all the presentations

	
Bold* -Some presentations of the drugs are not available in generic

	
ST - Step Therapy, Clinical protocol for use

	
OB-GYN - Only in OB-GYN list

 

  

  

  

 

HEALTH PLAN OF THE COMMONWEALTH OFPUERTO  RICO 

PREFERRED DRUG  LIST 

ONCOLOGY 

2011-2012

	  	  	  	  	  	  
	
1.0

	
ANTIINFECTIOUS

	  	  	  
	  	  	  	  	  
	
1.1

	
MACROLIDS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
EEE/Sulfisoxazole susp.

	
Pediazole

	  	  
	  	
$

	
Erythromycin cap.

	  	  	  
	  	
$

	
Erythromycin stearate tab.

	
Erythrocin

	  	  
	  	
$

	
Erythromycin tab.

	  	  	  
	  	
$

	
Erythromycin EC* tab.

	
E-Mycin,

	  	  
	  	  	  	
EryTab

	  	  
	  	
$

	
Erythromycin

	  	  	  
	  	  	
ethylsuccinate* tab., susp.

	
E.E.S., Eryped

	  	  
	  	
$$

	
Azithromycin tab., susp.

	
Zithromax

	  	  
	  	  	
powder pack for susp. (1 gm)

	
Zithromax Tri-Pack

	  	
NF

	  	
$$

	
Clarithromycin tab., susp.

	
Biaxin

	  	  
	  	  	  	
Biaxin XL

	  	
NF

	
1.2

	
PENICILLINS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  	  
	  	  	  	
Pen-Vee K

	  	  
	  	
$

	
Amoxicillin* cap., tab.,

	
Trimox,

	  	  
	  	  	
chew tab., susp.

	
Amoxil,

	  	  
	  	  	  	
Wymox

	  	  
	  	
$

	
Penicillin G Procaine inj.

	  	  	  
	  	
$$

	
Penicillin G Benzathine inj.

	
Bicillin LA

	  	  
	  	
$$$

	
Amoxicillin/Clavulanic acid

	
Augmentin

	  	  
	  	  	
tab., susp.

	
Augmentin ES

	
NF

	  
	  	  	  	
Augmentin XR

	
NF

	  
	
1.3

	
SULFONAMIDES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Trimethoprim /

	
Bactrim, Bactrim DS,

	  	  
	  	  	
Sulfamethoxazole tab.,

	
Septra, Septra DS

	  	  
	  	  	
susp.

	  	  	  
	  	
$$$$

	
Sulfadiazine tab.

	  	  	  
	  	  	  	  	  	  
	
1.4

	
QUINOLONES

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Ciprofloxacin tab. (250 mg.,

	
Cipro

	  	  
	  	  	
500 mg., 750 mg.)

	  	  	  
	  	
$

	
Levofloxacin tab.

	
Levaquin

	  	  
	  	
$$$

	
Moxifloxacin

	
Avelox   P

	  	  
	  	
$$$$

	
Ciprofloxacin susp.

	
Cipro

	  	  
	  	  	  	  	  	  
	
1.5

	
ANTIVIRALS

	  	  	  
	  	  	  	  	  	  
	
1.5.1

	
HERPETIC INFECTIONS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Acyclovir tab., cap.

	
Zovirax

	  	  
	  	
$$

	
Acyclovir susp.

	
Zovirax

	  	  

 

  

  

  

 

	  	  	  	  	  
	
1.6

	
ANTIMYCOTICS

	  	  
	  	  	  	  
	  	
$

	
Terbinafine tab.

	
Lamisil

	
LC=84 tab.

	  	
$

	
Ketoconazole tab.

	
Nizoral

	  
	  	
$

	
Nystatin susp.

	
Mycostatin, Nystat

	  
	  	
$

	
Fluconazole tab., susp.

	
Diflucan

	  
	  	
$

	
Griseofulvin microsize tab.

	
Grifulvin V

	  
	  	
$$

	
Griseofulvin

	  	  
	  	  	
ultramicrosize tab.*

	
Gris-PEG

	  
	  	  	  	  	  
	
1.7

	
MISCELLANEOUS ANTIINFECTIOUS

	  	  
	  	  	  	  	  
	  	
$

	
Dapsone tab.

	
Dapsone

	  
	  	  	  	  	  
	
2.0

	
ANALGESICS, NARCOTICS AND AGENTS IN COMBINATION

	  
	  	  	  	  	  
	  	
$

	
Meperidine inj.

	
Demerol

	  
	  	
$

	
APAP/Codeine* tab., cap.,

	  	  
	  	  	
elixir, sol., susp.

	  	  
	  	
$

	
APAP/Hydrocodone tab.,

	  	  
	  	  	
cap., sol.

	  	  
	  	
$

	
Morphine sulfate tab., sol.

	  	  
	  	
$$

	
Codeine sulfate tab.

	  	  
	  	
$$

	
Oxycodone tab., cap., sol.

	
Roxicodone

	  
	  	
$$

	
Oxycodone/APAP* tab.

	  	  
	  	  	
cap., sol.

	  	  
	  	
$$$$

	
Morphine sulfate SR tab.,

	  	  
	  	  	
supp.

	  	  
	  	
$$$$

	
Fentanyl TDS

	
Duragesic

	  
	  	  	  	  	  
	
3.0

	
ANTICONVULSIVES

	  	  
	  	  	  	  	  
	  	
$

	
Phenytoin* chew tab,

	
Dilantin

	  
	  	  	
cap., susp.

	  	  
	  	
$$

	
Gabapentin cap., tab.

	
Neurontin

	  
	  	
$$

	
Gabapentin sol.

	
Neurontin

	  
	  	  	  	  	  
	
4.0

	
ANTIVERTIGO AND ANTIEMETICS

	  	  
	  	  	  	  	  
	  	
$

	
Promethazine inj.

	
Phenergan

	  
	  	
$

	
Metoclopramide syr., inj.

	
Reglan

	  
	  	
$

	
Trimethobenzamide inj.

	
Tigan

	  
	  	
$

	
Promethazine syr.

	
Phenergan

	  
	  	
$

	
Prochlorperazine tab.

	
Compazine

	  
	  	
$

	
Prochlorperazine inj.

	
Compazine inj.

	  
	  	
$

	
Metoclopramide

	
Reglan

	  
	  	
$

	
Promethazine* tab.

	
Phenergan

	  
	  	
$$

	
Ondansetron tab., ODT tab.

	
Zofran

	  
	  	
$$

	
Trimethobenzamide cap., supp.

	
Tigan

	  
	  	
$$

	
Promethazine supp.

	
Phenergan

	  
	  	
$$$

	
Prochlorperazine* supp.

	
Compazine

	  
	  	  	  	  	  
	
5.0

	
DERMATOLOGIC AGENTS/TOPICAL THERAPY

	  
	  	  	  	  	  
	
5.1

	
TOPICAL ANTIMYCOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Ketoconazole cr.,

	
Nizoral

	  
	  	  	
shampoo (2%)

	  	  

 

  

  

  

 

	  	  	  	  	  	  	  
	
5.2

	
MISCELLANEOUS TOPICAL AGENTS

	  	  
	  	  	  	  	  	  	  
	  	
$$$

	
Fluorouracil sol. (2%, 5%)

	
Efudex

	  
	  	
$$$$

	
Fluorouracil cr. (5%)

	  	
Efudex

	  
	  	  	  	  	  	  	  
	
6.0

	
AGENTS FOR THE MOUTH AND THROAT

	  	  
	  	  	  	  	  	  	  
	  	
$

	
Lidocaine viscous sol.

	  	
Xylocaine

	  
	  	
$$$

	
Clotrimazole troche

	  	
Mycelex

	  
	  	  	  	  	  	  	  
	
7.0

	
GASTROENTEROLOGY

	  	  	  
	  	  	  	  	  	  	  
	
7.1

	
AGENTS FOR ULCERS

	  	  	  	  
	  	  	  	  	  	  	  
	
7.1.1

	
H2 ANTAGONISTS

	  	  	  	  
	  	  	  	  	  	  	  
	  	
$

	
Ranitidine tab. (300 mg)

	  	
Zantac

	  
	  	
$

	
Cimetidine tab., sol.

	  	
Tagamet

	  
	  	
$$

	
Ranitidine syr.

	  	  	
Zantac

	  
	  	  	  	  	  	  	  
	
7.1.2

	PROTO PUMP INHIBITOR	  	  	  
	  	  	  	  	  	  	  
	  	
$$

	
Omeprazole cap.

	  	
Prilosec

	
LC=8 weeks

	  	  	  	  	  	  	  
	7.1.3	
MISCELLANEOUS AGENTS

	 	 	 	 
	  	  	  	  	  	  	  
	  	
$

	
Sucralfate tab.

	  	  	
Carafate

	  
	  	
$$$

	
Sucralfate susp.

	  	  	
Carafate

	  
	  	
$$$

	
Misoprostol tab.

	  	
Cytotec

	  
	  	  	  	  	  	  	  
	
2.2

	
ANTIDIARRHEA

	  	  	  	  
	  	  	  	  	  	  	  
	  	
$

	
Diphenoxylate/Atropine

	  	
Lomotil

	  
	  	  	
tab., liq.

	  	  	  	  
	  	  	  	  	  	  	  
	
8.0

	
ENDOCRINOLOGIC AGENTS

	  	  	  
	  	  	  	  	  	  	  
	
8.1

	
CORTICOSTEROIDS

	  	  	  	  
	  	  	  	  	  	  	  
	  	
$

	
Dexamethasone elixir,

	  	
Decadron

	  
	  	  	
syrup, sol.

	  	  	  	  
	  	
$

	
Prednisone tab.

	  	  	
Deltasone

	  
	  	
$

	
Dexamethasone tab.

	  	
Decadron

	  
	  	
$

	
Methylprednisolone* tab.

	  	
Medrol

	  
	  	
$

	
Prednisolone tab., syrup

	  	
Prelone

	  
	  	
$

	
Hydrocortisone* tab., sol.

	  	
Cortef

	  
	  	
$

	
Prednisolone sodium

	  	
PediaPred

	  
	  	  	
phosphate liq.

	  	  	  	  
	  	
$

	
Fludrocortisone acetate tab.

	
Florinef

	  
	  	  	  	  	  	  	  
	
9.0

	
MUSCULOSKELETAL SYSTEM AND RHEUMATOLOGY

	  	  	  	  	  	  	  
	
9.1

	
NON-STEROIDAL ANTIINFLAMMATORIES

	  	  
	  	  	  	  	  	  	  
	  	
$

	
Ibuprofen tab. (≥400 mg)

	
 

	  	
Motrin (≥400mg)

	
OTC are NF

	  	
$

	
Naproxen tab.

	  	  	
Naprosyn

	  
	  	
$

	
Indomethacin cap.

	 	  	
Indocin

	  
	  	
$

	
Sulindac tab.

	 	  	
Clinoril

	  

 

  

  

  

 

	  	  	  	  	  
	  	
$$

	
Naproxen EC tab.

	
EC-Naprosyn

	  
	  	
$$

	
Naproxen sodium tab.

	
Anaprox, Anaprox DS.

	  
	  	  	  	
Naprelan

	
NF

	  	
$$

	
Nabumetone tab.

	
Relafen

	  
	  	
$$

	
Indomethacin ER cap.

	
Indocin SR

	  
	  	
$$

	
Celecoxib cap.

	
Celebrex

	
ST, P

	  	  	  	  	  
	
10.0

	
NUTRIENTS AND VITAMINS

	  	  
	  	  	  	  	  
	
10.1

	
NUTRIENTS

	  	  
	  	  	  	  	  
	  	
$$

	
Iron dextran inj.

	
Infed

	  
	  	  	  	  	  
	
10.2

	
VITAMINS

	  	  
	  	  	  	  	  
	  	
$

	
Ferrous sulfate tab. (325 mg)

	
Several

	
OTC

	  	
$

	
Folic acid tab. (1 mg)

	  	  
	  	
$

	
Cyanocobalamin inj.

	
Vit. B-12 inj.

	  
	  	
$

	
Leucovorin inj.

	  	  
	  	
$

	
Ergocalciferol

	
Calciferol

	  
	  	
$$$$

	
Leucovorin tab.

	  	  
	  	  	  	  	  
	
11.0

	
ANTIHISTAMINES

	  	  
	  	  	  	  	  
	  	
$ Diphenydramine cap. (50mg)

	
Benadryl

	
OTC are NF

	  	  	  	  	  
	
12.0

	
CANCER

	  	  
	  	  	  	  	  
	
There shall be covered under the pharmacy coverage only the oral presentations of the cancer products pursuant to how they are detailed as follows. Other presentations shall be covered via the ambulatory chemotherapy clinics.

	  	  	  	  	  
	
12.1

	
ANTIMETABOLITES

	  	  
	  	  	  	  	  
	  	
$$

	
Methotrexate tab.

	  	  
	  	
$$$

	
Mercaptopurine tab.

	
Purinethol

	  
	  	
$$$

	
Thioguanine tab.

	  	  
	  	
$$$$$!

	
Capecitabine tab.

	
Xeloda

	
PA

	  	  	  	  	  
	
12.2

	
Alkalating Agents

	  	  
	  	  	  	  	  
	  	
$$

	
Lomustine cap.

	
CEENU

	  
	  	
$$$

	
Busulfan tab.

	
Myleran

	  
	  	
$$$$$

	
Melphalan tab.

	
Alkeran

	  
	  	
$$$$$!

	
Cyclophosphamide tab.

	
Cytoxan

	  
	  	
$$$$$!

	
Chlorambucil tab.

	
Leukeran

	  
	 	
$$$$$!! 

	Temozolomide cap.	
Temodar

	
PA

	  	
$$$$$!!

	
Procarbazine cap.

	
Matulane

	  
	  	  	  	  	  
	
12.3

	
PROGESTINS, ANDROGENS, ANTIANDROGENS

	  
	  	  	  	  	  
	
12.3.1

	
PROGESTINS

	  	  
	  	  	  	  	  
	  	
$$$

	
Megestrol acetate tab., susp.

	
Megace

	  
	  	
$$$$

	
Medroxyprogesterone acetate

	
Depo-Provera

	
PA

	  	  	
inj. (400 mg)

	  	  

 

  

  

  

 

	  	  	  	  	  	  
	12.3.3	
ANTIANDROGENS

	 	 	 
	  	  	  	  	  	  
	  	
$$$$

	
Flutamide cap.

	
Eulexin

	
PA

	  
	  	
$$$$$!

	
Bicalutamide tab.

	
Casodex

	
PA

	  
	  	  	  	  	  	  
	
12.4

	
CANCER OF THE MAMMA

	  	  	  
	  	  	  	  	  	  
	
12.4.1

	
ANTIESTROGENS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Tamoxifen tab.

	
Nolvadex

	  	  
	  	  	  	  	  	  
	
12.4.2

	
AROMATASE INHIBITORS

	  	  	  
	  	  	  	  	  	  
	  	
$

	
Anastrozole tab.

	
Arimidex

	  	  
	  	
$$$

	
Exemestane tab.

	
Aromasin

	
P

	  
	  	
$$$

	
Letrozole tab.

	
Femara

	  	
P

	
12.4.3

	
HORMONES

	  	  	  
	  	  	  	  	  	  
	  	
$$$$$!

	
Estramustine cap.

	
Emcyt

	  	  
	  	  	  	  	  	  
	
12.5

	
MISCELLANEOUS CANCER AGENTS

	  	  	  
	  	  	  	  	  	  
	  	
$$$

	
Hydroxyurea cap.

	
Hydrea

	  	  
	  	
$$$$

	
Leuprolide inj.

	
Eligard

	
PA, P

	  
	  	  	
(all the presentations)

	  	  	  
	  	
$$$$$

	
Leuprolide inj.

	
Lupron

	
PA, P

	  
	  	  	
(all the presentations)

	  	  	  
	  	
$$$$$!

	
Etoposide cap.

	
Vepesid

	  	  
	  	
$$$$$!

	
Dasatinib tab.

	
Sprycel

	
PA, P

	  
	  	
$$$$$!

	
Sunitinib cap.

	
Sutent

	
PA, P

	  
	  	
$$$$$!

	
Sorafenib tab.

	
Nexavar

	
PA, P

	  
	  	
$$$$$!

	
Nilotinib

	
Tasigna

	
PA, P

	  
	  	
$$$$$!

	
Everolimus tab.

	
Afinitor

	
PA, P

	  
	  	
$$$$$!

	
Goserelin implant

	
Zoladex

	
PA

	  
	 	
$$$$$!!

	Mitotane tab.	
Lysodren

	 	 
	 	
$$$$$!!

	Imatinib tab., cap.	
Gleevec

	
PA

	 
	  	  	  	  	  	  
	
12.6

	
IMMUNOSUPPRESSORS

	  	  	  
	  	  	  	  	  	  
	  	
$$$$

	
Azathioprine tab.

	
Imuran

	  	  
	  	
$$$$

	
Cyclosporine modified cap., sol.

	
Neoral

	
PA, P

	  
	  	
$$$$

	
Cyclosporine modified

	
Generic only

	
PA

	  
	  	  	
cap., sol.

	
Gengraf

	
NF

	  
	  	
$$$$$

	
Cyclosporine* cap., sol.

	
Sandimmune

	
PA

	  
	  	
$$$$$

	
Cyclosporine cap., sol.

	
Sandimmune

	
PA, P

	  
	  	
$$$$$!

	
Sirolimus tab., sol.

	
Rapamune

	
PA

	  
	  	
$$$$$

	
Mycophenolate sodium tab.

	
Myfortic

	
PA, P

	  
	  	
$$$$$!

	
Mycophenolate mofetil tab.,

	
CellCept

	
PA

	  
	  	  	
cap., liq.

	  	  	  
	  	
$$$$$!

	
Tacrolimus cap.

	
Prograf

	
PA

	  
	  	  	  	  	  	  
	
13.0

	
BIOTECHNOLOGY

	  	  	  
	  	  	  	  	  	  
	
13.1

	
ERYTHROID STIMULANTS

	  	  	  
	  	  	  	  	  	  
	  	
$$$$$

	
Darbepoetin alpha inj.

	
Aranesp

	
PA, P

	  
	  	
$$$$$

	
Epoetin alpha inj.

	
Procrit

	
PA, P

	  
	  	  	  	  	  	  
	
13.2

	
MYELOID STIMULANTS

	  	  	  
	  	  	  	  	  	  
	  	
$$$$$!!

	
Sargramostim inj.

	
Leukine

	
PA, P

	  

 

  

  

  

 

	  	  	  	  	  
	  	
$$$$$!!

	
Filgrastim inj.

	
Neupogen

	
PA, P

	  	
$$$$$!!

	
Pegfilgrastim inj.

	
Neulasta

	
PA, P

	  	  	  	  	  
	
13.3

	
INTERFERONS

	  	  
	  	  	  	  	  
	  	
$$$$$!!

	
Interferon alpha-2B inj.

	
Intron A

	
PA

	  	
$$$$$!!

	
Interferon Gamma-1B inj.

	
Actimmune

	
PA

 

Revised    2/26/2012

 

Code (for all the pages): 

NF - Unlisted 

PA - Requires preauthorization

P - Contracted brand name product (rebate)

Bold - Bioequivalent generic available in all the presentations 

Bold* - Some presentations of the drugs are not available in generic 

LC - Limit in the amount to be dispatched 

ST- Step Therapy,Clinical protocol for use

 

  

  

  

 

HIV-AIDS & HEPATITIS

 

HEALTH PLAN OF THE COMMONWEALTH OF PUERTO RICO 

PREFERRED DRUG LIST 

HIV-AIDS & HEPATITIS 

2011-2012

	  	  	  	  	  
	
1.0

	
ANTIINFECTIOUS

	  	  
	  	  	  	  	  
	
1.1.1

	
MACROLIDS

	  	  
	  	  	  	  	  
	  	
$

	
EES/Sulfisoxazole susp.

	
Pediazole

	  
	  	
$

	
Erythromycin cap.

	  	  
	  	
$

	
Erythromycin stearate tab.

	
Erythrocin

	  
	  	
$

	
Erythromycin tab.

	  	  
	  	
$

	
Erythromycin EC* tab.

	
E-Mycin,

	  
	  	  	  	
EryTab

	  
	  	
$

	
Erythromycin ethylsuccinate*

	
E.ES., Eryped

	  
	  	  	
tab., susp.

	  	  
	  	
$$

	
Azithromycin tab., susp.,

	
Zithromax

	  
	  	  	
powder pack for susp. (1gm)

	
Zithromax Tn-Pack

	
NF

	  	
$$$

	
Clarithromycin* tab., susp.

	
Biaxin

	  
	  	  	  	
Biaxin XL

	
NF

	
1.2

	
PENICILLINS

	  	  
	  	  	  	  	  
	  	
$

	
Ampicillin cap., susp.

	
Principen

	  
	  	
$

	
Penicillin VK tab., sol.

	
Veetids,

	  
	  	  	  	
Pen-Vee K

	  
	  	
$

	
Amoxicillin* cap., tab.,

	
Trimox,

	  
	  	  	
chew tab., susp.

	
Amoxil,

	  
	  	  	  	
Wymox

	  
	  	
$

	
Penicillin G Procaine inj.

	  	  
	  	
$$

	
Penicillin G Benzathine inj.

	
Bicillin

	
LA

	  	
$$$

	
Amoxicillin/Clavulanic acid

	
Augmentin

	  
	  	  	
tab., susp.

	
Augmentin ES

	
NF

	  	  	  	
Augmentin XR

	
NF

	  	  	  	  	  
	
1.3

	
SULFONAMIDES

	  	  
	  	  	  	  	  
	  	
$

	
Trimethoprim I

	
Bactrim, Bactrim DS,

	  
	  	  	
Sulfamethoxazole tab.,

	
Septra, Septra DS

	  
	  	  	
susp.

	  	  
	  	
$$$$

	
Sulfadiazine tab.

	  	  
	  	  	  	  	  
	
1.4

	
TETRACYCLINES

	  	  
	  	  	  	  	  
	  	
$

	
Doxycycline hyclate tab., cap.

	
Vibratab,

	  
	  	  	  	
Vibramycin

	  
	  	
$

	
Tetracycline cap.

	
Achromycin

	  
	  	
$

	
Minocycline cap.

	
Minocin

	  
	  	
$$$

	
Doxycycline syr., susp.

	
Vibramycin

	  
	  	
$$$$$

	
Demeclocycline tab.

	
Declomycin

	  
	  	  	  	  	  
	
1.5

	
QUINOLONES

	  	  
	  	  	  	  	  
	  	
$

	
Levofloxacin tab.

	
Levaquin

	  

 

  

  

  

 

	  	  	  	  	  
	  	
$

	
Moxifloxacin tab.

	
Avelox

	
P

	  	
$$$

	
Ciprofloxacin susp.

	
Cipro

	  
	  	  	  	  	  
	
1.6 

	ANTIVIRALS	  	  
	 	 	 	 	 
	
1.6.1 

	HERPETICS INFECTIONS	  	  
	 	 	 	 
	  	
$

	
Acyclovir tab., cap.

	
Zovirax

	  
	  	
$$

	
Acyclovir susp.

	
Zovirax

	  
	  	  	  	  	  
	
1.6.2

	
HIV-AIDS & HEPATITIS THERAPY

	  	  
	  	  	  	  	  
	
1.6.2.1

	
ANALOGOUS NON-NUCLEOSIDES OF TRANSCRIPTASE

	  
	  	  	  	  	  
	  	
$

	
Nevirapine tab., susp.

	
Viramune

	  
	  	
$$$$$

	
Delavirdirie tab.

	
Rescniptor

	  
	  	
$$$$$!

	
Efavirenz tab., cap.

	
Sustiva

	
P

	  	
$$$$$!

	
Nevirapine tab., susp.

	
Viramune

	  
	  	  	  	  	  
	
1.6.2.2

	
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE

	  
	  	  	  	  	  
	  	
$$

	
Stavudine cap., sol.

	
Zenit

	  
	  	
$$$$$

	
Zidovudine* tab.,

	
Retrovir

	  
	  	  	
cap., syr., inj.

	  	  
	  	
$$$$$!

	
Abacavir tab., sol.

	
Ziagen

	  
	  	
$$$$$

	
Didanosine delayed release

	
Videx EC

	  
	  	  	
cap.*

	  	  
	  	
$$$$$

	
Didanosine sol.

	
Videx

	  
	  	
$$$$$

	
Lamivudine tab., sol.

	
Epivir

	  
	  	  	  	  	  
	
1.6.2.3

	
ANALOGOUS NUCLEOSIDES OF TRANSCRIPTASE IN COMBINATION

	  	  	  	  	  
	  	
$$

	
Lamivudine / Zidovudine tab.

	
Combivir

	  
	  	
$$$$$!!

	
Abacavir/Lamivudine/

	
Trizivir

	
P

	  	  	
Zidovudine tab.

	  	  
	  	  	  	  	  
	
1.6.2.4

	
PROTEASE INHIBITORS

	  	  
	  	  	  	  	  
	  	
Covered through the Prevention and Treatment Centers for Transmissible Diseases

	  	
(CPTETs) (Immunology Clinics)

	  	  
	  	  	  	  	  
	
1.6.2.5

	
ORAL AGENTS FOR HEPATITIS B

	  	  
	  	  	  	  	  
	  	
$$$$$!!

	
Lamivudine tab., sol.

	
Epivir HBV

	
PA

	  	  	  	  	  
	
1.6.3

	
MISCELLANEOUS ANTIVIRALS

	  	  
	  	  	  	  	  
	  	
$$$$$!!

	
Ganciclovir cap.

	
Cytovene

	  
	  	
$$$$$!!

	
Valganciclovir tab.

	
Valcyte

	  
	
1.7

	
ANTIMYCOTICS

	  	  
	  	  	  	  	  
	  	
$

	
Terbinafine tab.

	
Lamisil

	
LC= 84 tab.

	  	
$

	
Ketoconazole tab.

	
Nizoral

	  
	  	
$

	
Nystatin susp.

	
Mycostatin, Nystat

	  
	  	
$

	
Fluconazole tab., susp.

	
Diflucan

	  

 

  

  

  

 

	  	  	  	  	  
	  	
$

	
Griseofulvin microsize tab.

	
Grifulvin V

	  
	  	
$$$

	
Griseofulvin ultramicrosize* tab.

	
Gnis-PEG

	  
	  	
$$$

	
Clotrimazole troches

	
Mycelex

	  
	  	
$$$

	
Itraconazole* cap., sol.

	
Sporanox

	
HIV-AIDS

	  	
$$$$$

	
Flucytosine cap.

	
Ancobon

	  
	  	  	  	  	  
	1.8	ANTITUBERCULOUS	 	 
	  	  	  	  	  
	  	
$

	
Isoniazid tab.

	  	  
	  	
$$

	
Isoniazid syr.

	  	  
	  	
$$$$

	
Ethambutol tab.

	
Myambutol

	  
	  	
$$$$

	
Pyrazinamide tab.

	  	  
	  	
$$$$

	
Rifampin cap.

	
Rifadin

	  
	  	
$$$$

	
Isoniazid/Rifampin cap.

	
Rifamate

	  
	  	
$$$$$

	
Ethionamide tab.

	
Trecator

	  
	  	
$$$$$!

	
Rifabutin cap.

	
Mycobutin

	  
	  	
$$$$$!

	
Cycloserine cap.

	
Seromycin

	  
	  	
$$$$$!

	
Capreomycin in

	
Capastat

	  
	  	  	  	  	  
	1.9	ANTIPA RASITES	 	 
	  	  	  	  	  
	  	
$$$

	
Albendazole tab.

	
Albenza

	  
	  	  	  	  	  
	1.10	ANTIMALARIA	 	 
	  	  	  	  	  
	  	
$

	
Pynimethamine tab.

	
Darapnim

	  
	  	
$

	
Primaquine phosphate tab.

	
Primaquine

	  
	  	  	  	  	  
	1.11	MISCELLANEOUS ANTIINFECTIOUS	 	 
	  	  	  	  	  
	  	
$

	
Dapsone tab.

	
Dapsone

	  
	  	
$

	
Clindamycin cap.

	
Cleocin

	  
	  	  	
(150mg, 300mg)

	  	  
	  	
$$$

	
Clindamycin cap. (75mg), SUSP.

	
Cleocin

	  
	  	
$$$

	
Pentamidine inh.

	
NebuPent

	  
	  	
$$$$

	
Streptomycin inj.

	  	  
	  	
$$$$$!

	
Atovaquone susp.

	
Mepron

	  
	  	  	  	  	  
	
2.0

	
AGENTS FOR THE MOUTH AND THROAT

	  	  
	  	  	  	  	  
	  	
$

	
Lidocaine viscous sol.

	
Xylocaine

	  
	  	
$$$

	
Clotrimazole troche

	
Mycelex

	  
	  	  	  	  	  
	
3.0

	
ANTIDIARRHEA

	  	  
	  	  	  	  	  
	  	
$

	
Diphenoxylatel

	
Lomotil

	  
	  	  	
Atropine tab., Iiq.

	  	  
	  	  	  	  	  
	
4.0

	
ENDOCRINOLOGIC AGENTS

	  	  
	  	  	  	  	  
	
4.1

	
CORTICOSTEROIDS

	  	  
	  	  	  	  	  
	  	
$

	
Prednisone tab.

	
Deltasone

	  
	  	
$

	
Dexamethasone tab.

	
Decadron

	  
	  	
$

	
Methylprednisolone* tab.

	
Medrol

	  
	  	
$

	
Prednisolone syrup

	
Prelone

	  
	  	
$

	
Hydrocortisone* tab., sol.

	
Cortef

	  

 

  

  

  

 

	  	  	  	  	  
	  	
$

	
Fludrocortisone acetate tab. Floninef

	  	  
	  	
$

	
Dexamethasone elixir,

	
Decadron

	  
	  	  	
syrup, sol.

	  	  
	  	  	  	  	  
	
5.0

	
MISCELLANEOUS AGENTS

	  	  
	  	  	  	  	  
	  	
$

	
Ferrous sulfate tab. (325mg)

	
Varios

	
OTC

	  	
$

	
Leucovorin inj.

	  	  
	  	
$$$

	
Megestrol acetate tab., susp.Megace

	  	  
	  	
$$$$$

	
Leucovorin tab.

	  	  
	  	  	  	  	  
	
6.0

	
BIOTECHNOLOGY

	  	  
	  	  	  	  	  
	
6.1

	
ERYTHROID STIMULANTS

	  	  
	  	  	  	  	  
	  	
$$$$$

	
Darbepoetin alfa inj.

	
Aranesp

	
PA, P

	  	
$$$$$

	
Epoetin alfa inj.

	
Procrit

	
PA, P

  

  

  

ATTACHMENT 6

 

	
PUERTO RICO HEALTH INSURANCE ADMINISTRATION

Retail Pharmacy Reimbursement Level

Effective date: November 1, 2011

	
Pharmacy Type

	
Ingredient Cost

(AWP Discounts)

	
Dispensive Fee

	
Independent:

	
 

	
 

	
Brand

	
11%

	
$2.50

	
Bioequivalent Generics

	
ASES’ MAC List

	
$2.50

	
Non *MAC Generics

	
11%

	
$2.50

	
Local Pharmacy Chains:

	
 

	  
	
Brand

	
11%

	
$2.50

	
Bioequivalent Generics

	
ASES’ MAC List

	
$2.50

	
Non MAC Generics

	
11%

	
$2.50

	
National Pharmacy Chain:

	
 

	  
	
Brand

	
15%

	
$1.75

	
Generics

	
ASES’ MAC List

	
$2.50

	
Non-MAC Generics

	
15%

	
$2.00

	
*Walgreens

	
Not Contracted

	  
	
Diagnostic and Treatment Centers

	
 

	  
	
Brand

	
12%

	
$2.50

	
Generics

	
ASES’ MAC List

	
$2.50

	
Non-MAC Generics

	
12%

	
$2.50

	
 

	
 

	  
	
*MAC=Maximum Allowable Cost

	
 

	
Rev./06.2013

 

  

  

  

 

ATTACHMENT 7

UNIFORM AND MANDATORY PROTOCOL FOR THE CONDITIONS INCLUDED IN THE

SPECIAL COVERAGE

 

	
 

Diagnoses

	
 

Definitive diagnoses in the criteria

for inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration of

the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

 

UNIFORM AND MANDATORY PROTOCOL FOR THE CONDITIONS INCLUDED IN THE

SPECIAL COVERAGE

REVISED AS OF 7-2009

 

I.    PURPOSE

The benefits of the State health system should be similar for all patients or beneficiaries, regardless of the region, geographical area or participating Insurance company.

 

To make uniform and to regulate throughout Puerto Rico and by all the insurance companies and participating groups, the process of the identification, inclusion and coverage similar for all the beneficiaries with a Special Condition diagnosis.

 

To facilitate to the beneficiaries as well as to the providers, the dynamics required in the Special Conditions, without burocratic delays, as could occur if there existed different protocols for each Insurance Company or Group.

 

The following table presents in a detailed fashion the diagnoses that are included as of today under the special coverage, as well as the required diagnostic criteria, tests, examinations and procedures indicated for the follow-up of the special condition indicated, it also outlines in a clear fashion the assignment of risk, so that discrepancies, erroneous constructions, delays in the service and/or treatments can be prevented. In like manner, it details the effectiveness and duration of the coverage, as well as other considerations.

 

The condition of Autism is updated within the catalogue of Special Conditions.

 

  

  

  

 

	
 

Diagnoses

	
 

Definitive diagnoses criteria for

inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration

of the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

	
HIV-AIDS

	
1. Positive Western Blot

or

(IFA) positive

Immunofluorescent Assay

 

and/or

 

2. CD4 lower than 200

and/or

3. Evidence of Opportunistic Diseases:

-  Candidiasis

-  Cancer of the neck of the uterus (invasive)

-  Cocciodioidomycosis, Cryptococcosis, Cryptosporydiosis

-  Illness due to Cytmegalovirus

-  Encephalopathy (related to eh HIV)

-  Simple herpes (serious infection)

-  Histplasmosis

-  Isoporiasis

-  Daposi’s Sarcom

-  Lymphoma (certain types)

-  Mycobacterium avium complex

-  Pneumonia due to pneumocystis carinii/jiroveci

-  Pneumonia (recurrent)

-  Progressive multifocal leukoencephalopathy (PML)

-  Septicaemia due to salmonella (recurrent)

-  Toxoplasmosis of the brain

-  Tuberculosis

-  Emaciation syndrome

 

	
The effectiveness of the Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that the registration of the special condition be officially documented within a prudent period of time that could be established within 30 days or less. The special coverage shall be in effect while the eligibility in the PSG is maintained. If its eligibility is interrupted, for six (6) months or less, upon renewing its eligibility, it must be registered once again in the special coverage without having to repeat all the laboratories and going through the evaluation and registry procedure. Once again.

	
1.     Recounting of CD4 lymphocytes – 4 per year

2.     Viral Load test – 4 per year

3.     Genotype twice per year

4.    Amplification of the ARM of the HIV (RCP-TI)

5.     Analysis of the DNA of the branched chain (DNAr)

6.     Test of resistence to medications.

7.    Urine tests.

8.     Tests for other sexually transmitted diseases.

9.    Endoscopies which are diagnostic and/or thereapeutic

10.   X-ray and nuclear tests or studies (CT; MRI; Sonography; MRS)

11.   Biopsies

12.   Bronchoscopies and broncholveolar wash

13.   Ophtalmologic examinations

14.   Cultures and preparations for fungi

15.   Baciloscopies

16.  Analysis of cephalorachideal fluid

	
The medical services related to the condition, follow-up, complications, or complications of the diagnosis or of the treatment that may arise as part of the diagnostic studies performed, or of the complications themselves inherent to the disease. Among others:

· Candidiasis

· Cancer of the neck of the uterus (invasive)

· Cocciodioidomycosis, Cryptococcosis, Cryptosporydiosis

· Illness due to Cytmegalovirus

· Encephalopathy (related to eh HIV)

· Simple herpes (serious infection)

· Histplasmosis

· Isoporiasis

· Daposi’s Sarcom

· Lymphoma (certain types)

· Mycobacterium avium complex

· Pneumonia due to pneumocystis carinii/jiroveci

· Pneumonia (recurrent)

· Progressive muyltifocal leukoencephalopathy

· Septicaemia due to salmonella (recurrent)

· Toxoplasmosis of the brain

· Tuberculosis

· Emaciation síndrome

· Non-melanoma skin cáncer

· Nephropathies associated to HIV

· Anal Dysplasia

· Ano-genital neoplasias

 

 

 

 

 

 

 

	
Must be referred to the coverage for its registration as soon as possible due to any of the following:

 

1- PCP 2-

2- HIC specialist

3- Infectious disease specialists

4- Pneumologists

5- Dermatologists

6- Hematologists/ Oncologists

7- Handlers of cases of immunology clinics

In these cases, the Pharmacy coverage shall be immediately activated by the PBM, once it has entered the Registry. To be able to activate the coverage the Subscription Area in the newly entered cases shall assign the IPA and the PCP.

	
Autism

	1- Gastrointestinal problems	The effectiveness of the Special 	Endoscopies and all those to be	The medical services related to the 	It must be referred to the 

 

  

  

  

 

	 

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 
	
 

	
2- Allergies

	
Coverage shall begin from the date when the definitive diagnosis is established.

It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established within 30 days or less.

The special coverage shall be in effect as long as the insured maintains his/her eligibility to the PSG in effect. If his/her eligibility is interrupted, for six (6) months or less, upon renewing his/her eligibility must be registered once again in the special coverage without having to repeat the clinical procedures or going through the evaluation and registration process once again.

	
determined by the PCP, gastroenterologist, allergist or ENT; justified by the condition or complications.

	
condition its complications, or complications of the treatment shall be at the risk of the Insurance Company from the date of the effectiveness of the Special Coverage.

There shall be included in the same any medication indicated to treat or control the special condition or conditions that may arise as part of the diagnostic studies performed.

	
special coverage for its registration by any of the following:

1- Psychiatrist

2- PCP

3- Gastroenterologist

4- Any other specialist as soon as possible, once the condition has been diagnosed.

 

  

  

  

 

	  

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 
	
Erythematous Systemic Lupus

 

 

 

 

	
Have a minimum of four (4) of the following criteria:

1. Malar eruption

 

2. Discoidal Lupus

 

3. Photosensitivity

 

4. Oral or nasal ulcers

 

5. Non-erosive arthritis on two (2) or more peripheral articulations.

 

6. Serositis:

· Pleuritis and/or

· Pericarditis

 

7. Renal findings:

· Proteinuria of >0.5g/d and/or

· Cellular cylinders

8. Neurological findings:

· Convulsions and/or psychosis

 

9. Hematological findings:

· Hemolytic anaemia and/or

· Thrombocythopenia <100,000 and/or

· Leukopenia <4,000 and/or

· Linphocytopenia <1,500

 

10. Immunological findings:

· Anti-ds DNA and/or

· Anti-Sm and/or

· Ab Anti-phospholipids

 

11. Positive ANA

· Usually > 1:80 dil.

	
The effectiveness of the Special Coverage shall commence from the date when the definitive diagnosis is made. It’s imperative that the registration of special condition be officially documented within a prudent period of time that could be established within 30 days or less.

 

The special coverage shall be in effect while the eligibility in the PSG is maintained. If the eligibility is interrupted, for six (6) months or less, upon the renewal of the eligibility, it must be registered once again in the special

Coverage without having to repeat the laboratory tests and going through the evaluation and registration procedure once again.

	
To be determined by the Rheumatologist, Neurologist, Cardiologist, Nephrologist, Hematologist, Pneumologist, Dermatologist, and justified by complications. Among others:

·   CRP

·   ESR

·   Anti-DNA

·   Hepatic function

·   Renal function

·   CPK – Isoenzymes

·   U/a

·   EKG

·   Echocardiograms

·   X-rays

·   Brain CT

·   Brain MRI

·   EEG

·   CBC and platets

·   Coombs test

·   Complement

·   ANA, FANA

·   Biopsies

	
The medical services related to the condition, follow-up, complications and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurer from the date of effectiveness of the Special Coverage.

There shall be included in the same any medication indicated for treatment or control of the special condition or conditions that may arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

 

	
Must be referred to the special coverage for its registration by any of the following:

PCP

Rheumatologist

Neurologist

Cardiologist

Nephrologist

Hematologist

Pneumologist

Dermatologist or any other specialist participating in the diagnosis, the moment it is definitive.

 

 

  

  

  

 

	  

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 
	
Scleroderma

 

 

	
The American College of Rheumatology requires for its diagnosis at least one (1) criterion greater than or two (2) lesser criteria:

GREATER CRITERIA: (1)

Proximal scleroderma

Loss of skin elasticity

Hyperpigmentation and hypopigmentation of the skin in the pattern of salt and pepper

 

or

MINOR CRITERIA: (2)

· Sclerodactylia

· Loss of substance from the finger pads

· Pulmonary fibrosis in both bases

 

In addition to at least one of the following:

· Positive biopsy of skin

· Positive ANA >1:80 dil.

· Evaluation and certification from the Rheumatologist or Dermatologist.

 

 

 

 

 

 

	
The effectiveness of the Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be documented officially in the registry of special conditions within a prudent period of time which could be established at 30 days or less.

The special coverage shall be in effect while the eligibility in the PSG is maintained.

If its eligibility is interrupted, during six (6) months or less, upon the renewal of the eligibility, must be registered once again in the special coverage without having to repeat the laboratories and go through the evaluation and registry procedure.

	
As required by:

1. Rheumatologist

2. Dermatologist

3. Cardiologist

4. Pneumologist

5. Gastroenterologist

 

Among others:

-Lung X-rays

-Pulmonary function tests

-Chest CT

-Thallium centellography

-SPECT

-Esophagogram

-Esophagoscopy

-Esophagus Manometry

-Antibodies

-Erithrosedimentation

-CRP

-U/a

	
The medical services related to the condition, follow-up, complications and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurerr from the date of effectiveness of the Special Coverage.

There shall be included in the same any medication indicated to treat or control the special condition or conditions that

May arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

	
Must be referred to the special coverage for ist registration by any of the following:

-PCP

-Rheumatologist

-Dermatologist

 

 

  

  

  

 

 

	  

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 
	
Chronic Renal Diseases

 

Level III

 

 

Level IV

 

 

	
 

 

 

 

Glomerular Filtration Rate of 30 to 59 cc/min./1.73 m2

 

Glomerular Filtration Rate of 15 to 29 cc/min./1.73 m2

	
The effectiveness of the Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be officially documented in the registry of special conditions within a prudent period of time that could be established in 30 days or less. The special coverage shall be in effect while the eligibility in the PSG is maintained. If its eligibility is interrupted, during six (6) months or less, upon

renewal of the eligibility, may be registered once again in the special coverage without having to repeat the laboratory tests and going through the evaluation and registry procedure.

	
The continuous monitoring of the patients at risk for this condition is important for the early identification and registration of these, prior to commencing dialysis.

 

The visits to the Nephrologist and the laboratories related to the chronic renal condition are considered at the risk of the Insurance company

	
All the medical services related to the condition, its complications and/or the complications of the treatment, from the date of effectiveness of the coverage is at the risk of the Insurance company. Included but not limited to:

-Insertion of catheters for dialysis

-Surgeries to establish arterio-venous fistulas

-Required immunizations

-Administration of haematopoietic agents

-Transfusions

-Infections related to catheters

	
May be referred by:

-PC

-Internist

-Nephrologist

-Urologist

 

	
Chronic Renal Diseases

 

Level V

	
 

 

 

 

Glomerular Filtration Rates

<15 cc. min./1.73 m2

	
The Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

In the Renal-IPA all the services of the insurer ordered by the Nephrologist shall be at the risk of the insurance companies. The surgery necessary to set up the fistula required for the hemodialysis and the insertion of the catheters for the dialysis are considered part of the risk of the insurance companies, even when the insured person is not registered.

	
 

	
Once the Registration for Chronic Renal Condition has been authorized, the insured receives a notice by mail, indicating to him/her the changes in his/her coverage or IPA change to one of the Renal IPAs (Dialysis Center). The IPA change shall be effective the month when the request for change is made. From that moment onwards, the IPA ceases to receive the per capita payment corresponding to this insured person. The risk of the services received by the insured person before the change in the IPA or registration of the insured person shall be at the risk of the IPA, except the ones directly related to the dialysis.

The ambulatory services, not the emergency ones, that is provided to these insured persons at the Renal IPA have

	
May be referred by:

-PCP

-Internist

-Nephrologist

-Urologist

	
Chronic

 

	
 

	
Once the fistula has been set up,

 

	
 

	
to be coordinated by means of the 

	
 

 

  

  

  

 

 

	  

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 
	Renal

Diseases

(cont.)

	  	 it may be registered in the Renal IPA.	 	aforementioned referral from the   Nephrologist, who will go on to become the primary physician for these insured persons.	 
	
Tuberculosis

 

	
A. Tuberculin test (although negative, could have TB)

+

B. Thorax x-rays

     a. (infiltrates, cavities, consolidation, hilar lymphatic nodules, milar)

+

C. Certification from the Pneumologist

or

D. Samples of sputum for AFB and culture for M, tuberculosis

or

E. Brchial Wash (BW) (when they cannot expectorate)

or

F. Biopsies (affected site)

 

G. HIV Test

 

	
The Special Coverage shall commence from the date when the definitive diagnosis is made. It’s imperative that the registry of the special condition be officially documented within a prudent period of time that could be established in 30 days or less. The coverage shall be variable, depending on the duration of the treatment, which may vary from six (6) months up to two (2) years.

 

	
Samples of sputum for AFB and curture for M. tuberculosis as ordered by the physicians in charge of the treatment.

 

	
The medical services related to the condition, follow-up, complications, and/or complications of the diagnostic procedure and/or of the treatment shall be at the risk of Insurance company from the date of effectiveness of the Special Coverage. There shall be included in the same any medication indicated to treat or control the special condition or conditions that may arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

 

Follow-up chest x-rays until the completion of the treatment is at the risk of the insurance company.

 

The Department of Health covers:

·   Tuberculin

·   Cultures

·   Bronchial Wash

·   Medical Treatment

	
It’s of great importance to prepare the report required by Law for the TB Control Program of the Department of Health as soon as possible for its registration.

 

 

  

  

  

 

	
 

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 

	
Cancer

 

 

	
-Positive Pathology or Biopsy

-Specialized studies if it cannot be confirmed via pathology. Ex: CT-Scan, MRI, Sonogram

 

 

	
The Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

 

 

	
The ones justified on the basis of their condition, its complications of the treatment at the petition of the specialist.

 

 

	
In general, the procedures for the purpose of diagnosing are tat ht risk of the IPA; the presumptive diagnoses (ex: “rule out”, the biopsy or surgery procedures, by means of which one can obtain samples of the pathological tissues to perform the diagnosis and the hospitalizations associated to these, shall be considered at the risk of the IPA, except when the procedure confirms the definitive diagnosis which in that case shall be a the risk of the insurance company. The hospitalization for the carrying out of the definitive diagnosis shall only be considered at the risk of the Insurance company, if the diagnosis is confirmed in the same and a schedule is established in which to receive radiation therapy or chemotherapy, if necessary. All the tests or procedures prior to the confirmatory test are at the risk of the IPA.

 

The medical services related to condition, follow-up complications, and/or complications of the diagnostic procedure and/or the treatment shall be at the risk of the Insurance company from the date of effectiveness of the Special Coverage. There shall be included in the same any medication indicated to treat or control the special condition or conditions that could arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

 

	
It’s necessary that when requesting the registration of an insured person with a cancer diagnosis, the completed registration sheet be provided with copy of the pathology results, other studies that confirm the diagnosis, the information about the recommended treatment and the period of time in which they shall be receive it.

If all this information is not provided, the insured person shall be temporarily registered during four (4) months, while the IPA or the specialist send the information that is necessary for the definitive registration.

The registration may be requested by:

-PCP

-Surgeon

-Gynecologist

-Urologist

-Oncologist

-Radiation therapist in charge of the insured person.

 

	  

 

  

  

  

 

	
 

Diagnoses

	  

Definitive diagnoses criteria for

inclusion in the Special

Coverage

	  

Effectiveness and Duration

of the Coverage

	  

Tests and Labs for

follow-up

	  

Assignment of Risks

	  

General

Considerations

	 	 	 	 	 	 

	
 

 

	
 

	
 

	
  

	
This coverage requires that the insured person register with the insurance company in the Cancer Registry and it shall be extended until the chemotherapy and radiation therapy treatment has been completed.

 

-Once the tumor has been eliminated and there exists no evidence of metastasis and (the person) is in remission or not requires chemotherapy and/or radiation therapy treatments, the services shall no longer be considered at the risk of the Insurance company.

-The cases of insured persons who have been diagnosed with cancer in the past and are free of the illness at the present time, shall be considered at the risk of the IPA.

-The follow-up on the part of the oncologist, surgeon, etc. with regard to the insured persons in remission shall also be at the risk of the IPA.

 

	
 

 

  

  

  

 

 

	
 

Diagnoses

	
 

Definitive diagnoses criteria for

inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration

of the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

	 	
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

	 	 	 	 
	
Skin Cancer-

IN SITU Carcinoma

	
Positive biopsy

	
The Special Coverage shall commence from the date on which the definitive diagnosis is established.

	  	
Medical services at the time of the surgery as long as they are for the purpose of establishing the diagnosis are at the risk of the insurance company All the medical services to confirm the diagnosis are at the risk of the insurance company.

	  

 

  

  

  

 

	
 

Diagnoses

	
 

Definitive diagnoses criteria for

inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration

of the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

	
Skin cancer – such as Invasive Melanoma or those of the Squamous cells with Evidence of Metastasis

 

	
1. Positive Pathology or Biopsy

 

2. Special studies:  CT Scan, MRI, Sonogram

 

	
The Special Coverage shall commence from the date on which it is established.  It’s imperative that it be officially documented the registry of special condition within a prudent period of time that could be established in 30 days or less.

 

	  	
The time that the radiation therapy lasts or the surgical procedure until completed.  The medical services related to the condition, follow-up, complications and/or complications of the diagnostic procedure and/or the treatment shall be at the risk of the Insurance company from the date of effectiveness of the Special Coverage.  There shall be included in the same any medication in indicated to treat or control the special condition or conditions that could arise as part of the diagnostic studies.

 

	  
	
Multiple Sclerosis (MS)

	
McDonald revised criteria:

The diagnosis is confirmed when there concurs a combination of:

1. Two (2) different episodes of neurogical sysmptoms verifiable by a Neurologist.

 

or

 

2. Symptoms that indicate damage or injury in more than one region of the Central Nervous System.

 

+

 

MRI

 

+

 

Laboratory tests with abnormal findings and consistent with MS.

 

+

 

 

	
The Special Coverage shall commence from the date on which the definitive diagnosis is established.  It’s imperative that it be officially documented in the registry of special condition within a prudent period of time that could be established in 30 days or less.

The Special Coverage shall be in effect while the insured person continues to be eligible in the PSG.  If the eligibility is interrupted, during six (6) months or less, upon renewal of the eligibility, may be registered once again in the special coverage without having to repeat the laboratory tests and go through the evaluation and registration procedure once again.

 

	
All the once indicated by the condition and its complications.

 

Among others:

1. MRI

2. Extraction and examination of the spinal liquid.

3. IgG tests in Spinal fluid.

4. Evoked potentials.

5. Tests

 

Neuropsychological ones.

1. Evaluation of the urinary system.

 

	
The medical services related to the condition, follow-up, complications and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurance Company from the date of effectiveness of the Special Coverage.  There shall be included in the same any medication indicated for the treatment or control of the condition of the special condition or conditions that could arise as part of the diagnostic studies performed, or  of the complications pertaining to the disease.

	
The treatment for the MS patients is multidisciplinary.  It must include:

1. Neurologist who is making the diagnosis

2. and other health professionals such as:

·  Urologists

·  Psychiatrist

·  Psychologists

·  Neuro-ophtalmologists

 

 

 

  

  

  

 

	
 

Diagnoses

	
 

Definitive diagnoses criteria for

inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration

of the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

	 	
3. Absence of another illness or condition which may be causing the symptoms or the laboratory findings.

	 	 	 	 
	
Cyst Fibrosis (CF)

	
1. Evaluation from the pneumologist

 

2. Perspiration test

 

3. Clinical picture

	
The Special Coverage shall commence from the date when the definitive diagnosis is established.  It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

The special coverage shall be in effect while the insured person remains eligible in the PSG.  If the eligibility is interrupted, for six (6) months or less, upon renewal of the eligibility, they must be registered once again in the special coverage without having to repeat the laboratory tests and going through the evaluation and registration process once again.

	
At least every 3 months:

 

1. Sputum culture

2. Pulmonary function

3. Nutritional evaluation

4. Review of postural drainage techniques

 

Once a year:

 

1. Hepatic function

2. Levels of vitamins A; E

 

One occasion:

 

1. Genetic tests CFTR-DNA test

	
The medical services related to the condition, follow-up, complications, and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurance Company from the date of effectiveness of the Special Coverage.  There shall be included in the same any medication indicated to treat or control the special condition or conditions that may arise as part of the diagnostic studies performed, or from complications pertaining to the disease.

	  
	
  Rheumatoid Arthritis

	
Clinical Picture

 

Criteria of the American College of Rheumatology:  at least four (4) out of seven (7) must be present:

 

1. Perarticular morning numbness of at least one hour in duration and that is present for at least six (6) weeks.

2. Swelling of the soft tissues (arthritis) in three or more articulations, present for at least six (6) weeks.

3. Swelling (arthritis) of the proximal interphalangic (PIP) and/or metacarpophalangic (MCP) articulations and/or of the carpus for at least during six (6) weeks.

4. Symmetric arthritis present at least during six (6) weeks.

	
The Special Coverage shall commence from the date when the definitive diagnosis is established.  It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

 

The Special Coverage shall be in effect while the insured person remains eligible in the PSG.  If the eligibility is interrupted, for six (6) months or less upon renewal of the eligibility may be registered once again in the special coverage without having to repeat the laboratory tests and going the evaluation and registration procedure.

	
To be determined by the primary physician and/or the rheumatologist. Among others:

1. ESR

2. CRP

3. CBC

4. Hepatic function test

5. CCP (citric citrullinated peptide)

6. ANA test

7. X-rays

	
The medical services related to the condition, follow-up, complications, and/or complications of the diagnosis and/or the treatment shall be at the risk of the Insurance Company from the date of effectiveness of the Special Coverage.

 

There shall be included in the same any medication indicated to treat or control the special condition or conditions that could arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

	
May be referred by:

1. PCP

2. Rheumatologist

 

  

  

  

 

	
 

Diagnoses

	
 

Definitive diagnoses criteria for

inclusion in the Special

Coverage

 

	
 

Effectiveness and Duration

of the Coverage

	
 

Tests and Labs for

follow-up

	
 

Assignment of Risks

	
 

General

Considerations

	 	
5. Subcutaneous nodules.

6. Positive test for the Rheumatoid factor.

7. Radiographic erosions and/or Perarticular osteopenia in hands and/or carpus.

 

II.  Rheumatological evaluation

 

	 	 	 	 
	
Aplastic Anemia

	
I. Hematological evaluation:

1. Absolute count of neutrophils < 500/mm3

2. Platelets < 20,000 mm3

3. Reticulocytes < 1%

 

and

 

II. Aspiration and/or biopsy of bone marrow

	
The Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

 

The Special Coverage shall be in effect while the insured person remains eligible in the PSG.  If the eligibility is interrupted for six (6) months or less, upon renewal of the eligibility, it may be registered once again in the Special Coverage without having to repeat the laboratory tests and going through the evaluation and registration process once again.

	
The ones required by the Hematologist or Internist.

	
The medical services related to the condition, follow-up, complications, and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurance Company from the date of effectiveness of the Special Coverage.  There shall be included in the same any medication indicated to treat or control the special condition or conditions that may arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

	
May be referred by:

1. PCP

2. Hematologist

3. Internist

 

	
Hemophilia

	
I. Evaluation of the Hematologist:

 

a. Severe:  Levels of Factor VIII < 1%

b. Moderate:  Level of Factor VIII < 1-5%

c. Slight: Level of Factor VIII 5-25% with manifestations of severe bleeding

 

II.  Levels of Clotting Factors:

 

a. Patients with severe Hemophilia A and B.

b. Patients with severe Hemophilia A and B with the presence of inhibitors.

c. Moderate Hemophilia A and B with the presence of inhibitors

	
The Special Coverage shall commence from the date when the definitive diagnosis is established. It’s imperative that it be officially documented in the special condition registry within a prudent period of time that could be established in 30 days or less.

The Special Coverage shall be in effect while the insured person remains eligible in the PSG.. If the eligibility is interrupted, for six (6) months or less, upon the renewal of the eligibility, can be registered once again in the special coverage without having to repeat the laboratory tests and going through the evaluation and registry procedure once again.

	
Levels of inhibitors every (6) months

	
The services related to the condition, follow-up, complications, and/or complications of the diagnosis and/or of the treatment shall be at the risk of the Insurance company from the date of effectiveness of the Special Coverage.

There shall be included in the same any medication indicated to treat or control the special condition or conditions that could arise as part of the diagnostic studies performed, or of complications pertaining to the disease.

	  

  

  

  

ATTACHMENT 8

	  
	
CO-PAYS & CO-INSURANCE - effective on July 1, 2013

 

	
  

	  	
Federal

 

	  	
CHIPS

	
Commonwealth

Population

	
ELA*

	
SERVICES

	  	
100

	  	
110

	  	
230

	
300

	
310

	
320

	
330

	
400

	
HOSPITAL

 

	  	
HOSPITAL

	  	
HOSPITAL

	
HOSPITAL

	
HOSPITAL

	
Admissions

	  	
$0

	  	
$3

	  	
$0

	
$3

	$5	

$6

	
$20

	
$50

	
Nursery

	  	
$0

	  	
$0

	  	
$0

	
$0

	
$0

	

$0

	
$0

	
$0

	
EMERGENCY ROOMS

	  	
EMERGENCY 

ROOMS

	  	
EMERGENCY 

ROOMS

	
EMERGENCY ROOMS

	
EMERGENCY ROOMS

	
Emergency Room (ER) Visit

	  	
$0

	  	
$0

	  	
$0

	
$1

	
$5

	

$10

	
$15

	
$20

	
Non-emergency visit to a hospital emergency room.

	  	
$3.80

	  	
$3.80

	  	
$0

	
$15

	
$15

	

$15

	
$15

	
$20

	
Trauma

	  	
$0

	  	
$0

	  	
$0

	
$0

	
$0

	

$0

	
$0

	
$0

	
 AMBULATORY VISITS TO 

	  	
AMBULATORY VISITS TO 

	  	
AMBULATORY 

VISITS TO

	
AMBULATORY VISITS TO

	
AMBULATORY VISITS TO

	
Primary Care Physician

	  	
$0

	  	
$1

	  	
$0

	
$0

	
$1

	

$2

	
$2

	
$3

	
Specialist

	  	
$0

	  	
$1

	  	
$0

	
$1

	
$1

	

$3

	
$4

	
$7

	
Sub-Specialist

	  	
$0

	  	
$1

	  	
$0

	
$1

	
$1

	

$3

	
$5

	
$10

	
Pre-natal services

	  	
$0

	  	
$0

	  	
$0

	
$0

	
$0

	

$0

	
$0

	
$0

	
OTHER SERVICES

 

	  	
OTHER SERVICES

	  	
OTHER SERVICES

	
OTHER SERVICES

	
OTHER SERVICES

	
High-Tech Laboratories**

	  	
$0

	  	
50¢

	  	
$0

	  $1	

$1

	

$2

	
$3

	
20%

	
Clinical Laboratories**

	  	
$0

	  	
50¢

	  	
$0

	  $1	

$1

	

$2

	
$3

	
20%

	
X-Rays**

	  	
$0

	  	
50¢

	  	
$0

	  $1	

$1

	

$2

	
$3

	
20%

	
Special Diagnostic Tests**

	  	
$0

	  	
$1

	  	
$0

	  $1	

$2

	

$2

	
$6

	
40%

	
Therapy – Physical

	  	
$0

	  	
$1

	  	
$0

	  $1	

$2

	

$2

	
$3

	
$5

	
Therapy – Respiratory

	  	
$0

	  	
$1

	  	
$0

	  $1	

$2

	

$2

	
$3

	
$5

	
Therapy – Occupational

	  	
$0

	  	
$1

	  	
$0

	  $1	

$2

	

$2

	
$3

	
$5

	
Vaccines

	  	
$0

	  	
$0

	  	
$0

	  $0	

$0

	

$0

	
$0

	
$0

	
Healthy Child Care

	  	
$0

	  	
$0

	  	
$0

	  $0	

$0

	

$0

	
$0

	
$0

	
DENTAL

 

	  	
DENTAL

	  	
DENTAL

	
DENTAL

	
DENTAL

	
Preventive (Children)

	  	
$0

	  	
$0

	  	
$0

	  $0	

$0

	

$0

	
$0

	
$0

	
Preventive (Adults)

	  	
$0

	  	
$1

	  	
$0

	  $0	

$1

	

$2

	
$3

	
$3

	
Restorative

	  	
$0

	  	
$1

	  	
$0

	  $0	

$1

	

$5

	
$6

	
$10

	
PHARMACY***

 

	  	
PHARMACY***

	  	
PHARMACY***

	
PHARMACY***

	
PHARMACY***

	
Generic (Children 0-21)

	  	
$0

	  	
$0

	  	
$0

	  $0	

$0

	

$0

	
$0

	
$5

	
Generic (Adults)

	  	
$1

	  	
$1

	  	
N/A

	  $1	

$2

	

$3

	
$5

	
$5

	
Brand (Children 0-21)

	  	
$0

	  	
$0

	  	
$0

	  $0	

$0

	

$0

	
$0

	
$10

	
Brand (Adults)

	  	
$3

	  	
$3

	  	
N/A

	  $3	

$4

	

$5

	
$7

	
$10

	
  

	  	
Federal

	  	
CHIPS

	
 Commonwealth Population

	
ELA*

	
SERVICES

	  	
100

	  	
110

	  	
230

	  300	
310

	

320

	
330

	
400

	
*

	
  Code 400 in ELA column apply for the population subscribed as public employees of the Puerto Rico Government.

	
**

	
  Apply for diagnostic tests only. Copays will not apply in tests required as preventive treatment.

	
***

	
  Co-pays will apply for each drug included in the same prescription pad. Exceptions shown on Pharmacy (Children 0-21) does not apply for 400 ELA employees.

 

  

  

  

 

Attachment 9

Information Data Processes and Data Exchange Layout

 

  

  

  

 

ASES

Enrollment Manual

June 2011

  

  

  

 

ASES

Enrollment Manual

June 2011

 

Table of Contents #

 

	
I. INTRODUCTION

	  	  	  
	  	
A.

	
BACKGROUND

	  	
B.

	
BASIC ELIGIBILITY CONCEPTS

	  	
C.

	
GENERAL ENROLLMENT CONCEPTS

	  	  	  
	
II. ENROLLMENT PROCESS

	  	  	  
	  	
A.

	
DATA FLOW 

	  	  	
i. Mi Salud

	  	  	
ii. Platino

	  	
B.

	
ENROLLMENT RECORD 

	  	  	
i. Data definition

	  	  	
ii. Uses

	  	  	
iii. Edit & Update Process

	  	
C.

	
CARRIER RESPONSIBILITIES 

	  	
D.

	
ENROLLMENT RECORD REJECTIONS 

	  	  	
i. Reject Process

	  	  	
ii. Error Codes

	  	  	  
	
III. PREMIUM PAYMENT

	  	  	  
	  	
A.

	
CONCEPTS

	  	
B.

	
RELATION TO ENROLLMENT

	  	
C.

	
TYPES OF PAYMENT CALCULATIONS

	  	  	  
	
IV. SYSPREM – ENROLLMENT IN HISTORY

	  	  	  
	  	
A.

	
ENROLLMENT CONCEPTS 

	  	
B.

	
SYSPREM FUNCTIONALITY 

	  	
C.

	
PREMIUM PAYMENT FOR SYSPREM ENROLLMENTS 

	  	  	  
	
V. ADDENDUMS

	  	  	  
	  	
A.

	
 ENROLLMENT RECORD LAYOUT 

	  	
B.

	
 Consistency Hierarchy Table

	  	
C.

	
 ERROR CODE TABLE 

	  	
E.

	
FLOW DIAGRAM 

 

  

  

  

 

I.  Introduction This document is the reference manual to guide Insurance Companies and Medicare Advantage Organizations contracted by ASES in enrolling their contracted beneficiaries.

 

	  	
a. 

	
Background

 

	  	
Previous to January 2006 Mi Salud beneficiaries were assigned to MCO’s or TPA’s by region. (MCO’s, TPA’s and MAO’s will be referred to as “carriers” in this document). Enrollment, which is the process by which the carrier sends an electronic record to ASES notifying of the subscription of a member, was done at the family level. With one record the carrier would enroll all the members of a family. At the most there could be two carriers in a region, one MCO and one TPA so conflicts were minimal. The establishment of the Medicare Platino Plans by ASES starting on January 2006 increased the complexity of identifying in the ASES database which member is covered by which organization. Once Platino was implemented the enrollment had to be done at the member level since a family could have members subscribed by different carriers. The complexity was also affected by having MAO’s providing  services  to  all  the  ASES  regions.  Therefore Platino beneficiaries had a wide choice of options which included the capacity to change carriers on a monthly basis.

 

	  	
b.

	
Basic Eligibility Concepts

 

	  	
i.

	
Eligibility for Mi Salud beneficiaries is determined by Medicaid Offices.  Typically the beneficiaries are given eligibility for a year after which they must recertify.

	
  

	
ii.

	
Those beneficiaries which do not recertify are cancelled at the eligibility expiration date. This occurs at the end of each month.

	
  

	
iii.

	
Data for eligible beneficiaries is sent by Medicaid Offices to ASES and updated in the ASES database on a daily basis.

	
  

	
iv.

	
ASES sends any  updates,  cancellations  or  additions  to  the carriers on a daily basis.

	  	
1)

	
Mi Salud carriers receive data for all the members in their contracted regions.

	  	
2)

	
Platino  carriers  receive  data  for  all  their members enrolled in each contracted region.

	
  

	
v.

	
Mi Salud eligible members are those which appear as eligible in the ASES database.

	
  

	
vi.

	
Platino eligible members are those Mi Salud eligible members which also have Medicare A&B coverage.

	 	 	 
	
  

	
1)

	
Medicare  A&B  coverage  is  determined  by  the Platino carriers by querying CMS.

	
  

	
2)

	
Platino carriers also have to query ASES to determine Mi Salud eligibility.

 

	
  

	
c.

	
General Enrollment Concepts

 

	  	
The enrollment record (see attached) used by the carriers to notify ASES of the subscription of a member contains a series of data elements for verification of correctness and to inform ASES the particulars of the enrollment. A member can be enrolled in one of three different  Plan Types :

 

	  	
i.   01 = Mi Salud

ii.  02 = Platino MA-SNP (Special Needs Plan)

iii. 03 = Platino MA-PD (Medicare Advantage Prescription Drugs)

 

	  	
A particular carrier can offer different products under a Plan Type. These products are identified by their Plan Version  number. ASES assigns a Plan Version  number for each Platino product contracted. For Mi Salud enrollments the Plan Version field must equal the coverage code  assigned to the particular beneficiaries. Some of the Plans contracted with ASES may require the assignment of Primary Centers  (IPAs) and /or  PCP s to the beneficiaries. The enrollment record includes those fields as well as the Plan Type and Version. The record also informs of the date the member was processed by the carrier and the effective date of the enrollment. (For more detail se section II.b below.)

 

	
II.

	
Enrollment Process

 

	  	
a.

	
Data Flow

 

	  	
The data flow for Mi Salud and Platino enrollments is similar with the principal exception of the queries that are needed in the Platino process. (see flow diagram attached)

 

  

  

  

 

	  	
i.

	
Mi Salud – The process starts with the receipt of the eligibility data by the carriers. The carriers update their database and communicate with the beneficiaries. The beneficiaries visit the carriers’ premises and sign up in the Mi Salud Plan. The carrier then produces the electronic enrollment record and sends it to ASES. These transmissions occur on a daily basis. In ASES the records are passed through an edit program. The records that pass the edits are updated to the ASES database and the beneficiaries are deemed enrolled. Those record found with error are returned to the carriers for correction. Until the records are submitted correctly the member is not enrolled in ASES.

 

	
  

	
ii.

	
Platino – Before a Platino Plan can enroll a member it must verify Medicare coverage by querying CMS. They must also query ASES to verify if the member is eligible for Mi Salud. Once those requirements are met then the enrollment is submitted to ASES. In ASES the record follows the same process as described above for Mi Salud.

 

	  	
b.

	
Enrollment Record

 

	  	
i.

	
Data Definition – The enrollment record contains the following data elements to be complimented by the carrier:

 

1)        RECORD_TYPE – This is always an “E” it identifies the record as an enrollment file record.

 

2)        TRAN_ID  –  This  is  the  field  which  identifies  to  the ASES system which action to take based on the data contained in the record. It can have one of several values:

	
  

	
a)        E = means that the record is a new enrollment for a member which has not been previously enrolled.

	
  

	
b)        C = Change Carrier. Used when the member has selected a different carrier than the one in which he/she is presently enrolled. It is also used for initial enrollment in Platino Plans.

	
  

	
c)        P = Changes the Plan Type. It is used when a member enrolled under a particular carrier chooses to change the product the carrier offers to one which is identified under a different Plan Type under the same carrier. Example: changing from an MA-PD Plan (Type 03) to a SNP Plan (Type 02) under the same carrier.

	
  

	
d)        V = Type  Version  change.  It  is  used  when  a member enrolled under a particular carrier and Plan Type chooses to change the product the carrier offers to one which is identified under the same Plan Type but with a different version number under the same carrier. Example: changing from a SNP Plan (Type 02 Version 001) to a SNP Plan (Type 02 Version 002) under the same carrier. The version change value in the Tran_id is also used when a Mi Salud member changes coverage code. In this case the carrier must reissue an ID Card with the new benefits and submit a version change enrollment record to ASES where the Version number is equal to the coverage code.

	
  

	
e)        I = IPA (Primary Center) Change. Used to record in ASES a change in the beneficiaries’ selected IPA  under  the  same  carrier,  Plan  Type  and Version.

	
  

	
f)        1 = PCP1  change.  Used to  record  in  ASES  a change in the beneficiaries’ selected PCP1 under the same carrier, Plan Type, Version and IPA.

	
  

	
g)       2 = PCP2  change.  Used  to record  in  ASES  a change in the beneficiaries’ selected PCP2 under the same carrier, Plan Type, Version and IPA.

	
  

	
h)       3 = PCP1 and PCP2 change. Used to record in ASES a change in the beneficiaries’ selected PCP1  and PCP2 under the same carrier, Plan Type, Version and IPA.

	
  

	
i) X = delete incorrect enrollment 10)

	
  

	
j) O = Contract number change only 11)

	
  

	
k) D = Disenroll. For future use.

	
  

	
 

3)        PROCESS_DATE – Sign up date. Date the member contracted with the carrier. Relationship with effective date:

a) Platino – Process date must be less than effective date.

b) Mi Salud – process date must be equal or less than effective date.

 

4)        REGION – Contains ASES region code. Must be the region in which the member is located in the ASES database. Platino carriers obtain this code from the ASES query response.

 

5)        CARRIER - Two digit carrier code assigned by ASES.

 

6)        MEMBER_PRIMARY_CENTER – Up to four digits assigned by carrier to identify their Primary centers (IPAs). Not required for some Plan Types/Versions.

 

7)        ODSI_FAMILY_ID – Eleven digit family ID assigned by MEDICAID OFFICES (ODSI). This is the first part of the key for the beneficiaries in the ASES database. Platino carriers obtain this code from the ASES query response.

 

8)        MEMBER_SSN– Social Security number of the member. It is required that this number matches with the one for the member in the ASES database.

 

9)        MEMBER_SUFFIX – Two digit number which identifies a member within a family. Second part of the key in the ASES database.

 

  

  

  

 

10) EFFECTIVE_DATE  –  Date  in  which  the  carriers starts coverage for the member under the enrolled Plan or   effective   date   of   the   change   for   which   the

 

11) PLAN_TYPE – Plan Type code under which the member is enrolled.

 

12) PLAN_VERSION – Plan version under which the member is enrolled.

13) MPI – Master Patient Index. Unique number which identifies a Member in ASES and MEDICAID OFFICESs databases.

 

14) PCP1 – Fifteen digit number assigned by carriers. Use to identify the PCP1 selected by the beneficiaries.

 

15) PCP1_EFFECTIVE_DATE  –  Date  in  which  the PCP1 assignment was effective.

 

16)         PCP2 – Fifteen digit number assigned by carriers. Use to identify the PCP2 selected by the beneficiaries.

 

17)         PCP2_EFFECTIVE_DATE  –  Date  in  which  the PCP2 assignment was effective.

 

18)         FAMILY_PRIMARY_CENTER – IPA assigned to all Mi Salud family members.

 

19)         FAM_PRIMARY_CENTER_EFF_DATE    –Datein which the assignment of the family IPA was effective.

 

20)         IPA_PCP_CHANGE_REASON – Not in use.

 

21)         MEDICARE   INDICATOR   –   Required   for Platino enrollments. (1=A&B, 3=A, 9=B)

 

22)         HIC  NUMBER  –  Medicare  Health  Insurance Claim Number. Required for Platino enrollment.

 

23)         IPA_ESPECIAL – A “1” indicates that the member is assigned to a special IPA which is not the family IPA. Used for Mi Salud.

 

24)         Contract Number – Contract number assigned by the carrier. It should be the number by which the member is identified in the carriers ID card and internally in their database.

 

25)         Special Enroll – Used to identify that the enrollment is for a newborn (N) or an emergency (E) case submitted by MEDICAID OFFICES or ASES. 

When this field is used then if the values is:

 

a) N – The system allows enrollment as of the date of birth.

b) E – The system allows enrollment as of the certification date.

c) This mechanism can be utilized in cases where the date of birth or certification is on or after January 1, 2006.

 

26) Other data elements complimented by ASES – When the record is edited the ASES system enters the following data in the enrollment record:

a) Reject Identifier - As a result of the edits the record could  be  accepted  or  rejected.  This  field  contains  the codes that specify that result. ( “A” = Accepted; “M” = Accepted Retroactive; “R” = Rejected; “X” = Deleted)

b) Record Key – Internal number assigned by the ASES system.

c) Error Codes one to ten – record up to ten possible error codes.

d) Update Date – Date to which the edit run belongs. Correspond to the date of the daily cycle the edit run was a part of.

e) Update User – ASES internal user code.

 

ii. Uses

1.   The  enrollment  record  can  be  used  to  trigger  several actions in the ASES database. The content of the TRAN_ID field determines which action. An “E” for a Mi Salud carrier will perform the original enrollment of a member. A “C” will transfer a member from one carrier to the one submitting the enrollment or perform the original enrollment for a Platino carrier. Codes P, V, I, 1, 2, and 3 will inform the ASES system that the carrier has changed a beneficiaries Plan, Version, IPA or PCP. An “X” will delete a previously submitted record and an “O” will change a beneficiaries Contract number. In the future a “D” will produce the disenrollment of a member from its existing carrier.

 

  

  

  

 

iii.        Edit and update process – Carriers can transmit enrollment files to ASES on a daily basis. They must follow the naming convention for those files which is as follows:

 

1.      CCYYMMDD.SUS

1.      CC = Carrier Code

2.      YY = Year

3.      MM = Month

                            4.      DD = Day

5.      .SUS = File extension identifies enrollment file.

 

The enrollment file can contain records pertaining to any of the regions contracted by the carrier. The files received by 9:00am are entered in the ASES daily cycle. If a file is received after 9:00am it will be entered in the following day’s cycle. In the cycle there are several steps which handle the enrollment records:

 

2) Enrollment Merge – joins the enrollment files from all carriers into a single file.

 

3)           Enrollment Region Split – Separates the merged file into different files (one per region) based on the region code in the enrollment records. If the record sent does not have a valid region code it will go into a special error file and will not continue processing.

 

4)           Edits - ASES run a separate edit and update cycle for each  region.  The  enrollments  are  passed  though  the  edit programs and are identified as valid or rejected.

 

5)           Update - Valid enrollments will be used to update the beneficiaries’ record in the ASES database. In this process the data in the enrollment record is entered into the beneficiaries’ record. There are to types of Valid enrollments:

 

a)   Reject   identifier   =   A   –   Identifies   an   accepted enrollment which is to be applied at a future effective date. The update process moves the enrollment fields (carrier, Plan, Version, Ipa and PCP) to the fields destined for new enrollments in the member’s record. Until the new effective date is reached the member stays under the present enrollment condition (same carrier, Plan, Version, Ipa and PCP). At the month end cycle previous to the effective date the new field are moved to the actual fields and the enrollment becomes effective.

 

b) Reject identifier = M – Indicates a retroactive enrollment.   In   these   cases   the   enrollment   data (carrier, Plan, Version, Ipa and PCP) is updated directly to the actual enrollment field in the member’s record.

 

6)           Carrier eligibility file extract – When the member’s information is updated because of an enrollment being processed, a record is sent to the carrier affected in the Carrier eligibility file which is produced in every daily cycle.

 

c. Carrier Responsibilities - In order to process enrollment transactions correctly the carriers need to maintain in their particular systems the updated member eligibility data received from ASES. Such data is sent by ASES in the following files:

i.          Carrier Eligibility File (Daily & Month End) – Produced by the   ASES   daily   cycle.   Contains   all   the   data   pertaining   to   the beneficiaries that have been added, updated or cancelled in the daily cycle. This includes updates caused by enrollment records being processed in that cycle. The carrier’s system must identify the following situations based on the data received in these files:

 

1) When a member is added.  

a) Mi Salud carriers must start the enrollment process with the member.

 

2) When a member changes carrier:

a) The carrier which lost the member must identify the loss of business.

 

3) When  any  of  the  enrollment  data  changes.  This includes Plan Type, Version, IPA, PCPs.

a) The carrier system must be updated accordingly, If not this could cause the rejection of future enrollment record submissions.

 

4) When a Member’s demographics Changes:

a) The carrier needs to update the new data in their database.

 

5) When a member is cancelled:

a) All carriers must cancel effective at the end of the month

b) Carriers  should  follow  up  with  member  in  case  the cancellation is caused by expiration of certification.

 

6) When a member has a change in coverage code:

a)        Carriers must evaluate if the new coverage code requires that the member be enrolled in a different Plan_Version  and  send  a  Version  change  enrollment record to ASES before the end of the month.

b)         Members where the Plan_Version does not agree

with  the  coverage  code  will  be  disenrolled  by  ASES during the month end cycle. (For valid members, the carrier must then re-enroll the member under a new Plan_Version that agrees with the new coverage code.)

 

  

  

  

 

ii.         Enrollment Reject File – Produced by the ASES daily cycle. It contains the enrollment records rejected by the validation program. The carrier must examine the rejected records and take action to correct the cause based on the error codes included. See details below about the specific error codes. The carriers system must have the capability of identifying the errors and provide the mechanisms for correction and submittal to ASES for reprocessing.

 

d. Enrollment Record Rejections

i.          Reject Process - Rejected enrollments are sent daily on a file which includes the error codes for the edit that failed the validation process. The carriers must correct the errors found and submit the corrected records to ASES in the next enrollment file. The file name for the reject file is:

 

1.       CCYYMMDD.rjc

a.       CC = Carrier Code

b.       YY = Year

c.       MM = Month

d.       DD = Day

e.       .rjc = File extension identifies reject file.

 

ii.           Error  Codes  –  The  attached  (Subscription Error table) table  contains  the  error  codes produced by the Validation Program. Additional descriptions and possible corrective actions have been included to assist in the correction process.

 

III. Premium Payment

 

 a. Concepts - The new Premium Payment System works under the concept that premiums are calculated and paid for only those beneficiaries that are enrolled by the first day of the payment month. The carriers do not need to submit billing documents or files. There is one payment run per month per ASES region in which the payment for all carriers in the region is calculated.

 

b. Relation to Enrollment - Enrolled beneficiaries are those which are eligible and assigned to a particular carrier as the result of an enrollment transaction. For a particular month’s run the system will consider enrolled beneficiaries in the ASES database with an enrollment date (update date in ASES) previous to the 1 st  day of that month. Beneficiaries enrolled after that date will be considered for payment in the next payment run after the enrollment date.

 

c.            Types of payment calculations - The payment system computes several categories of payments:

a.  Monthly  payments  –  For  all  beneficiaries  enrolled  at  the beginning of the month for which the system is run ( Payment Month ).

b. Prorate Payments – Prorate payments are calculated for Mi Salud beneficiaries  that  were  enrolled  during  the  previous  month  to  the payment  month.  A  prorated  daily  premium  is  calculated  based  on effective date of the enrollment.

c. Retroactive Payments – Is calculated when the effective date of the enrollment is previous to the payment month. In Platino this calculation may include the previous month since no prorate is paid and because the enrollment always starts at the beginning of a month. In Mi Salud retroactive payments are always for periods two month or more before the payment month.

d. Retroactive  prorate  payments  -  Retroactive  prorate  payments  are calculated when the effective date of the enrollment falls within the first month considered for a retroactive payment

e. Adjustments – Adjustments are calculated when a member changes Carrier retroactively after ASES had paid the first carrier in a previous payment run. The adjustment takes away the premium amount paid the first carrier.

 

IV.           SYSPREM – Enrollment in History

 

a.           Enrollment concepts

i.           Enrollments are applied to the current eligibility data.

ii.          Enrollments are allowed only in a member’s current eligibility period. The current eligibility period  is the:

1)            eligibility period after a cancellation period (for a member that has been cancelled and then re-certified)

	
  

	
2)

	
the current period since the initial update in ASES (as eligible) and the present time when the member has not been cancelled and remains eligible

	
iii.      

	
When an enrollment is not sent in time by the carrier (or a rejected record is not corrected) the eligibility data for the member will remain un-enrolled.

iv.           Premiums will not be paid for un-enrolled beneficiaries when the premium payment system is run.

	
v.

	
If the member is then cancelled or enrolled in a second carrier the first carrier is prevented (by the system edits) to enroll the member in a period previous to the cancellation or the enrollment.

  

  

  

 

b.           SYSPREM Functionality.  The SYSPREM sub-system will permit the enrollment of beneficiaries to be recorded in historic data. The main functions are:

 

i.           Identification of enrollment records that are candidates for processing against the history database.  Rejected with error codes:

1)           107- Effective date before current eligibility period for family

2)           108- Effective date before current eligibility period for member

3)           280- Family must be eligible in current eligibility period

4)           281- Member must be eligible in current eligibility period

5)           177- Enrolled in another carrier at or after effective date

 

ii.         Limitations:

1) Member must be active on effective date

2) Member must not have family members with errors not acceptable by SYSPREM in the same Mi Salud enrollment batch

3) Enroll record must not have Effective Date before 01/01/2006***

 

iii.  New Error Codes (Reject File) for accepted history enrollments:

1) 996 – SYSPREM record inserted in history. No action by the carrier is required.

 

iv.  New Error Codes (Reject File) for rejected history enrollments:

1) 980 - Process date in enroll record must be greater than process date of the previously enrolled Member record

2) 981 – Member must not have family members with errors not acceptable by SYSPREM in the same enrollment batch (for Mi Salud).

3) 982 – Enroll record must not have Effective Date before 01/01/2006***

v.        Carrier  Eligibility  File  –  The  daily  carrier  eligibility  file  will include the data for the members updated in history by the SYSPREM sub-system. The TRAN_ID field will contain an “H” to identify history data. The carriers must modify their systems so that the SYSPREM data is not included as actual data when processing the eligibility file.

 

c.             Premium Payment for SYSPREM enrollments

 

i.              Monthly Premium Payment run will include all SYSPREM records processed during the previous month.

ii.             Payment will be calculated for months from the effective date of the SYSPREM enrollment up to:

1) The month in which the member is enrolled in a different carrier

2) The month in which the Member is cancelled

3) Actual Billing date

 

d.             SYSPREM in summary

i.             SYSPREM will enroll beneficiaries in history for cases where the enrollment cannot be applied to actual data.

ii.            Some members will not be enrolled in history because they are:

1) Not eligible at the effective date

2) Enrolled in a different carrier

iii.          Carriers need to evaluate cases rejected by SYSPREM in order to determine:

1) Errors in the effective date assigned

2)  Correctness  of  the  beneficiaries’  data  included  in  the enrollment record

 

V. Addendums

 

e.     Enrollment Record Layout

f.     Consistency Hierarchy Table

g.    Error Code Table

h.    Flow Diagram

 

  

  

  

Addendum – b

 

Enroll Relationship Requirements

 

ENROLLMENT RECORD DATA – BASIC FIELD RELATIONSHIP

	
TRANS_ID

	
CARRIER

	
Plan_TYPE

	
VERSION

	
Primary_Center

	
PCP1

	
PCP2

	
E – New Enrollment

	
Y

	
Y

	
Y

	
Y

	
Y

	
O

	
C – Change Carrier

	
Must be different 

to ASES DB

	
Y

	
Y

	
Y

	
Y

	
O

	
P – Plan change

	
Must be the same 

as in ASES DB

	
Must be different

to ASES DB

	
Y

	
Y

	
Y

	
O

	
V – Version Change

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be different 

to ASES DB

	
Y

	
Y

	
O

	
I – Change Primary Center

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be different 

to ASES DB

	
Y

	
O

	
1 – Change PCP1

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Y

	
N

	
2 – Change PCP2

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
N

	
Y

	
3 – Change PCP1 & PCP3

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Must be the same 

as in ASES DB

	
Y

	
Y

Y = Field must have data

N = The field must be blank

O = Use of this field is Optional

Notes:

	
1.

	
If the Plan Detail Table indicares that a a Primary Center of PCP is required the enrollment record must include date in those fields.

	
2.

	
If the Plan Detail Table indicares that a a Primary Center of PCP is not required the enrollment record must not include date in those fields.

	
3.

	
Retroactive Enrollment – For Plan_Type other than “01” (Reforma) any changes (Trans_ID not “E”) after the effective date will be treated as Retroactive Enrollments (Trans_ID = “E”).  Actual fields will be populated instead of new fields.

 

  

  

  

 

ENROLLMENT AND CARRIER IPA/PCP CHANGE FILE

 

	
November 1, 2007

	
This file is received by ASES from the insurance companies and TPO’s on a daily basis. It contains data pertinent to new enrollment and families which have selected to change their enrollment to the organization sending the file. Modified for Medicare Plan Enrollment on September 2005.  Concept change from one record per family enrolled to one record per member.  Modify to include special enroll field on novembre 2007.  Modified on April 2013 to include Trailer record for the Migration Project.

	
Member Record

	  	  	  
	
Record Fields

	
Position

	
Size

	
Notes

	
RECORD_TYPE

	
1

	
1

	
“E” for Enrollment Record (Constant)

	
 

TRAN_ID

	
2

	
1

	
E=new enrollment, P=Plan Type change, C=Carrier change, V= Version change, I=IPA change, 1=PCP1 change, 2=PCP2 change, 3=PCP1 and PCP2 change, X= Delete incorrect enrollment, O=Contract Number Change only

	
PROCESS_DATE

	
3

	
8

	
MMDDYYYY - Date Enrolled by Carrier

	
REGION

	
11

	
1

	
Region code

	
CARRIER

	
12

	
2

	
Carrier code

	
MEMBER_PRIMARY_CENTER

	
14

	
4

	
IPA or PHO code

	
ODSI_FAMILY_ID

	
18

	
11

	  
	
MEMBER_SSN

	
29

	
9

	  
	
MEMBER_SUFFIX

	
38

	
2

	  
	
EFFECTIVE_DATE

	
40

	
8

	
MMDDYYYY- Card issue date for new Reforma enrollment (Trans_ID= E) or Effective date (1st day of month) for other Trans_ID’s

	
PLAN_TYPE

	
48

	
2

	
See Plan Type Table

	
PLAN_VERSION

	
50

	
3

	
Used to identify version of Plan within PLAN_TYPE (if needed)

	
MPI

	
53

	
13

	
Alpha-numeric ej.-“0080012345678”

	
PCP1

	
66

	
15

	
Text

	
PCP1_EFFECTIVE_DATE

	
81

	
8

	
MMDDYYYY

	
PCP2

	
89

	
15

	
Text

	
PCP2_EFFECTIVE_DATE

	
104

	
8

	
MMDDYYYY

	
FAMILY_PRIMARY_CENTER

	
112

	
4

	
IPA or PHO code

	
FAM_PRIMARY_CENTER_EFF_DATE

	
116

	
8

	
MMDDYYYY

	
IPA_PCP_CHANGE_REASON

	
124

	
2

	
Code Table to be supplied

	
MEDICARE INDICATOR

	
126

	
2

	
1=A&B, 3=A, 9=B

	
HIC NUMBER

	
127

	
12

	  
	
Reject Identifier

	
 

139

	
 

1

	
“A” = Accepted; “M” =  MA Retroactive; “R” =  R ejected; 

“X” = Deleted

	
Record Key

	
140

	
14

	
YYYYMMDD999999

	
Error Code 1

	
154

	
3

	
Indicates error (see error code table)

	
Error Code 2

	
157

	
3

	
Indicates error (see error code table)

	
Error Code 3

	
160

	
3

	
Indicates error (see error code table)

	
Error Code 4

	
163

	
3

	
Indicates error (see error code table)

	
Error Code 5

	
166

	
3

	
Indicates error (see error code table)

	
Error Code 6

	
169

	
3

	
Indicates error (see error code table)

	
Error Code 7

	
172

	
3

	
Indicates error (see error code table)

	
Error Code 8

	
175

	
3

	
Indicates error (see error code table)

	
Error Code 9

	
178

	
3

	
Indicates error (see error code table)

	
Error Code 10

	
181

	
3

	
Indicates error (see error code table)

	
Update Date

	
184

	
8

	
YYYYMMDD

	
Update User

	
192

	
8

	
“SYSTUPD ”

	
IPA_ESPECIAL

	
200

	
1

	
1 = IPA Especial

	
Contract Number

	
201

	
13

	
Character left justified

	
Special Enroll

	
214

	
1

	
E = Emergency N = New Born

	
Filler

	
215

	
15

	  
	  	
230

	  	  

 

  

  

  

 

	
TRAILER Record

	  	  	  
	
Record Fields

	
Position

	
Size

	
Notes

	
RECORD_TYPE

	
1

	
7

	
“TRAILER” for Record (Constant)

	
FILLER

	
8

	
10

	
SPACES

	
NUMBER OF RECORDS

	
18

	
8

	
99999999 Numeric – right justified – zero filled

	
Filler

	
26

	
10

	
SPACES

	
Filler

	
36

	
3

	
“230” (Numeric Constant)

	
Filler

	
39

	
191

	
SPACES

	  	
230

	  	  

*** NUMBER OF RECORDS FILED CONTAINS THE SUM OF THE NUMBER OF RECORDS IN THE FILE NOR INCLUDING THE TRAILER.

 

  

  

  

Addendum – c

 

Error Code Table

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SUBSCRIPTION FILE ERROR DESCRIPTION

 

	
Error

Code

	
Error Message

	
Additional Description (where needed)

	
Possible Corrective Actions

	
011

	
Invalid Record Type

	  	
Must be “E”

	
021

	
Spaces in Trans ID.

	  	  
	
022

	
Invalid Trans ID.

	  	  
	
031

	
Spaces in Process Date.

	  	  
	
032

	
Invalid Process Date.

	  	  
	
033

	
Except for newborns enrollments, Process

Date should be less or equal than Effective Date and greater or equal than three months before Effective Date (Reforma)

	
For Mi Salud (Plan Type = 01) the Process Date must be equal or less  that the Effective Date. Effective Date has to be within 2 months of the Process Date.

	
Verify process date versus effective date.

	
034

	
If Tran_Id = “E” and Reform and

Process_Date >= 11/16/2006, then

Effective_Date cannot be 11/01/2006

	
Special edit for coverage conversion of

Nov.2006.

	  
	
035

	
Process Date should be less than Effective

Date and greater or equal than three months before Effective Date (Platino)

	
For Platino (Plan Type = 02 or 03) the Process Date must be  less  that the Effective Date. Effective Date has to be within 2 months of the Process Date.

	
Verify process date versus effective date.

	
036

	
Process Date should be greater or equal than

three months before

PCP1_EFFECTIVE_DATE

	
PCP1_EFFECTIVE_DATE can not be more

than 3 month greater that the process date.

	  
	
037

	
Process Date should be greater or equal than

three months before

PCP2_EFFECTIVE_DATE

	
PCP2_EFFECTIVE_DATE can not be more

than 3 month greater that the process date.

	  
	
038

	
Process Date should be greater or equal than

three months before

FAM_PRIMARY_CENTER_EFF_DATE

	
FAM_PRIMARY_CENTER_EFF_DATE can

not be more than 3 month greater that the process date.

	  
	
041

	
Spaces in Region

	  	  
	
042

	
Invalid Region

	  	  
	
  051

	
Spaces in Carrier

	  	  
	
052

	
Invalid Carrier

	  	  
	
053

	
Carrier equal to actual Carrier and is

requesting a change.

	
The enrollment has a C (carrier change) in the Tran_ID and the carrier is the same as the carrier in the member record in ASES.

	
Verify if the record should have been send with another Tran_ID (like V or I). If not the member is already enrolled and no further action should be required.

	
054

	
If plan type=01 and effective_date is future should be 1st of the month

	
Enrollments for future dates must have effective dates for the 1st of the month.

	  

 

  

  

  

 

	
055

	
Carrier not contracted in the municipality or region at the enrollment effective date.

	
Match Carriers_contracted table by Carrier and region. The effective date of the enrollment has to be within the effective and expiration dates of the selected carriers_contracted table record for that carrier and Region. Carrier must be contracted at the effective date of the enrollment. The enrollment record plan_type has to be 01 if the Reforma column is “Y”. Else the plan in the enrollment has to be “02” or “03”. The Plan_Type must match the carriers_contracted table record for the effective date of the enrollment. If the “Todos_Municipios” column is “N” then the municipality code in the member_eligibility record for the member in the enrollment record has to match one of the municipality codes in the selected table record. If some municipalities are contracted in a region then the municipality code must match.

	
Carrier should review member’s address an

insure that the municipality in included in the ASES contract.

	
056

	
Plan type = 01 and effective date is 20101001 at enrollment, and new_plan_type = 02 and new_carrier_eff_date is 20101001 at member_eligibility

	
This is a temporary error code to be operating during the month of September 2010 related to the October 1, 2010 conversion.

	  
	
057

	
Plan type = 01 and effective date is 20101001 at enrollment, and plan_type = 02 at member_eligibility

	
This is a temporary error code to be operating during the month of September 2010 related to the October 1, 2010 conversion.

	  
	
061

	
Trans ID in (“E”,“C”,“P”,“V”,“I”) and is required then Member Primary Center had spaces

	
Member Primary center is required when the

enrollment has a Tran_ID of “E”,“C”,“P”,“V”,“I” in Reforma or if the Platino Plan is identified as requiring Primary Center.

	  
	
062

	
Trans ID in (“1”,“2”,“3”) and Member PrimaryCenter is different from actual subscribed Primary Center.

	
The enrollment is for a PCP change but has aPrimary Center different from the one in the member record in ASES.

	
PCP changes are accepted if the record has thesame carrier, Plan Type, Version and IPA as the ASES database for the member. Check if the intention is to change both the IPA and the PCP and submit a IPA change (Tran_ID = I) with the new IPA and PCPs.

	
063

	
Primary Center equal to actual Primary Center

	
IPA change when the IPA in the ASES database for the member is the same.

	
Verify if the record should have been send with another Tran_ID. If not the member is already enrolled in the IPA and no further action should be required.

	
064

	
if Tran_ID=“D” should be space

	  	  
	
065

	
For the Special region. Invalid Member

Primary Center for Direct Contract Carrier. A record in our tables was not found for the given region, carrier, member_primary_center and effective_date.

	
Incorrect IPA in the enrollment record.

	
Verify and correct.

 

  

  

  

 

	
066

	
For any region other than Special. Invalid

Member Primary Center for Direct Contract Carrier. A record in our tables was not found for the given region, carrier, member_primary_center and effective_date.

	
Incorrect IPA in the enrollment record.

	
Verify and correct.

	
071

	
Spaces in Family ID

	  	  
	
072

	
Length of Family ID not equal 11

	  	  
	
073

	
Family ID Not Found

	
Family_Id not found in the region indicated in the enrollment record.

	
Verify if the family ID used is correct. Verify if the region code is the correct one for the member.

	
081

	
Spaces Member SSN

	  	  
	
082

	
Length of Member SSN not equal 9

	  	  
	
083

	
Member SSN Not Found

	  	
Verify if the Member SSN used is correct. Verify if the region code is the correct one for the member.

	
091

	
Spaces in Member Suffix

	  	  
	
092

	
Length of Member Suffix not equal 2

	  	  
	
093

	
Member Suffix Not Found in ASES Eligibility

	
No record for the member found in the ASES database.

	
Verify that the assignment of the Suffix in the carrier database coincides with ASES. If the family_id or the Member SSN is also in error this code will appear.

	
101

	
Spaces in Effective Date

	  	  
	
102

	
Invalid Effective Date

	  	  
	
103

	
In Enroll and Reform, effective date should be less than run process date

	
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the Effective Date has to be less than the run date. It is assumed that the member was enrolled before the enrollment record was sent to ASES. Original enrollments are not for future periods.

	
Verify dates and correct.

	
104

	
Other than Enroll and Reform, effective date should be greater than daily process date and 1st of the month.

	
For Reforma (Plan Type = 01) where the Tran_ID is not E the effective date must be greater than the run date and 1st of the month.

	
Verify dates and correct.

	
105

	
Other than Reform, effective date should be

1st of the month.

	  	  
	
106

	
if TRAN_ID IN (“D”) then effective date should

be 1st of the month

	  	  
	
107

	
EFFECTIVE DATE SHOULD BE DURING

THE LAST ACTIVE PERIOD FOR THE FAMILY

	
The family to which the member belongs was cancelled after the effective date in the enrollment record.

	
This cases will be submitted to be  enrolled in history under the new version of the enrollment system (SYSPREM).

	
108

	
EFFECTIVE DATE SHOULD BE DURING

THE LAST ACTIVE PERIOD FOR THE MEMBER

	
The the member was cancelled after the effective vdate in the enrollment record.

	
This cases will be submitted to be  enrolled in history under the new version of the enrollment system (SYSPREM).

 

  

  

  

 

	
109

	
There should be records for family at

family_eligibility_history at or before effective_date except for special_enroll in (‘E’,‘N’)

	
The family was not eligible at the effective date in the enrollment record.

	
Verify the Effective Date submitted and correct.

Verify if the enrollment should be identified as new born or emergency and correct accordingly.

	
10A

	
If special_enroll = ‘E’, effective date should be at least as recent as the family eligibility effective date.

	
For emergencies the effective date can not be less that the family eligibility effective date.

	
Verify and correct.

	
10B

	
If special_enroll = ‘N’, effective date should be at least as recent as member birth date and effective date should not be more than a year forward from the birth date

	
For new borns the effective date can not be less than the birth date or a year after the birth date.

	
Verify and correct.

	
111

	
Spaces in Plan Type

	  	  
	
112

	
Length of Plan Type not equal 2

	  	  
	
113

	
Invalid Plan Type,Carrier and Plan Version

	
Enrollment records have to match the Plan

Type and Plan Version contracted by the carrier with ASES.

	
Verify and correct.

	
114

	
if Trans_ID=“D” should be “01”

	  	  
	
121

	
Spaces in Plan Version

	  	  
	
122

	
Length of Plan Version not equal 3

	  	  
	
123

	
Invalid Plan Version

	  	
Verify that the Plan, Version in the enrollment is the Plan Version contracted with ASES.

	
124

	
if Trans_ID=“D” should be “001”

	  	  
	
131

	
Length of MPI Number not equal 13

	  	  
	
132

	
MPI Number Not Found in ASES Eligibility

	  	
Verify that the correct MPI was used.  Verify if the region code is the correct one for the member.

	
141

	
Spaces in PCP1 when Tran ID <> “2” <>“D” is required.

	
For enrollments where the PCP1 is required

the PCP1 Field must not be in spaces.

	  
	
142

	
PCP1 should be spaces when Tran ID = “2”

=“D”

	
For changes in PCP2 the PCP1 field must be

spaces.

	  
	
151

	
Spaces in PCP1 Effective Date when Tran ID

<> “2” <>“D” is required.

	
Spaces or invalid date was entered in PCP1

Effective Date in enrollments where PCP1 is required.

	
Verify and correct.

	
152

	
Invalid PCP1 Effective Date when Tran ID <>

“2” <> “D” is required.

	  	  
	
153

	
PCP1 Effective Date whitout spaces when

Tran ID <> “2” <> “D” is not required.

	
PCP1 effective date must be in spaces when the enrollment is not for a PCP2 change and PCP1 is not required.

	
Verify and correct.

	
154

	
PCP1 Effective Date should be spaces when

Tran ID = “2”

	
PCP1 effective date must be in spaces when the enrollment is  for a PCP2 change.

	
Verify and correct.

	
155

	
In Enroll, PCP1 effective date should be less

than run process date

	
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the PCP1 Effective Date has to be less than the run date. It is assumed that the member was enrolled before the enrollment record was sent to ASES. Original enrollments are not for future periods.

	
Verify and correct.

	
156

	
Other than Enroll, PCP1 effective date should be 1st of the month.

	  	  

 

  

  

  

 

	
157

	
if PCP1 not null PCP1_effective_Date should

be not null and viceversa

	
When there is data in the PCP1 field there should be a valid date in the PCP1 Effective Date field and vice versa.

	
Verify and correct.

	
158

	
if new enroll, carrier change or ipa change,

and PCP1 not null, PCP1_effective_Date should be same as Effective_Date. if plan type change, plan version change, pcp1 change or pcp1 and pcp2 change, and PCP1 not null, PCP1_effective_Date should be greater or equal than Effective_Date in member_eligibility.

	  	
Verify and correct.

	
161

	
Spaces in PCP2 when If Trans_ID in (“2”, “3”)

	
Tran_ID 2 and 3 require data in PCP2 field.

	
Verify and correct.

	
162

	
PCP2 should be spaces when If Trans_ID not

in (“2”, “3”)

	  	  
	
171

	
Spaces in PCP2 Effective Date when If

Trans_ID in (“2”, “3”)

	
Tran_ID 2 and 3 require date in PCP2 effective Date field field.

	
Verify and correct.

	
172

	
Invalid PCP2 Effective Date when Tran ID <> “2”

	
Invalid data in PCP2 Effective Data

	  
	
173

	
In Enroll, PCP2 effective date should be less

than run process date

	
For Reforma (Plan Type = 01) original enrollment (Tran_ID = E) the PCP2 Effective Date has to be less than the run date. It is assumed that the member was enrolled before the enrollment record was sent to ASES. Original enrollments are not for future periods.

	
Verify and correct.

	
174

	
Other than Enroll, PCP2 effective date should be 1st of the month.

	  	  
	
175

	
if PCP2 not null PCP2_effective_Date should be not null and viceversa

	
When there is data in the PCP2 field there should be a valid date in the PCP2 Effective Date field an dvice versa.

	  
	
176

	
if Tran_ID=“D” should be null

	  	  
	
177

	
Enrolled in other carrier at or after enrollment

Effective Date

	
The member was enrolled in another carrier after the effective date in the enrollment record

	  
	
178

	
if new enroll, carrier change or ipa change,

and PCP2 not null, PCP2_effective_Date should be same as Effective_Date. if plan type change, plan version change, pcp2 change or pcp1 and pcp2 change, and PCP2 not null, PCP2_effective_Date should be greater or equal than Effective_Date in member_eligibility.

	  	
Verify and correct.

	
179

	
Future subscription already set for another

carrier at enrollment future Effective Date

	  	  
	
181

	
Is required then Family Primary Center had

spaces

	
family Primary Center required for Reforma

	  
	
182

	
Is not required and Family Primary Center

didn’t had spaces.

	  	  
	
183

	
if Tran_ID = “D” should be space

	  	  
	
191

	
Is required and Family Primary Center

Effective Date have spaces

	  	  
	
192

	
Incorrect Family Primary Center Effective

Date

	  	  
	
193

	
Is not required and Family Primary Center

Effective Date did not have spaces

	  	  
	
194

	
if Tran_ID=“D” should be null

	  	  
	
200

	
if Tran_ID = “D” should be space

	  	  

 

  

  

  

 

	
 211

	
Incorrect Plan and Version:  Members is not

Federal Medicaid

	
The Plan Type and Version contracted by the

carrier require that the member be Federal Medicare and the ASES database indicates the member is not Federal Medicare.

	  
	
221

	
Duplicate Enrollment

	
Two enrollment records entered in the same

daily run for the same member as defined by

Family_ID and Suffix.

	  
	
222

	
Already Enroll in the Same Carrier

	
When the Tran_ID is E and the ASES

database has the member as enrolled in the same carrier

	
Verify if the record should have been send with another Tran_ID (like V or I). If not the member is already enrolled and no further action should be required.

	
223

	
Already Enroll in Other Carrier

	
When the Tran_ID is E and the ASES

database has the member as enrolled in another carrier.

	
Verify if the record should have been send with a carrier change Tran_ID (E).

	
224

	
Member Not Eligible At Carrier Effective Date

	  	  
	
225

	
Incorrect SSN

	  	  
	
226

	
Incorrect MPI

	  	  
	
227

	
Trans ID = “P” and Carrier is different from

actual subscribed Carrier.

	
Only the current carrier in the ASES database can submit a Plan Change enrollment record. The Member is enrolled under a different carrier in the ASES database.

	
 Verify if the record should have been send with another Tran_ID.

	
228

	
Trans ID = “V” and Carrier or Plan Type are

different as the actual data.

	
Version changes are allowed under the same carrier and Plan Type. Only the current carrier in the ASES database can submit a Version Change enrollment record. The Member is enrolled under a different carrier or Plan Type in the ASES database.

	
 Verify if the record should have been send with another Tran_ID

	
229

	
Trans ID = “I” and Carrier or Plan Type or

Version are different as the actual data.

	
Ipa changes are allowed under the same carrier, Plan Type and Version. Only the current carrier in the ASES database can submit a IPA Change enrollment record. The Member is enrolled under a different carrier or Plan Type or Version in the ASES database.

	
Verify if the record should have been send with another Tran_ID

	
22A

	
Trans ID in (“1”, “2”, “3”) and Carrier orPlan

Type or Version or Primary Center  are different as the actual data.

	
PCP changes are allowed under the same carrier, Plan Type, Version and IPA. Only the current carrier in the ASES database can submit a PCP Change enrollment record. The Member is enrolled under a different carrier or Plan Type or  version or IPA in the ASES database.

	
 Verify if the record should have been send with another Tran_ID

	
22B

	
if TransID=3 , PCP1 and PCP2 both effective dates must be future or retroactive dates

	  	  
	
22C

	
Member in the same family should be in the

same carrier,plan_type,version,primary center, PCP1, PCP2

	
For Reforma members in a family.

	  
	
22D

	
Invalid new field date values

	
Effective date can not be greater than run date by more than 4 months

	  
	
22E

	
if PLAN_TYPE=“01”  then PLAN_VERSION

should be the same as the

COVERAGE_CODE

	
In Enrollment record for Reform (Plan Type

01) beneficiaries the Version field must match the coverage code field in the ASES database for the member being enrolled.

	
Verify and correct.

 

  

  

  

 

	
22F

	
if PLAN_TYPE=“01” and exists an Error_code

in one family_id all member are rejected

	
When and enrollment record for one family member has errors, all the family members are given the 22F error code. This Keeps all the enrollment record for a family together and avoids partial processing of the family members in the same run.

	
 

 

 

Correct the errors other than 22F in all family Members.

	
22G

	
if PLAN_TYPE=“02” or “03” (Platino) then

PLAN_VERSION in the Enrollment record should match the PLAN_VERSION with the same COVERAGE_CODE assigned in the Plan Detail table.

	
For Platino enrollments: The member Coverage Code is assigned a specific Version in the Plan Detail Table. If a different Version is used this error will be produced. For members with Coverage  Code 012 or 013 the Version for Coverage Code 011 must be used.

	
  

Correct Version and submit Enrollment again.

	
241

	
When Plan Type =1  and new enrollment

	  	  
	
242

	
carrier change to plan type =1 and alredy

exist in Member eligibility table

	  	  
	
250

	
if Tran_ID = “D” should be space

	  	  
	
260

	
if Tran_ID = “D” should be space

	  	  
	
270

	
if Tran_ID=“D” should be null

	  	  
	
280

	
Family should be elegible

	  	  
	
281

	
Member should be eligible

	  	  
	
980

	
Record already enrolled in history has higher or equal process date.

	  	  
	
981

	
Rejected family member has errors not accepted by SYSPREM.

	  	  

	
982

	
Effective Date before ‘01/01/2006’

	  	  
	
983

	
Already subscribed in the same Carrier at the specified Effective Date.

	  	  
	
984

	
Tran_Id = ‘E’, Effective Date is not 1st of the month and member is already subscribed in another Carrier.

	  	
Must be resubmitted as a carrier change (tran_id = “C”. Effective date must be 1st of the  following month.

	
985

	
If special_enroll = ‘E’, effective date should be at least as recent as member certification date at the specified Effective Date.

	  	  
	
986

	
For SYSPREM processing, the Effective Date should be before the Effective Date of the current record at Member Eligibility.

	  	
Verify Effective Date.

	
995

	
Had 22F but was re-evaluated because the records with errors in its family were processed by SYSPREM.

	  	  
	
996

	
Processed by SYSPREM

	
Not an Error

	
No Action Should be taken.

	
998

	
Spaces in Record Key.

	
Not an Error

	
 No Action Should be taken.

	
999

	
New Case with a Record Key.

	
Not an Error

	
 No Action Should be taken.

 

  

  

  

 

Addendum d - Carrier Eligibility File Layout

CARRIER ELIGIBILITY FILE

MEMBERS RECORD

 

CARRIER ELIGIBLITY OUTPUT FILE

 

This file is created by the HCRE export program and contains the demographic and eligibility information sent to ASES from the Department of Health and verified by ASES as eligible for Health Reform. Modified on May 2003 for the direct contracting pilot project.

Modified on March 2004 for Smartcard project. See entries in bold and highlighted.

Modified on Sept. 2005 for Medicare Project. Modified August 2006 to add Coverage Fiels for new PSG contrating. 

Modified on January 2008 to add tran_id = H for sysprem records. Modify for Mediti on January 2011.

 

	
# Field

	
Record Fields

	
Position

	
Size

	
Notes

	
1

	
RECORD-TYPE

	
1

	
1

	
“M” for member

	
2

	
TRAN-ID

	
2

	
1

	
E=eligible, I=ineligible, R=reject, H= SYSPREM (history)

	
3

	
PROCESS-DATE

	
3

	
8

	
MMDDYYYY

	
4

	
FAMILY-SSN

	
11

	
9

	
SSN of Head-of-Household

	
5

	
FAMILY-SUFFIX

	
20

	
2

	
Zero fill, right justify.

	
6

	
FILLER

	
22

	
1

	  
	
7

	
MEMBER-SSN

	
23

	
9

	  
	
8

	
MEMBER-SUFFIX

	
32

	
2

	  
	
9

	
FILLER

	
34

	
14

	  
	
10

	
1ST-LAST-NAME

	
48

	
15

	  
	
11

	
2ND-LAST-NAME

	
63

	
15

	  
	
12

	
FIRST-NAME

	
78

	
20

	  
	
13

	
MIDDLE-INITIAL

	
98

	
1

	  
	
14

	
RELATIONSHIP

	
99

	
1

	  
	
15

	
DATE-OF-BIRTH

	
100

	
8

	
MMDDYYYY

	
16

	
PLACE-OF-BIRTH

	
108

	
1

	  
	
17

	
SEX

	
109

	
1

	  
	
18

	
CATEGORY

	
110

	
1

	  
	
19

	
CATEGORY-2

	
111

	
1

	  
	
20

	
CONDITION

	
112

	
1

	  
	
21

	
SOURCE-CODE

	
113

	
1

	  
	
22

	
RECEIVE-SS

	
114

	
1

	  
	
23

	
MED-INS-CODE

	
115

	
1

	
Zero fill, right justify.

	
24

	
POLICY

	
116

	
2

	  
	
25

	
CLASS

	
118

	
1

	  
	
26

	
CLASS-2

	
119

	
1

	  
	
27

	
DENIAL-CAT

	
120

	
1

	  
	
28

	
DENIAL-CAT-2

	
121

	
1

	  
	
29

	
MARITAL-STATUS

	
122

	
1

	  
	
30

	
SSN

	
123

	
9

	  
	
31

	
PREG-IND

	
132

	
1

	  
	
32

	
ABSENT-PARENT

	
133

	
1

	  
	
33

	
HICN

	
134

	
11

	  
	
34

	
PILOT-CAT

	
145

	
1

	  
	
35

	
PILOT-CLASS

	
146

	
1

	  
	
36

	
PILOT-DENIAL

	
147

	
1

	  
	
37

	
HCRE-ELIGIBILITY-IND

	
148

	
1

	  
	
38

	
HCRE-DENIAL-CODE

	
149

	
2

	
Zero fill, right justify.

	
39

	
OTHER-INSURER1

	
151

	
2

	
Insurance co. code NOT USED

	
40

	
OTH_POLICY1

	
153

	
20

	
Policy number NOT USED

	
41

	
OTHER-INSURER2

	
173

	
2

	
Insurance co. code NOT USED

	
42

	
OTH_POLICY2

	
175

	
20

	
Policy number NOT USED

	
43

	
OTHER-INSURER3

	
195

	
2

	
Insurance co. code NOT USED

	
44

	
OTH_POLICY3

	
197

	
20

	
Policy number NOT USED

 

  

  

  

 

	
45

	
GROUP-IDENT

	
217

	
2

	
“06” - ELA, “02” - Veteran, “22” - Small Bus. Zero fill, right justify.

	
46

	
ODSI-FAMILY-NO

	
219

	
11

	
“Gx”+HOH SSN for ELA (x=0,1,2 ... by subscription period)

	
47

	
ELA-ERRORS

	
230

	
10

	
5 2-digit error codes for ELA-SB-Vet

	
48

	
AGENCY

	
240

	
5

	
Agency # for ELA / Group Num for SB. Zero fill, right justify.

	
49

	
MASTER PATIENT INDEX (MPI)

	
245

	
13

	  
	
50

	
MEMBER CERTIFICATION DATE

	
258

	
8

	
MMDDYYYY

	
51

	
CONTRACT NUMBER

	
266

	
13

	
Include Suffix.

	
52

	
MEMBER PRIMARY CENTER

	
279

	
4

	  
	
53

	
MEMBER PRIMARY CENTER EFFECTIVE DATE

	
283

	
8

	
MMDDYYYY

	
54

	
MEMBER NEW PRIMARY CENTER

	
291

	
4

	  
	
55

	
MEMBER NEW PRIMARY CENTER EFFECTIVE DATE

	
295

	
8

	
MMDDYYYY

	
56

	
PCP1

	
303

	
15

	  
	
57

	
PCP1 EFFECTIVE DATE

	
318

	
8

	
MMDDYYYY

	
58

	
PCP2

	
326

	
15

	  
	
59

	
PCP2 EFFECTIVE DATE

	
341

	
8

	
MMDDYYYY

	
60

	
NEW PCP1

	
349

	
15

	  
	
61

	
NEW PCP1 EFFECTIVE DATE

	
364

	
8

	
MMDDYYYY

	
62

	
NEW PCP2

	
372

	
15

	  

	
63

	
NEW PCP2 EFFECTIVE DATE

	
387

	
8

	
MMDDYYYY

	
64

	
CARD ID NUMBER

	
395

	
15

	  
	
65

	
CARD ID DATE

	
410

	
8

	
MMDDYYYY

	
66

	
ELA INDICATOR

	
418

	
1

	
1=NO PREMIUM

2=PREMIUM

Spaces when not ELA.

	
67

	
PRIMARY CENTER PCP CHANGE REASON

	
419

	
2

	
Based on the Reason of Code table.

	
68

	
MEDICAID INDICATOR

	
421

	
1

	
1=Medicaid Federal, 2=SCHIPS 3=Estatal4= Estatal other

	
69

	
MEDICARE INDICATOR

	
422

	
1

	
1=A&B, 3=A, 9=B

	
70

	
CARRIER

	
423

	
2

	  
	
71

	
CARRIER_EFF_DATE

	
425

	
8

	
MMDDYYYY

	
72

	
NEW_CARRIER

	
433

	
2

	  
	
73

	
NEW_CARRIER_EFF_DATE

	
435

	
8

	
MMDDYYYY

	
74

	
PLAN_TYPE

	
443

	
2

	
“bb”=eligible not enrolled, See Plan Type table

	
75

	
PLAN_TYPE_EFF_DATE

	
445

	
8

	
MMDDYYYY

	
76

	
PLAN_VERSION

	
453

	
3

	
Version of MA plan enrolled

	
77

	
PLAN_VERSION_EFF_DATE

	
456

	
8

	
MMDDYYYY

	
78

	
NEW_PLAN_TYPE

	
464

	
2

	  
	
79

	
NEW_PLAN_TYPE_EFF_DATE

	
466

	
8

	
MMDDYYYY

	
80

	
NEW_PLAN_VERSION

	
474

	
3

	  
	
81

	
NEW_PLAN_VERSION_EFF_DATE

	
477

	
8

	
MMDDYYYY

	
82

	
INSTITUTIONAL_STATUS

	
485

	
1

	
Y or N

	
83

	
HIC NUMBER MA

	
486

	
12

	  
	
84

	
AUTO_ENROLL_INDICATOR

	
498

	
1

	
0 = Not Auto; >0 = Auto Enroll

	
85

	
AUTO_ENROLL_DATE

	
499

	
8

	
MMDDYYYY

	
86

	
IPA_ESPECIAL

	
507

	
1

	
1 = IPA Special

	
87

	
CMS_Cert_Status

	
508

	
2

	
Status of certification in CMS

	
88

	
Coverage_Code

	
510

	
3

	  
	
89

	
New Contract Number

	
513

	
13

	  
	  	
Special_Enroll

	
526

	
1

	
E = Emergency N = New Born

	
90

	
FILLER

	
527

	
13

	  
	  	
540

	  

*** All are Text Fields

  

  

  

CARRIER ELIGIBILITY FILE

FAMILY RECORD

 

CARRIER ELIGIBLITY OUTPUT FILE

 

This file is created by the DAILY export program and contains the demographic and eligibility information sent to ASES from the Department of Health and verified by ASES as eligible for Health Reform.  (Modified on May 2003 for the direct contracting pilot project. See entries in bold. Modified on March 2004 for Smartcard project.  See entries in bold and highlighted. Modified on July 2005 for Medicare Project. Modified on January 2008 to add tran_id = H for sysprem records.) Modified for Mediti on January 2011.

 

	
# Field

	
Record Fields

	
Position

	
Size

	
Notes

	
1

	
RECORD-TYPE

	
1

	
1

	
“F” for family

	
2

	
TRAN-ID

	
2

	
1

	
E=eligible, I=ineligible, R=reject, H= SYSPREM (history)

	
3

	
PROCESS-DATE

	
3

	
8

	
MMDDYYYY

	
4

	
FAMILY-SSN

	
11

	
9

	
SSN of Head-of-Household(HOH)

	
5

	
FAMILY-SUFFIX

	
20

	
2

	
“00”

	
6

	
FILLER

	
22

	
14

	  
	
7

	
ODSI-FAMILY-ID

	
36

	
11

	
“Gx”+HOH SSN for ELA (x=0,1,2 ... by subscription period)

	
8

	
HOH-1ST-LAST-NAME

	
47

	
15

	  
	
9

	
HOH-2ND-LAST-NAME

	
62

	
15

	  
	
10

	
HOH-FIRST-NAME

	
77

	
20

	  
	
11

	
REGION

	
97

	
1

	  
	
12

	
MUNICIPALITY

	
98

	
4

	
Zero fill, right justify.

	
13

	
FACILITY

	
102

	
4

	  
	
14

	
INVESTIGATION-IND

	
106

	
1

	  
	
15

	
TRANSACTION-TYPE

	
107

	
1

	  
	
16

	
EFFECTIVE-DATE

	
108

	
8

	
Start date of eligibility MMDDYYYY

	
17

	
FINANCIAL-RESP-PCT

	
116

	
1

	  
	
18

	
CERTIFIER-NUMBER

	
117

	
2

	  
	
19

	
EXPIRATION-DATE

	
119

	
8

	
End date of eligibility MMDDYYYY

	
20

	
COND-ELIG-IND

	
127

	
1

	  
	
21

	
MAILING-ADDRESS1

	
128

	
25

	  
	
22

	
MAILING-ADDRESS2

	
153

	
25

	  
	
23

	
MAILING-CITY

	
178

	
16

	  
	
24

	
MAILING-ZIP

	
194

	
5

	  
	
25

	
MAILING-ZIP4

	
199

	
4

	  
	
26

	
RESIDENCE-ADDRESS1

	
203

	
25

	  
	
27

	
RESIDENCE-ADDRESS2

	
228

	
25

	  
	
28

	
RESIDENCE-CITY

	
253

	
16

	  
	
29

	
RESIDENCE-ZIP

	
269

	
5

	  
	
30

	
RESIDENCE-ZIP4

	
274

	
4

	  
	
31

	
PHONE

	
278

	
7

	  
	
32

	
OTHER-INSURER1

	
285

	
2

	
Insurance co. code Not USED

	
33

	
OTH-POLICY1

	
287

	
20

	
Policy number NOT USED

	
34

	
OTHER-INSURER2

	
307

	
2

	
Insurance co. code NOT USED

	
35

	
OTH-POLICY2

	
309

	
20

	
Policy number NOT USED

	
36

	
OTHER-INSURER3

	
329

	
2

	
Insurance co. code NOT USED

	
37

	
OTH-POLICY3

	
331

	
20

	
Policy number NOT USED

	
38

	
MEMBERS

	
351

	
2

	
# members in family

	
39

	
ODSI-MEMBERS-ELIGIBLE

	
353

	
2

	
# members eligible ODSI / optionals ELA-SB-Vet

	
40

	
USER-CODE

	
355

	
6

	  
	
41

	
ENTRY-DATE

	
361

	
8

	
MMDDYYYY

	
42

	
PCT-OF-POVERTY-LEVEL

	
369

	
3

	  
	
43

	
DEDUCTIBLE-LEVEL-CODE

	
372

	
1

	  
	
44

	
HCRE-MEMBERS-ELIGIBLE

	
373

	
2

	
# members eligible by ASES. Zero fill, right justify.

	
45

	
HCRE-DENIAL-CODE

	
375

	
2

	
Zero fill, right justify.

 

  

  

  

 

	
46

	
CARRIER-CODE

	
377

	
2

	  
	
47

	
EFFECTIVE-CARRIER-DATE

	
379

	
8

	
For Family Carrier . MMDDYYYY

	
48

	
ELA-ERRORS

	
387

	
10

	
5 2-digit error codes for ELA-SB-Vet

	
49

	
MANCOMUNADO

	
397

	
1

	
Y / N (ELA Only)

	
50

	
FILLER

	
398

	
3

	  
	
51

	
Family-PRIMARY-CENTER

	
401

	
4

	
IPA or PHO

	
52

	
NEW-CARRIER

	
405

	
2

	
New carrier code

	
53

	
NEW-Family-PRIMARY-CENTER

	
407

	
4

	
new IPA or PHO for families changing carrier

	
54

	
NEW-Family-PRIMARY CENTER EFFECTIVE DATE

	
411

	
8

	
MMDDYYYY - effective date of IPA/PHO change

	
55

	
CONTRACT NUMBER

	
419

	
13

	
Common part of Contract

	
56

	
REGION ASES

	
432

	
1

	  
	
58

	
NEW CARRIER EFFECTIVE DATE

	
433

	
8

	
New Carrier MMDDYYYY

	
59

	
FAMILY PRIMARY CENTER EFFECTIVE DATE

	
441

	
8

	
MMDDYYYY

	
60

	
CERTIFICATION DATE

	
449

	
8

	
MMDDYYYY

	
61

	
PRIMARY CENTER PCP CHANGE REASON

	
457

	
2

	
Base on Reason Code table.

	
62

	
AUTO_ENROLL_INDICATOR

	
459

	
1

	
0 = Not Auto; >0 = Auto Enroll

	
63

	
AUTO_ENROLL_DATE

	
460

	
8

	
MMDDYYYY

	
64

	
PAM NEW FAMILY ID

	
468

	
11

	
New Family_Id assigned by PAM for Meditis.  Use as a reference only.

	
65

	
FILLER

	
479

	
61

	  
	  	
540

	  

*** All are Text Fields

 

  

  

  

 

CARRIER ELIGIBILITY OUTPUT FILE – Insurance Record

This file is created by the HCRE export program and contains the demographic and eligibility information sent to ASES from the Department of Health and verified by ASES as eligible for Health Reform.  This Insurance Record is added for the Meditis Implementaion on Februar 2011.

 

	
# Field

	
Record Fields

	
Position

	
Size

	
Notes

	
1

	
RECORD-TYPE

	
1

	
1

	
“I” for Insurance

	
2

	
TRAN-ID

	
2

	
1

	
E=eligible

	
3

	
PROCESS-DATE

	
3

	
8

	
MMDDYYYY

	
4

	
ODSI-FAMILY-ID

	
11

	
11

	  
	
5

	
Member Suffix

	
22

	
2

	  
	
6

	
Health Insurer Code

	
24

	
3

	
 Code identifies Insurance Company

	
7

	
Policy Number

	
27

	
20

	  
	
8

	
Policy-EXPIRATION DATE

	
47

	
8

	  
	
9

	
Covered Services

	
55

	
40

	
 20 coverage code filed (2 characters each)

	
10

	
FILLER

	
95

	
445

	  
	  	  	
540

	  	  

*** All are text fields

 

  

  

  

 

Addendum – e

 

Flow Diagram

 

 

  

  

  

 

ASES 820 Mapping

 

 

 

  

  

  

 

 

 

  

  

  

 

 

  

  

  

 

 

 

  

  

  

 

 

 

  

  

  

 

 

 

  

  

  

 

 

  

  

  

 

ASES Query Process

ASES QUERY FILE

 

	
  ELIGIBILITY QUERY FILE LAYOUT

	  
	
  August 1, 2008

	  
	
This file is produced by MA Carriers and sent to ASES to verify the elegibility of Medicare Beneficiaries in the GHIP (Reforma).

 

	  
	
 Query Record

	
 # Field

	
 Record Fields

	
Position

	
Size

	
Notes

	
 1

	
 RECORD TYPE

	
1

	
1

	
“Q” for Query

	
 2

	
 PROCESS DATE

	
2

	
8

	
YYYYMMDD

	
 3

	
 BENEFICARY SSN

	
10

	
9

	  
	
 4

	
 1ST LAST NAME

	
19

	
15

	  
	
 5

	
 2ND LAST NAME

	
34

	
15

	  
	
 6

	
 FIRST NAME

	
49

	
20

	  
	
 7

	
 SEX

	
69

	
1

	
1 = Male, 2 = Female

	
 8

	
 DATE OF BIRTH

	
70

	
8

	
YYYYMMDD

	
 9

	
 REGION

	
78

	
1

	  
	
 10

	
 CARRIER

	
79

	
2

	
Carrier Code

	
 11

	
 EFFECTIVE DATE

	
81

	
8

	
For historical queries.  Enter the enrollment date for the enrollee.  YYYYMMDD Fortmat.  Day must be the first of the month.  If the query is not hystorical, leave in blank.

 

	
 12

	
 FILLER

	
89

	
11

	  
	  	
100

	  

 

*** All are Text Fields

  

  

  

 

	
QUERY RESPONSE FILE LAYOUT

	  
	
October 20, 2008

	  
	
This file is sent by ASES to Carriers as a response to query records. The Response Record informs if a Beneficiary is elegible for GHIP (Reform) coverage. It provides the key data elements which the Carrier will use to notify enrollment to ASES once approved by CMS.

 

	
Query Response Record

	
# Field

	
 Record Fields

	
Position

	
Size

	
Notes

	
1

	
 RECORD_TYPE

	
1

	
1

	
“R” for Response

	
2

	
 CARRIER_PROCESS_DATE

	
2

	
8

	
YYYYMMDD

	
3

	
 BENEFICARY SSN

	
10

	
9

	  
	
4

	
 CARRIER_1ST_LAST_NAME

	
19

	
15

	  
	
5

	
 CARRIER_2ND_LAST_NAME

	
34

	
15

	  
	
6

	
 CARRIER_FIRST_NAME

	
49

	
20

	  
	
7

	
 CARRIER_SEX

	
69

	
1

	
1 = Male, 2 = Female

	
8

	
 CARRIER_DATE OF BIRTH

	
70

	
8

	
YYYYMMDD

	
9

	
 CARRIER_REGION

	
78

	
1

	  
	
10

	
 CARRIER

	
79

	
2

	
Carrier Code

	
11

	
 ASES_1ST_LAST_NAME

	
81

	
15

	  
	
12

	
 ASES_2ND_LAST_NAME

	
96

	
15

	  
	
13

	
 ASES_FIRST_NAME

	
111

	
20

	  
	
14

	
 ASES_SEX

	
131

	
1

	
1 = Male, 2 = Female

	
15

	
 ASES_DATE OF BIRTH

	
132

	
8

	
YYYYMMDD

	
16

	
 ASES_REGION

	
140

	
1

	  
	
17

	
 ELEGIBILITY_INDICATOR

	
141

	
1

	
Y or N

	
18

	
 ODSI FAMILY ID

	
142

	
11

	  
	
19

	
 MEMBER SUFFIX

	
153

	
2

	  
	
20

	
 MPI

	
155

	
13

	
Alpha-numeric ej.-”0080012345678”

	
21

	
 MEDICAID INDICATOR

	
168

	
1

	
1 = Federal Medicaid

	
22

	
 ELEGIBILITY_EFFECTIVE_DATE

	
169

	
8

	
YYYYMMDD

	
23

	
 ELEGIBILITY_EXPIRATION_DATE

	
177

	
8

	
YYYYMMDD

	
24

	
 ASES_PROCESS_DATE

	
185

	
8

	
YYYYMMDD

	
25

	
 MESSAGE_CODE

	
193

	
6

	
Spaces= no errors, 01=SSN no match, 02=Sex no match, 03=DOB no match, 04=Region no match, 05=Miembro de municipio no contratado por Carrier, 06=Empleado ELA, 07=SSN no match (history records)

 

	
26

	
 ASES_DEDUCTIBLE_LEVEL

	
199

	
1

	  
	
27

	
 MUNICIPIO

	
200

	
4

	
Codigo Municipio en ASES

	
28

	
 FECHA DE EFECTIVIDAD

	
204

	
8

	
Para uso en queries historicos. Formato YYYYMMDD.

	
29

	
 CODIGO DE CUBIERTA

	
212

	
3

	
Codigo de Cubierta (Coverage Code)

	
30

	
 FILLER

	
215

	
5

	  
	  	
220

	  

 

  

  

  

 

 

  

  

  

 

Carrier to ASES Data Submissions

 New File Layouts

Version 1.7C

March 07, 2011

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

Carrier to ASES Data Submissions

File Layouts

 

TABLE OF CONTENTS

 

	
Version Changes

	
5

	  	  
	
NOTES

	
14

	
Changes and Additions in Data File Layouts

	
14

	
General Notes on data layout requirements

	
20

	
File Naming Convention

	
23

	  	  
	
SERVICES INPUT FILE LAYOUT

	
27

	  	  
	
CLAIMS INPUT FILE LAYOUT

	
35

	  	  
	
PROVIDERS INPUT FILE LAYOUT

	
41

	  	  
	
IPA INPUT FILE LAYOUT

	
44

	  	  
	
CAPITATION INPUT FILE LAYOUT

	
46

	  	  
	
ERROR RETURN FILE LAYOUT

	
48

	  	  
	
CLAIMS PROCESSING SUMMARY FILE LAYOUT

	
49

	  	  
	
File Processing CODES

	
50

	  	  
	
File Validation ERROR CODES

	
51

	  	  
	
File Validation WARNING CODES

	
57

	 	 

 

	
 ATTACHMENTS

	
58

	  	  
	
ATTACHMENT I - MUNICIPALITY CODES

	
59

	  	  
	
ATTACHMENT II - CARRIER CODES

	
63

	  	  
	
ATTACHMENT III - SPECIALTY CODES

	
65

	  	  
	
ATTACHMENT IV - PLACE OF SERVICE CODES

	
71

	  	  
	
ATTACHMENT V

	
77

	  	  
	
ATTACHMENT VI - PROVIDER TYPE CODES

	
78

	  	  
	
ATTACHMENT VII - CLAIMS / SERVICES BASIC FLOW OVERVIEW

	
79

 

  

  

  

 

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Carrier to ASES Data Submissions

File Layouts

 

Version Changes

 

Version 1.7C

 

CLAIMS Input File Layout -

 

New codes for Plan Type and Plan Version and Region to include Government Employee claims. Substitution of content on field MPI with Contract Number for Government Employee Only.

New field #19 Network Provider.

Changed the size for all 6 diagnosis codes from 6 to 8.

 

NOTE THAT THE LENGTH OF THE CLAIMS INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW 267. 

SERVICES Input File Layout -

 

New field #34 Coverage Code.

 

PROVIDER Input File Layout -

 

New field #22 Network Provider.

 

CAPITATION Input File Layout -

 

Capitation Type updated to include type “F” for fixed payment capitations.

 

ATTACHMENTS –

 

Attachment II –                     Carrier Codes: Updated.

 

Version 1.7B

 

SERVICES Input File Layout -

 

Validation Rules clarified.

 

ERROR CODES Table -

 

Error codes C413.2 and C418.5 added.

 

ATTACHMENTS –

 

Attachment I –         Value added to table

Notes added to end of table.

Attachment II –        Carrier Codes: Updated.

 

Numerous updates have been made throughout the layouts to adjust, complete, or expand descriptions and validation rules.  Field numbers and the text are highlighted to indicate these changes in BLUE.

 

  

  

  

 

Version 1.7A

 

NOTES

 

Changes and Additions and Data File Layouts

 

UPDATED: Validation Process

INSERTED: Provider File Changes

 

PROVIDER Input File Layout -

 

MODIFIED: field 22 has been redefined as filler, replacing pcp_prov.

MODIFIED: field 23 has been redefined as filler, replacing pcp_ipa.

 

Version 1.6

 

NOTES

 

Changes and Additions and Data File Layouts

 

INSERTED: Validation Process INSERTED: Primary Carrier ID INSERTED: IPA codes and Provider codes INSERTED: Attending Provider

 

GENERAL Notes on data layouts requirements

 

INSERTED: MIP Numbers in fields.

 

SERVICES Input File Layout -

 

MODIFIED: field 19 has been redefined as filler, replacing tos_code.

MODIFIED: field 34 has been redefined as filler, replacing rx_form.

MODIFIED: Risk Type is allowed to be “UNK” for Unknown on PBM submitted files.

MODIFIED: Stop Loss Flag should be set to “N” on PBM submitted files.

 

CLAIMS Input File Layout -

 

MODIFIED: field 19 has been redefined as filler, replacing age.

INSERTED: Primary Carrier ID has been added as a required field

 

NOTE THAT THE LENGTH OF THE CLAIMS INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW 253. 

CAPITATION Input File Layout -

 

INSERTED: MPI Number has been added and as a required field.

 

NOTE THAT THE LENGTH OF THE CAPITATION INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW 128.

 

  

  

  

 

Version 1.5

 

NOTES

 

Changes and Additions and Data File Layouts

 

INSERTED: Pharmacy Provider IDs

INSERTED: Provider telephone numbers

 

INSERTED: Capitation amount

INSERTED: Capitation adjustments

INSERTED: Claims / Services File Handling

INSERTED: Other File Handlin

 

GENERAL Notes on data layouts requirements

 

INSERTED: Justification and Filling of Fields

INSERTED: References to CMS 1500 and UB-92

 

File Naming Convention –

 

Added notes on the naming of the ERROR Return Files.

 

SERVICES Input File Layout -

 

MODIFIED: Prescription Days has been redefined to be 999 (3 digits in length)

INSERTED: Total Quantity Dispensed has been added and should be filled for Pharmacy claims

 

NOTE THAT THE LENGTH OF THE SERVICE INPUT FILE LAYOUT HAS CHANGED – LENGTH IS NOW 279.

 

ERROR RETURN File Layout –

 

MODIFIED:  Error Code field expanded to 600 bytes to allow for maximum possible error codes.

 

ATTACHMENTS –

 

Attachment II – Carrier Codes: Updated and corrected

 

Attachment VII – Claims / Services Basic Flow Overview: Added

 

Version 1.4

 

NOTES – File Naming Convention -

 

INSERTED:

 

ERROR RETURN File Layout -

 

INSERTED:

 

ERROR CODES Table -

 

INSERTED:

 

WARNING CODES Table –

 

INSERTED:

 

ATTACHMENTS –

 

Attachment II – Carrier Codes: Updated

 

  

  

  

 

Version 1.3

 

NOTES - Changes and additions in data file layouts -

  

ADDED: Explanation of Provider ID and the functioning of the ID on the Provider table.

 

NOTES - General Notes on data layout requirements -

 

MODIFIED: Amount fields

 

SERVICES Input File Layout -

 

INSERTED: Encounter Type (moved from Claims Input File Layout)

REMOVED: Primary Center (moved to Claims Input File Layout)

REMOVED: Service Center

 

CLAIMS Input File Layout -

 

REMOVED: Encounter Type (moved to Services Input File Layout)

INSERTED: Primary Center (moved from Services Input File Layout)

REMOVED: Service Provider Specialty

 

PROVIDERS Input File Layout -

 

INSERTED: Prov Telephone

 

IPA Input File Layout -

 

MODIFIED: IPA Code

REMOVED: Service Provider Specialty

 

 CAPITATION Input File Layout -

 

INSERTED: Family ID

MODIFIED: Capitation Amount

 

ATTACHMENTS -

 

INSERTED: Attachment I – Municipality Codes

INSERTED: Attachment II – Carrier Codes

INSERTED: Attachment III – Specialty Codes

INSERTED: Attachment IV – Place of Service Codes

INSERTED: Attachment V – Type of Service Codes

INSERTED: Attachment VI – Provider Type Codes

 

  

  

  

NOTES

 

Changes and Additions in Data File Layouts

 

ASES new file layouts for submission by Carriers for data generated from October 1, 2006 forward.

 

The following data layouts will be discontinued after the Data Layouts have been established in production and their use is stabilized:

 

Claims and Encounter Input File Layout

 

The following data layouts will be used with the submission of data from October 2006:

 

Services Input File Layout

Claims Input File Layout

 

New data layouts will be required from October 2006 as follows:

 

Provider Input File Layout

IPA Input File Layout

Capitation Input File Layout

 

Administrative Expenses - Table M from current monthly report will be use as a basis for gathering administrative expense data. Some expansion to include FTE data will be developed.

 

The Provider and IPA files will be used to build and maintain reference files within ASES’s systems for Providers, PCPs and IPA/HCOs.  At implementation carriers will be required to supply full files and every month thereafter to submit files of additions and changes to maintain these in an up-to-date status.

 

  

  

  

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Provider ID - ASES will not try to specify the format or construction of Provider IDs and will accept on incoming data the codes used by the delivering entity.  Internally within the ASES database system, a single ID will be generated for each provider.  The ASES system will be developed to match the carrier’s provider data to ASES’s stored provider data and therefore map IDs between the systems.  It is expected therefore that an actual provider who has multiple IDs across several of the carriers will still resolve to a single Provider ID in ASES.  The key to this will be the matching of records supplied to maintain the Provider file, which has been put into practice by Milliman in similar MedInsight projects in which multiple source entities are involved.

 

To implement this strategy, ASES requires that carriers provide accurate and timely provider files on a monthly basis.  The Provider file maintained in ASES from this data will be used to validate the Provider ID fields on the other data files being submitted, especially for Claims & Encounters and for Capitation.

 

PHARMACY PROVIDER IDs –

 

After considering situations presented by various carriers with regard to the coding of the Provider ID field on claims and in the Provider Input File for pharmacy claims we have decided to make the following change to the layout definitions and instructions. For pharmacy claims only

 

If the carrier includes all PBM providers (pharmacies) in its own provider file and these are part of the Provider Input File delivered to ASES then the carrier has no problem and should continue to handle the data in this way.   This assumes that in coding pharmacy providers into the Provider Input File for ASES the carrier is capable of filling all the required fields and the records will pass validation and be accepted.  When claims are validated the Billing Provider on the claim record will be validated against the Provider file and will be matched even if the provider is unique for the carrier.

 

For carriers who do not include PBM providers in their own Provider File - the claims must be coded with the Provider ID supplied by the PBM.  This ID in turn must be a valid NABP/NCPDP number identifying the pharmacy uniquely regardless of which PBM sourced the data.  The carrier will not include these pharmacy providers in their Provider Input File to ASES avoiding the problems created by their not having all the details required for the providers contracted by the PBM and not the carrier.  On Claims the carrier will use this same Provider ID from the PBM for the Billing Provider which will be matched during the validation against pharmacy providers loaded from PBM Provider Input File submissions to ASES.  The carrier’s records will still be found to fail validation if this provider number cannot be validated.

 

PROVIDER telephone numbers –

 

Prov Telephone remains a required field on the Provider Input Layout.  In the event, and as an exception, if the carrier does not have the actual provider’s telephone number they should insert their own (Carrier’s) telephone number.  This also applies to the IPA Work Phone field in the same way.

 

Note that all telephone number fields must be filled using only numbers.   No spaces or ()- characters should be included.   For example, the telephone number (939) 123-4567 will be coded in the data field as 9391234567

 

CAPITATION AMOUNT –

 

The amount to be reported on capitation records must be a net amount that represents any costs associated with providing services which are not reported in claims and encounters.  This may come from formal contracts with providers such as HCO/PCPs, or any other financial arrangement or allocation of costs.

 

The number should represent a calculation which includes the earned capitation for the period less claims paid amounts, if any, chargeable against the provider risk.  Other types of deductions which may be taken out of the provider’s payment such as repayment of advances, retentions for reserves should not be included in the calculation.

 

CAPITATION ADJUSTMENTS –

 

There may be circumstances in which capitation payments which have already been reported, need in a later month to be adjusted or even reversed.  To accomplish this, the Capitation records will behave differently than Claims and Services.  The carrier will send a new record for the provider / member / experience date with an amount to be added or subtracted from the previously reported amount.  If a capitation of $10.00 is to be reversed then the new record should contain the same information as the original but with a new Capitation Date and a Capitation Amount of -$10.00.  Inside MedInsight the capitation for that Provider / Member for that particular date will be the aggregate of all the records and this example will result in $0.00.

 

  

  

  

 

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Note that, as Capitation net amounts for any particular record may be negative, a reversal in such a case would be a positive amount.

CLAIMS / SERVICES File Handling –

 

CLAIMS /  SERVICES Files will be handled as related data sets in that a Claim must be associated with one or more Services.  While each type of file will have its own validation process, the relationship between claims records and services records will also be part of the validation process.

 

For new record sets, a Claim record, which validates successfully for all its data elements, will be rejected if there is not at least one valid Service record with a corresponding Carrier and Claim-ID.  Similarly, a Service record, which validates on all its data elements, will be rejected if there is not a valid claim record with a corresponding Carrier and Claim-ID.

 

“I” transactions may represent new claims in which case the relationship between Claim and Service records must be within the Claims Input File and Services Input File in the same submission.  When “I” records represent an update to records submitted in prior periods then a Claim record or a Service record may be submitted by itself provided it corresponds respectively to valid Service or Claim records matching on Carrier and Claims-ID already loaded in the database.

 

Claims and Services file will pass through a validation process as shown in Attachment VII.  Pre-validation will check the basic structure of the file and its records and may result in a file being rejected without proceeding to full record validation.  Such rejections may be caused for example, by – file names which fail to follow the naming convention, a file containing wrong length records or other basic tests.

 

A file which is processed through full validation may also be rejected if it fails to meet the error threshold level.  All files which are rejected will be notified to the carrier with an explanation of why the file is rejected.  No records from such a file will be retained in the system and the carrier will be required to re-submit the rejected file in its entirety before the next months files become due.  Such re-submitted files must be carefully named using the sequence number part of the naming convention to ensure the name is distinct from the rejected file and is named in the correct order.

 

If a file is accepted after validation, any records with errors will be returned in an Error Return file.  Only the individual records which are rejected must be corrected and re-submitted and not the entire file.   Such re-submitted records are to be included with the following month’s file.

 

OTHER File Handling –

 

For files other than Claims and Services, the handling in terms of file rejection and record rejection will be similar to that described above for the Claims and Services.  IPA, Provider and Capitation files will be validated individually without relationship to other files.

 

VALIDATION PROCESS –

 

The processing of files will take place on an individual file basis with first a Pre-Validation step in which files may be rejected if they fail structurally, cannot be read or are misnamed.  A file rejection report will indicate the cause of the rejection and the file must be corrected and re-submitted immediately.

 

On files which pass Pre-Validation there will be a two step validation process.  First, validation will take place on individual files to determine the compliance of each field with the validation rules.  Records marked in error will then be removed and files will be passed to a staging area at which point cross-file validation will take place.

 

In the staging area, files will be checked for fields which depend on other files or previously loaded data.  Such validations include the requirement for claims records to have at least one matching, valid service record and for service records that have a valid matching claim.  Also, fields on service records which are particular to the type of claim will be validated after matching to a claim record and the type of claim can be determined from Bill Type (e.g. Pharmacy field on service records will be validated after matching to a claim record with a Bill Type of “P”).  Any records marked in error at this stage will also be removed.

 

Files will be tested for error threshold compliance.  Those files which fail to achieve an error rate below the threshold will be rejected. In such cases, the rejected records will not be placed on the Held Records table and the rejected file will need to be re-submitted after correction in its entirety, but an Error Return file will be created and retuned to the carrier with the details of the records which were marked in error.

 

  

  

  

 

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File Layouts

 

Error records from accepted files will be placed on the Held Records table and the corresponding Error Return file will be given back to the carrier.  These rejected records need to be corrected and included in the following month’s submission.

 

Carriers  need  to  distinguish  error  return  files  as  being  for  file  rejects  or  record  records  and  process  them  accordingly.    The Claims/Services Basic Flow diagram in Attachment VII has been updated to reflect this process.

 

A Claims Processing Summary File will be generated which will contain a record for each file in a processing period (including expected files which were not received).  The layout of this file is contained in the section of tables defining each of the file layouts. This file is an electronic “report” on the validation process and will be placed with the error-return files on the FTP server for the carriers to download.

 

Primary Carrier ID –

 

A field for the Primary Carrier ID has been added to the Claims Input Layout to recognize the MCO or TPA which enrolls the member and assigns IPA and PCP Provider IDs.  The Carrier ID filed will carry the ID of the carrier generating the Claims Input File.  These files will contain the same value when the reporting carrier is an MCO or TPA.  When the reporting carrier is an MBHO or PBM the Carrier ID will contain the code of the MBHO or PBM and the Primary Carrier ID will contain the code of the MCO or TPA of the member.

 

IPA codes and Provider codes –

 

The Primary Carrier ID field has been added to be able to distinguish the validation of IPA and Provider codes by carrier.   The Primary Carrier ID will carry the code of the MCO or TPA which contracts the members IPA and PCP Provider.  In Claims records the codes for IPA and PCP Provider will be those created by the MCO/TPA and delivered to the MBHOs and PBMs in eligibility/enrollment data exchanges.

 

 Attending Provider –

 

The validation rules for Attending Provider have been changes to remove the requirement that the value match a valid provider (i.e. a provider code reported by the carrier in its Provider file.  The field is still required.

 

Municipality Service –

 

Recognizing that claims may be processed for services outside of Puerto Rico, code 0666 has been added to the list of Municipality Codes.  This value is valid only for use in the field Municipality Service on the Claims Input File.  This value should be used only when services are paid for outside of Puerto Rico.

 

PROVIDER FILE CHANGES –

 

The PCP Flag and IPA Code fields have been removed from the Provider Input File Layout.   It has become obvious through the experience gained in testing so far, that the value of these fields on the provider file is overwhelming outweighed by the complexities produced.  PCP and IPA codes will still be required on claims and these will be validated to ensure that they are valid Provider codes and IPA codes but no attempt will be made in validation to cross check that the PCP Provider on claims has been flagged as a PCP on the Provider table or that there is a correlation between PCP and IPA in the provider table.  With this change there should be no need for carriers to report providers on multiple records.

 

These fields have been eliminated from the Provider file and the validations rules in other files have been adjusted accordingly.  These changes do not affect the record length of the Provider Input Layout.

 

General Notes on data layout requirements

 

Date Fields -  All date fields in the following data layout are defined to the same size and format as YYYYMMDD.  An 8 byte field where YYYY = 4 digit year, MM = 2 digit month and DD = 2 digit day.  1 digit month and day values must always have the leading zero (0). Date fields must contain a valid date with months between 01 and 12 and days between 01 and maximum day in month. July 1, 2006 will be coded as 20060701.

 

  

  

  

 

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Amount Fields – All amount fields representing money must be numeric and are defined as 9 bytes in the format 9(7)v99 where v represents and implied decimal point.  This allows a maximum of 7 digits for dollars plus the last two digits for cents.  These numbers are always right justified and zero filled to the left.  As examples:

 

$1.23 will be coded as          000000123

$100.00 will be coded as      000010000

 

All amount fields are positive and follow the above definition unless clearly specified otherwise.

End of Record Filler – All file layouts have been designed to end with a filler field of 1 byte which must always be coded as an “*” character.  This is done to avoid issues between different systems when generating and transferring ASCII files in which ending field may be empty.  The fixed End of Record Filler guarantees that all records in a file can be constructed to the fixed length format as defined in the layouts.

 

Justification and filling of Fields – The layouts have all been specified to provide fixed length fields and fixed length records.  While other methods can be used, it is felt that this provides the best common ground for working with multiple entities each of which uses varying systems.  To be sure everyone understands the same about the comments on justification and filling the following examples are given to help keep this concept clear.

 

All numeric fields must be filled completely with numeric digits.  If there are exceptions these are clearly spelled out in the documentation of the layouts.  Typically numeric field are right justified and to keep them numeric must be zero filled.  In a field specified as numeric such a 9(7)v99 where v represents an implied decimal the following examples illustrate how data will look in the field –

 

	
Value

	
Field

	
12.50

	
000001250

	
101

	
000010100

	
1,234.56

	
000123456

	
1,000,000

	
100000000

 

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All alphanumeric fields must be filled completely.  If the value of data in the field is less than the width of the field then care must be taken to ensure that the field is filled with blanks.  Allowing “NULLS” or other special characters through may cause unexpected results and make reading, loading and validation of the data difficult.  Typically alphanumeric field are left justified and filled to the right with blanks to complete the field.  In a field specified as alphanumeric such a X(20) the following examples illustrate how data will look in the field where the [ ] characters represent the start and end of the field –

 

	
Value

	
Field

	  
	
P.R.

	
[ P.R.

	
]

	
José Rivera

	
[ José Rivera

	
]

	
blanks 

	
[

	
]

	
(Metro-North Region)

	
[(Metro-North Region)

	
]

 

References to CMS 1500 and UB-92 – All references to CMS 1500 or UB-92 in this document are for convenience and correspond equally to equivalent electronic formats and will apply equally to the next version of CMS 1500 or the UB-04 when implemented.

 

MPI Number fields – In all files in which MIP Number is required, carriers should code all 9s if the MPI is unknown.  This should not be true for any current beneficiary. This exception will continue until such time as ASES determines that the issue of MPI being unavailable has disappeared from historical data. For Government Employee MPI should be filled with Contract Number.

 

  

  

  

  

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File Layouts

 

File Naming Convention

 

All files to be delivered to ASES by the carriers must follow the naming conventions below. Files which do not fit the naming convention will be ignored and the carrier deemed to have failed in delivery of such a file.

 

File names must adhere strictly to this naming convention as the structure includes information for identification of the carrier, region, dates and file type.  If not named correctly the file cannot be processed properly.

 

The general format of file names will be –

 

	
 

 

Where:

	
Dccrymms.fff

 

Character 1

	  	
 

 

Always “D”

	  	
Characters 2-3

	  	
cc           =           Carrier Code   (See attachment II)

	  	
Character 4

	  	
r           =           Region as defined by ASES

	  	
A

B

E 

F

G

J

L

M

S

Z

P

Y

	
= =

=

=

=

=

=

=

=

=

=

=

	
Arecibo / North Region

Bayamón / Metro-North Region

Este / East Region

Fajardo / North-East Region

Guayama / South-East Region

Sanjuan / San Juan Region

Aguadilla / North-West Region (used for historical purposes only)

Montaña / Central Region (used for historical purposes only)

Suroeste / South-West Region

Mayaguez / West Region

SPECIAL / SPECIAL pseudo region

Government Employee

y           =           Last digit of year

	  	
Character 5

	  	  
	  	
Characters 6-7

	  	
mm       =          Month

	  	
Character 8

	  	
s           =           sequence number of file submission.

 

	  	
All submission start with s = 0 and continue in numeric if files are re-submitted to 9

	  	
If files must be re-submitted beyond 9, then alphabetic characters will be  used  a, b, c ...

 

	  	
Character 9

	  	
Always “.”

	  	
Characters 1-12 

	  	
Extension code identifying type of file

	 	 	 	 
	  	
SRV

	
for

	
SERVICES

	  	
CLM

	
for

	
CLAIMS

	  	
PRV

	
for

	
PROVIDERS

	  	
IPA

	
for

	
IPA

	  	
CAP

	
for

	
CAPITATIONS

                         

  

  

  

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

Carrier to ASES Data Submissions

File Layouts

 

Files are always dated for the month being reported. For example, when sending claims paid in September 2009 the ymm part of the file name will be  909  while the file will be sent to ASES in October.

 

When a file which is common for multiple regions is sent, the region code may be set as “X”.  This can only apply to files such as Provider and IPA.  Claims, Services and Capitation  must  be sent for their individual regions.

 

Examples of completing this naming convention are –

 

For imaginary carrier 96 in the Metro-North region files for services and payments in April 2008 will be named as follows –

 

Services                           D96B8040.SRV

Claims                              D96B8040.CLM

Providers                         D96B8040.PRV

IPA                                   D96B8040.IPA

Capitation                        D96B8040.CAP

 

When the Capitation file is rejected, the corrected file will be re-submitted as

D96B8041.CAP

 

If providers for carrier 96 are common with other contracted regions the file may have been submitted as

D96X8040.PRV

 

ERROR Return Files will be named by replacing the first character of the input file (the “D”) with an “E”.  For example, when a capitation file is delivered with the name D96G7111.CAP the ERROR Return file which contains all the errors for this capitation file will be named E96G7111.CAP.

 

ZIP Files will be accepted when named to the following standard. Use the file name as defined above, convert the “.” Between the body of the file name and the file extension to “_” and add the extension “.ZIP”. For Instance, using examples above -

 

	
Services file

	
D96B8040.SRV would become zipped as

	
D96B8040_SRV.ZIP

	
Claims file

	
D96B8040.CLM would become zipped as

	
D96B8040_CLM.ZIP

	
Providers

	
D96B8040.PRV would become zipped as

	
D96B8040_PRV.ZIP

	
IPA

	
D96B8040.IPA would become zipped as

	
D96B8040_IPA.ZIP

	
Capitation

	
D96B8040.CAP would become zipped as

	
D96B8040_CAP.ZIP

 

Return files to carriers will be zipped in a similar fashion when their size justifies it.

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Typ- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
1

	
trans_code

	
varcha (1)

	
Transaction Code

	
Identify the action to be taken with the record. I for Insert or E for Delete.

 

	
X

	
Required

Must equal “I” or “E”

	
2

	
pmt_stat

	
varcha (1)

	
Payment Status

	
Indicates payment action on the service represented by this record.

P for Paid or D for Denied

	
X

	
Required

Must equal “P” or “D”

	
3

	
carrier_id

	
varcha (2)

	
Carrier ID

	
Value that identifies carrier. Must be a valid code.

See Carrier Code List in Attachment II.

	
99

	
Required

Must be two (2) digits (numeric).

Must equal a valid Carrier ID as assigned by

ASES.

 

	
4

	
claim_id

	
varchar(20)

	
Claim ID

	
Unique Identification number within Carrier. May be Carrier’s Internal Claim Identification number.

This number is used to avoid duplicated

Claims, but allows multiple service lines within the same claim.

 

	
X(20)

	
Required

Left justified, blank filled to 20 characters if value is less than 20 characters.

Claim ID on Service must match with a Claim

ID on a Claim record.

	
5

	
Sv_line

	
smallint()

	
Service Line Number

	
Number identifying individual service within a given claim.

	
99

	
Required

Must be a 2 digit un-duplicated ID of the

Service Line within the Claim ID. (line numbers less than 10 must be zero filled right justified)

Duplicates within Claim ID on the same submission will be considered errors (the combination of the claim_id plus the

service_line_no must be unique within the carrier).

If Transaction Code is “E” then the key (Carrier

ID, Claim ID, Service Line Number) must exist.

 

	
6

	
enc_type

	
varchar(20)

	
Encounter Type

	
Indicates whether service is reimbursed to the Billing Provider or is covered under a capitation arrangement.

Valid values are –

“FFS” for fee for  service

“CAP” for capitated.

If value is “CAP”, service will have zero Paid Amount.

 

	
X(20)

	
Required for Transaction Code “I”

Must be a valid value

Must be left justified and blank filled

Not required for Transaction Code “E”

	
7

	
from_date

	
datetime()

	
Service From Date

	
Begin date of the treatment.

	
YYYYMMDD

	
Required for Transaction Code “I”

Must be a valid date.

Not required for Transaction Code “E”

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
8

	
to_date

	
datetime()

	
Service To Date

	
End date of the treatment.

	
YYYYMMDD

	
Required for Transaction Code “I”

Must be a valid date

Must be on or after Service From Date

Not required for Transaction Code “E”

 

	
9

	
paid_date

	
datetime()

	
Payment Date

	
For an Encounter, this will be the date the transaction is processed by the carrier.

For non-encounters, this will be the date of

payment for paid claims or the process date for denied claims.

 

	
YYYYMMDD

	
Required for Transaction Code “I”

Must be a valid date

Must be on or after Service To Date

Not required for Transaction Code “E”

	
10

	
Filler_10

	
n/a

	
Filler

	  	
X

	  
	
11

	
proc_code

	
varchar(15)

	
Procedure Code

	
For non-Pharmacy

Standard procedure code conforming to

HCPCS/CPT or HCSPC/CDT as appropriate

	
X(15)

	
Allowed for Transaction Code “I”

For claims from CMS1500 / UB92, when present must be a HCPCS/CPT code. For Dental claims must be a valid dental HCPCS/CDT code

For Pharmacy claims this must be all blanks

Not required for Transaction Code “E”

 

	
12

	
cpt_mod

	
varchar(2)

	
Procedure Modifier Code

	
Modifier code valid for the Procedure Code

	
XX

	
Allowed for Transaction Code “I”

Can only be present when Procedure Code is present and allows a modifier code.

Must be valid as a modifier for the Procedure code

Not required for Transaction Code “E”

 

	
13

	
rev_code

	
varchar(5)

	
Revenue Code

	
For UB92 Claims

NUBC Revenue Code

	
X(5)

	
Allowed for Transaction Code “I” For UB92 claims.

When present it must be a valid Revenue code.

Must be left justified, blank filled to the right

Not required for Transaction Code “E”

 

	
14

	
rx_ndc

	
varchar(11)

	
National Drug Code

	
For Pharmacy only.

National Drug Code value for prescribed drug in 5 4 2 format

	
X(11)

	
Allowed for Transaction Code “I” Required on Pharmacy claims

Must be a valid NDC code in 5 4 2 format filling all 11 bytes

For non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
15

	
tooth_code

	
varchar(3)

	
Tooth Code

	
For Dental only

ADA standard tooth number as required by

CDT code when procedure directly affects a tooth.

	
XXX

	
Allowed for Transaction Code “I”

Must be present on Dental claims when

Procedure code requires Tooth Code

Must be a valid Tooth Code when present Must be left justified and blank filled to complete the field

For non-Dental claims must be blank

Not required for Transaction Code “E”

 

	
16

	
surface_code

	
varchar(7)

	
Surface Code

	
For Dental only

ADA standard surface code as required by

CDT code when procedure directly affects one or more surfaces.

	
X(7)

	
Allowed for Transaction Code “I”

Must be present on Dental claims when procedure code requires Surface Code

Must be a valid Surface Code

Must be left justified and blank filled to complete the field

For non-Dental claims must be blank

Not required for Transaction Code “E”

 

	
17

	
cob_code

	
varchar(1)

	
COB Code

	
Identify if the beneficiary has other Health

Insurance for this service.

“Y if member has other health insurance, “N” otherwise

 

	
X

	
Required for Transaction Code “I”

Must be “Y” or “N”

Not required for Transaction Code “E”

	
18

	
pos_code

	
varchar(2)

	
Place of Service

	
Place of Service Code identifying the place in which the service is delivered.

See POS Code List in Attachment IV

 

	
XX

	
Required for Transaction Code “I”

Must be a valid Place of service Code

Not required for Transaction Code “E”

	
19

	
amt_billed

	
money()

	
Billed Amount

	
For non-Pharmacy

Cost of service as billed by the provider.

 

	
9(7)v99

	
Allowed for Transaction Code “I”

Required for non-Pharmacy claims.

Must be a number on all records

Cannot be left blank

Not required for Transaction Code “E”

	
20

	
amt_allowed

	
money()

	
Allowed Amount

	
For non-Pharmacy

Amount allowed for the service by the carrier

	
9(7)v99

	
Allowed for Transaction Code “I”

Required for non-Pharmacy claims.

Must be a number on all records

Cannot be left blank

For pmt_stat “P” (Payment Status = “paid”) this must be greater than zero.

Not required for Transaction Code “E”

 

	
21

	
Deduct

	
money()

	
Deductible

	
Amount paid by member before payments by the carrier begin for this service

 

	
9(7)v99

	
Required for Transaction Code “I”

Must be a number on all records

Cannot be left blank

Not required for Transaction Code “E”

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
22

	
Copay

	
money()

	
Co-Pay

	
Amount paid by member as dollar co-payment for this service

	
9(7)v99

	
Required for Transaction Code “I”

Must be a number on all records

Cannot be left blank

Not required for Transaction Code “E”

 

	
23

	
Cob

	
money()

	
COB Amount

	
Amount paid by other Health Insurance attributable to this service.

	
9(7)v99

	
Required for Transaction Code “I”

Must be a number on all records

Cannot be left blank

Not required for Transaction Code “E”

 

	
24

	
Coins

	
money()

	
Coinsurance Amount

	
Amount paid by member as percentage of cost for this service

	
9(7)v99

	
Required for Transaction Code “I”

Must be a number on all records

Cannot be left blank

Not required for Transaction Code “E”

 

	
25

	
amt_paid

	
money()

	
Paid Amount

	
Amount paid by carrier for this service

	
9(7)v99

	
Required for Transaction Code “I”

Must be zero for encounters

Must be zero for Services with Payment Status of “D”

 

For Services with pmt_stat = “P” (Payment Status = Paid) one of the following calculations must be valid within a record –

 

For non-Pharmacy:

amt_paid = amt_allowed - deduct - copay - cob - coins

For Pharmacy:

amt_paid = rx_ingr_cost - deduct - copay - cob - coins + rx_disp_fee

 

For Plan Type “02” or “03” only -amt_paid may be zero if the appropriate calculation above results in 0.00.

 

For Plan Type “01” the amt_paid must be greater than zero.

 

Not required for Transaction Code “E”

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
26

	
rx_disc

	
money()

	
Drug Discount

	
For Pharmacy only

Amount Discounted at the Pharmacy

This is the discount given from AWP to get the

Ingredient Cost

When drug is paid from a MAC list the discount amount will be Zero (0)

This field does not form part of the calculation to get Amount Paid but can be used with Ingredient Cost to work back to AWP.

 

	
9(7)v99

	
Allowed for Transaction Code “I” Required on Pharmacy claims

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

	
27

	
rx_ingr_cost

	
money()

	
Ingredient Cost

	
For Pharmacy only

Cost of ingredient(s) dispensed for this Service

	
9(7)v99

	
Allowed for Transaction Code “I”

Required on Pharmacy claims

Must be greater than zero

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

	
28

	
rx_disp_fee

	
money()

	
Dispensing Fee

	
For Pharmacy only

Dispensing fee charged by pharmacy

	
9(7)v99

	
Allowed for Transaction Code “I”

Required on Pharmacy claims

Must be a number

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

	
29

	
rx_days_supply

	
smallint()

	
Prescription Days

	
For Pharmacy only

Number of days prescribed and dispensed

	
999

	
Allowed for Transaction Code “I”

Required on Pharmacy claims

Must be greater than zero

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

	
30

	
rx_drug_type

	
varchar(2)

	
Drug Type Code

	
For Pharmacy only

Code identifying type of drug on pharmacy claims

Valid codes are -

01=Generic

02=SSB

03=MSB

 

	
XX

	
Allowed for Transaction Code “I”

Required on Pharmacy claims

When present it must be one of the valid codes.

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
31

	
rx_daw

	
varchar(6)

	
Dispensed As Written

	
For Pharmacy only

Code indicating “Dispense as written” status of the prescription on pharmacy claims

Valid Codes are –

0 - NO DISPENSE AS WRITTEN (Substitution Allowed)

(or no product selection indicated)

1 - PHYSICIAN writes DISPENSE AS WRITTEN

2 - PATIENT REQUESTED

3 - PHARMACIST SELECTED BRAND

4 - GENERIC NOT IN STOCK

5 - BRAND DISPENSED, PRICED AS GENERIC

6 - OVERRIDE

7 - SUBSTITUTION NOT ALLOWED; BRAND MANDATED BY LAW

8 - GENERIC NOT AVAILABLE

9 - OTHER

	
X(6)

	
Allowed for Transaction Code “I” Required on Pharmacy claims

When present it must be one of the valid

codes.

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

	
32

	
rx_refill_cnt

	
varchar(6)

	
Refill Count

	
For Pharmacy only

The number of refills specified by the physician writing the prescription on pharmacy claims

	
9(6)

	
Allowed for Transaction Code “I” Required on Pharmacy claims When present must be a number

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

	
33

	
rx_par

	
varchar(7)

	
Participating Pharmacy Flag

	
For Pharmacy only

Indicates whether prescription was dispensed by a participating pharmacy on pharmacy

claims

Valid values –

“Y” = participating pharmacy

“N” = non-participating pharmacy

	
X(7)

	
Allowed for Transaction Code “I” Required on Pharmacy claims Left justified, blank filled

Must be “Y” or “N”

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

	
34

	
Cov_Code

	
Varchar(3)

	
Covarage Code

	
For government employee only

Indicates the coverage applied on the service.

	
X(3)

	
Allowed for Transaction Code “I”

Required for government employee claims

Left justified, blank filled

On non-government employee claims must be blank

Not required for Transaction Code “E”

	
35

	
filler_34

	
n/a

	
Filler

	  	
X(4)

	  

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal 

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
36

	
risk_type

	
varchar(3)

	
Risk Type

	
Distinguishes for this service whether risk belongs to PCP(/Group) or carrier.

If cost should be charged to PCP(/Group) then

value = “PCP”

Otherwise value = “CAR” (Carrier).

Where there is no risk sharing the value should be entered as “CAR”.

PBM ONLY – when a PBM is submitting this file this field should be coded as “UNK” for

Unknown.

 

	
XXX

	
Required for Transaction Code “I” Must be filled

Must be “PCP” or “CAR”

For PBM only value can be “UNK”

Not required for Transaction Code “E”

	
37

	
stop_loss_flag

	
Varchar(1)

	
Stop Loss Flag

	
When Risk Type is “PCP”,

set to “Y” if stop loss for PCP(/Group) has been reached for PCP on member Otherwise “N” .

When Risk Type is “CAR”, set to “N” PBM ONLY – set to “N”

 

	
X

	
Required for Transaction Code “I” Must be filled “”Y” or ”N”

Not required for Transaction Code “E”

	
38

	
applied_cost

	
varchar(1)

	
Cost Applied To

	
For Medicare Platino,

defines whether service is part of the ASES

coverage, the CMS (MA) coverage or both. When filled the valid values are –

1=ASES

2=CMS

3=BOTH (SPLIT)

 

	
X

	
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino) Must be filled and be a valid value

Not required for Transaction Code “I” for Plan

Type “01”

Not required for Transaction Code “E”

	
39

	
ases_split_amt

	
money()

	
ASES Split Amount

	
For Medicare Platino,

indicates the part of the Paid Amount allocated to ASES coverage.

	
9(7)v99

	
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino) Must be filled if Cost Applied To = 1 or 3

Not required for Transaction Code “I” for Plan

Type “01”

Not required for Transaction Code “E”

 

	
40

	
cms_split_amt

	
money()

	
CMS Split Amount

	
For Medicare Platino,

indicates the part of the Paid Amount allocated to CMS (MA) coverage.

	
9(7)v99

	
Required for Transaction Code “I” for Plan Type ”02” and ”03” (Medicare Platino) Must be filled if Cost Applied To = 2 or 3

Not required for Transaction Code “I” for Plan

Type “01”

Not required for Transaction Code “E”

	
41

	
extract_date

	
datetime()

	
Extract Date

	
Date on which record is originally extracted from Carrier’s system to create the Services Input File.

 

	
YYYYMMDD

	
Required

Must be a valid date

Must be later or equal to any other date field on record

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

SERVICES INPUT FILE LAYOUT

 

	  	
Field

	
Internal Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
42

	
rx_total_disp

	
Float()

	
Total Quantity Dispensed

	
For Pharmacy only

Total quantity of drug dispensed by pharmacy.

	
9(7)v99

	
Allowed for Transaction Code ”I” Required on Pharmacy claims

Must be a number, right justified, zero filled

On non-Pharmacy claims must be blank

Not required for Transaction Code “E”

 

	
43

	
Filler

	
n/a

	
End of Record Filler

	
Fixed filler with “*”

	
X

	
Required

Must be = “*”

 

	
RECORD LENGTH

	
279

	  

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

CAPITATION INPUT FILE LAYOUT

 

	  	
Field

	
Internal

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
1

	
carrier_id

	
varchar(2)

	
Carrier ID

	
Value that identifies carrier. Must be a valid code. See Carrier Code List in Attachment II.

	
99

	
Required

Must be two (2) digit s (numeric).

Must equal a valid Carrier ID as assigned by

ASES.

	
2

	
cap_id

	
varchar(20)

	
Capitation ID

	
Capitation payment ID must be a unique ID within carrier.

	
X(20)

	
Required

Must be left justified, blank filled to the right Must be a unique ID within Carrier

	
3

	
cap_type

	
varchar(1)

	
Capitation Type

	
Capitation type code defined as:

“P”=PCP

“S”=specialty

“F”=Fixed Payment

	
X

	
Required

Must be “P”, “S” or “F”

	
4

	
cap_date

	
datetime

	
Capitation Date

	
Date capitation paid.

	
YYYYMMDD

	
Required

Must be a valid date

	
5

	
expr_date

	
datetime

	
Experience Date

	
Experience date of capitation payment. This is the date for which the capitation payment applies.

	
YYYYMMDD

	
Required

Must be a valid date

	
6

	
prov

	
varchar(20)

	
Provider ID

	
Carrier assigned Provider ID of the provider to which the capitation payment is made.

	
X(20)

	
Required

Must be a valid Provider ID

	
7

	
ipa

	
varchar(10)

	
IPA ID

	
Carrier assigned ID of IPA/HCO.

This must be filled when Capitation type is PCP and IPA/HCO is involved (Must always be filled for Plan Type 01 by MCOs/TPAs when capitation payment is for PCP services)

	
X(10)

	
Required If Capitation Type is “P” and Carrier ID corresponds to Plan Type “01” Must be a valid IPA Code for the Carrier

	
8

	
region_code

	
varchar(1)

	
Region

	
Region of member

Regions are identified as:

“A” = North

“B” = Metro-North

“E” = East

“F” = North-East

“G” = South-East

“Z” = West

“J” = San Juan

“S” = South-West

‘P” = SPECIAL

	
X

	
Required

Must be valid ASES Region code

	
9

	
municipality_code

	
varchar(4)

	
Municipality

	
Municipality of residence of member. See Municipality Code in Attachment I.

	
XXXX

	
Required

Must be ASES Municipality Code All numeric, right justified, zero filled Must correspond to a municipality within Region Code

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

CAPITATION INPUT FILE LAYOUT

 

	  	
Field

	
Internal

Type- Size

	
Name

	
Description

	
Deliverable

Data Format

 

	
Validation Rules

	
10

	
member_ssn

	
varchar(9)

	
Member SSN

	
Social Security Number of member

	
9(9)

	
Required

Must be 9 digits (numeric)

	
11

	
family_id

	
varchar(11)

	
ASES Family ID

	
Family ID

as supplied in ASES Eligibility data.

	
X(11)

	
Required

ASES / ODSI Family ID Alphanumeric full 11 characters

	
12

	
member_suffix

	
varchar(2)

	
Member Suffix

	
Identifies the beneficiary within the family group. Must be the two digit member suffix as supplied in ASES Eligibility data.

	
99

	
Required

Must be 2 digits (numeric)

	
13

	
cap_amt

	
money

	
Capitation Amount

	
Capitation amount paid to provider  MAY BE NEGATIVE

SEE NOTES - Changes and Additions in Data File Layouts: CAPITATION AMOUNT

	
S9(7)v99

	
Required

Must be a number Signed, may be negative 10 byte field

Sign must appear in leftmost byte, other 9 bytes must be numeric

If the value is negative the sign byte must be a “-”, otherwise it must be blank.

	
14

	
extract_date

	
datetime()

	
Extract Date

	
Date on which record is originally extracted from Carrier’s system to create the Capitation Input File.

	
YYYYMMDD

	
Required

Must be a valid date

Must be later or equal to any other date field on record

	
15

	
mpi

	
Varchar(13)

	
MPI Number

	
Master Patient Index (MPI) As supplied in ASES Eligibility Data

	
X(13)

	
Required

Must be a valid MPI number

	
16

	
filler

	
n/a

	
End of Record Filler

	
Fixed filler with “*”

	
X

	
Required Must be = “*”

	
RECORDLENGTH

	
128

	  

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ERROR RETURN FILE LAYOUT

 

	  	
Field

	
Internal Type-

Size

	
Name

	
Description

	
DeliverableData

Format

	
1

	
Input_record

	
*

	
Input Record

	
A complete copy of the record from the carrier input file

	
*

	
2

	
Errors

	
varchar(600)

	
Error Codes

	
Codes for all errors found on record during validation. Each error will be separated by a comma.

	
X(600)

	
3

	
Process_date

	
datetime

	
Process Date

	
Date file/record was processed by MedInsight validation

	
YYYYMMDD

	
4

	
Filler

	
n/a

	
End of Record Filler

	
Fixed filler with “*”

	
X

	
RECORD LENGTH

	
*

 

	
● 

	
Size varies with Input Record. The specific error file will be dependent on the Input File being reported but the general structure will be as shown above.

 

	
 

                 *       For

 

	
.SRV

	
record length =

	
  888

	  	
.CLM

	
record length =

	
  862

	  	
.PRV

	
record length =

	
1,390

	  	
.IPA

	
record length =

	
1,063

	  	
.CAP

	
record length =

	
  737

  

	
● 

	
Processing, error and warning codes for each input file type are listed in the following tables

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

CLAIMS PROCESSING SUMMARY FILE LAYOUT

 

	  	
Field

	
Internal Type- Size

	
Name

	
Description

	
DeliverableData

Format

	
1

	
sub_filename

	
varchar(12)

	
Submitted File Name

	
The name of the file that was submitted from the carrier.

	
X(12)

	
2

	
err_filename

	
varchar(12)

	
Error File Name

	
The name of the file with error records and error codes created by ASES. If no error file exists, then this will be blank.

	
X(12)

	
3

	
process_code

	
varchar(6)

	
Processing Status Code

	
Processing code that identifies the status of file being processed. (SEE FILE PROCESSING CODES TABLE).

	
X(9)

	
4

	
process_desc

	
varchar(50)

	
Processing Status Description

	
Description of the status of the file being processed.

	
X(20)

	
5

	
notes

	
varchar(50)

	
Processing Notes

	
Any additional notes including the number of critical and warning errors found in the file.

	
X(50)

	
RECORD LENGTH

	
103

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Processing CODES

 

	
CODE

	
ERROR DESCRIPTION

	
GENERAL FILE PROCESSING CODES

	
G000

	
PASSED PREPROCESSING

	
G100

	
FILE IS EMPTY.

	
G105

	
UNABLE TO OPEN FILE OR FILE CORRUPTED.

	
G110

	
FILE CONTAINS ONE OR MORE WRONG LENGTH RECORDS.

	
G120

	
INVALID FILE NAME.

	
G125

	
FILE NAME PREVIOUSLY SUBMITTED.

	
G130

	
EXPECTED FILE MISSING FOR CURRENT RECORD LOAD.

	
G135

	
FILE EXCEEDED ERROR THRESHOLD

	
G199

	
FILE ACCEPTED

 

NOTE G000 - PASSED PREPROCESSING: such files have passed the pre-processing stage of validation but were not sent to full validation because of other issues. For example a .SRV file may be held because its corresponding .CLM file has a G110 error and failed pre-processing

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
CODE

	
ERROR DESCRIPTION

	
SERVICES FILE ERRORS

	
C400

	
TRANS_CODE INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘I’ OR ‘E’.

	
C401

	
PMT_STAT INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘P’ OR ‘D’.

	
C402

	
CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C403

	
CLAIM_ID MISSING. THIS IS A REQUIRED FIELD.

	
C403.2

	
CLAIM_ID INVALID. DOES NOT MATCH WITH A CLAIM_ID ON A VALID CLAIM RECORD.

	
C404

	
SV_LINE MISSING. THIS IS A REQUIRED FIELD.

	
C404.2

	
SV_LINE DUPLICATE WITHIN THE SAME CLAIM ID. (CARRIER_ID+CLAIM_ID+SV_LINE MUST BE UNIQUE)

	
C404.3

	
SV_LINE DOES NOT EXIST. FOR A TRANS_CODE E RECORD THE CARRIER_ID+CLAIM_ID+SV_LINE MUST ALREADY EXIST.

	
C405

	
ENC_TYPE INVALID. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C406

	
FROM_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C407

	
TO_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C407.2

	
TO_DATE INVALID. MUST BE EQUAL OR LATER THAN FROM_DATE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C408

	
PAID_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C408.2

	
PAID_DATE INVALID. MUST BE EQUAL OR LATER THAN TO_DATE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C410

	
COB_CODE INVALID. MUST BE EITHER ‘Y’ OR ‘N’ WHEN TRANS_CODE IS I

	
C411

	
POS_CODE INVALID. MUST BE A VALID PLACE OF SERVICE CODE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C412

	
AMT_BILLED INVALID. THIS IS A REQUIRED FIELD FOR NON-PHARMACY CLAIMS.

	
C413

	
AMT_ALLOWED INVALID. THIS IS A REQUIRED FIELD FOR NON-PHARMACY CLAIMS.

	
C413.2

	
AMT_ALLOWED INVALID. MUST BE GREATER THAN ZERO FOR PAID CLAIMS.

	
C414

	
DEDUCT INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.

	
C415

	
COPAY INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.

	
C416

	
COB INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.

	
C417

	
COINS INVALID. MUST BE A NUMBER ON ALL THE RECORDS WITH TRANS_CODE = I.

	
C418

	
AMT_PAID INVALID. MUST BE ZERO FOR ENCOUNTERS

	
C418.2

	
AMT_PAID INVALID. MUST BE ZERO FOR PAYMENT STATUS ‘D’.

	
C418.3

	
AMT_PAID INVALID. MUST BE EQUAL TO AMT_ALLOWED - DEDUCT - COPAY - COB - COINS (NON-PHARMACY CLAIMS).

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
C418.4

	
AMT PAID INVALID. MUST BE EQUAL TO RX INGR COST - DEDUCT - COPAY - COB - COINS + RX DISP FEE (PHARMACY CLAIMS).

	
C418.5

	
AMT_PAID INVALID. MUST BE GREATER THAN ZERO FOR PLAN_TYPE = “01” CLAIMS.

 

	
C419

	
RX_DISC INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

	
C420

	
RX_INGR_COST INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

 

	
C421

	
RX_DISP_FEE INVALID. THIS FIELD IS REQUIRED FOR PHARMACY CLAIMS.

 

	
C422

	
RX_DAYS_SUPPLY INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

 

	
C423

	
RX_DRUG_TYPE INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

 

	
C424

	
RX_DAW INVALID. MUST BE ONE OF THE VALID CODES. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

 

	
C425

	
RX_REFILL_CNT INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

	
C426

	
RX_PAR INVALID. IT MUST BE EITHER ‘Y’ OR ‘N’ ON PHARMACY CLAIMS.

	
C428

	
RISK TYPE INVALID. IT MUST BE EITHER ‘PCP’ OR ‘CAR’ (OR ‘UNK” FOR PHARAMCY). THIS IS A REQUIRE FIELD FOR TRANS_CODE I.

 

	
C429

	
STOP_LOSS_FLAG INVALID. MUST BE ‘Y’ OR ‘N’. THIS IS A REQUIRED FIELD FOR TRANS_CODE = I.

 

	
C430

	
APPLIED_COST INVALID. THIS IS A REQUIRED FIELD FOR TRANS_CODE = I WHEN PLAN TYPE = ‘02’ OR ‘03’.

	
C431

	
ASES SPLIT AMT INVALID. THIS IS A REQUIRED FIELD FOR TRANS CODE = I WHEN PLAN TYPE = ‘02’ OR ‘03’ AND APPLIED_COST = ‘1’ OR ‘3’.

	
C432

	
CMS SPLIT AMT INVALID. THIS IS A REQUIRED FIELD FOR TRANS CODE = I WHEN PLAN TYPE = ‘02’ OR ‘03’ AND APPLIED_COST = ‘2’ OR ‘3’.

	
C433

	
EXTRACT DATE MISSING. THIS IS A REQUIRED FIELD.

	
C433.2

	
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN FROM_DATE

	
C433.3

	
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN TO_DATE

	
C433.4

	
EXTRACT DATE INVALID. MUST BE LATER OR EQUAL THAN PAID_DATE

	
C434

	
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.

	
C435

	
RX_TOTAL_DISP INVALID. THIS IS A REQUIRED FIELD FOR PHARMACY CLAIMS.

 

	
CLAIMS FILE ERRORS

	
C300

	
TRANS_CODE INVALID. THIS IS A REQUIRED FIELD AND MUST BE ‘I’ OR ‘E’.

	
C301

	
CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C302

	
CLAIM_ID MISSING. THIS IS A REQUIRED FIELD.

	
C302.2

	
CLAIM_ID INVALID. CLAIM_ID CANNOT BE DUPLICATED. THIS IS A REQUIRED FIELD.

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
C302.3

	
CLAIM_ID DOES NOT EXIST. FOR A TRANS_CODE E RECORD THE CARRIER_ID + CLAIM_ID MUST ALREADY EXIST.

	
C303

	
PLAN_TYPE INVALID. MUST BE ‘01’, ‘02’ OR ‘03’. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

 

	
C303.2

	
PLAN_TYPE INVALID. ‘02’ OR ‘03’ MUST CORRESPOND TO A MEDICARE PLATINO CARRIER_ID.

	
C303.3

	
PLAN TYPE INVALID. ‘01’ MUST CORRESPOND TO A GHIP CARRIER, MBHO, PBM OR OTHER ASSIGNED CARRIER CODE WHICH IS NOT MEDICARE PLATINO.

	
C304

	
PLAN_VERSION MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C304.2

	
PLAN_VERSION MUST BE A 3 DIGIT CODE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C304.3

	
PLAN VERSION INVALID. CARRIER ID + PLAN TYPE + PLAN VERSION MUST CORRESPOND TO A PLAN DEFINITION CONTRACTED WITH ASES. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C305

	
BILL_TYPE INVALID. MUST BE ‘U’, ‘H’, ‘P’ OR ‘D’. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

 

	
C306

	
ADM_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C307

	
DIS_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C307.2

	
DIS_DATE INVALID. MUST BE EQUAL OR LATER THAN ADM_DATE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C308

	
REGION_CODE INVALID. MUST BE ‘A’, ‘B’, ‘E’, ‘F’, ‘G’, ‘Z’, ‘J’ or ‘S’. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C309

	
MUNICIPALITY RES INVALID. MUST CORRESPOND TO A VALID ASES MUNICIPALITY CODE AND BE WITHIN THE REGION IDENTIFIED BY REGION_CODE. REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C310

	
MUNICIPALITY CODE INVALID. MUST BE A VALID ASES MUNICIPALITY CODE. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C311

	
SSN_MAINH INVALID. MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C312

	
SSN_INVALID. MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C313

	
MEMBER_SUFFIX MISSING OR INVALID. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C314

	
PATIENT_NAME MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C315

	
FAMILY ID INVALID. THIS MUST BE ALPHANUMERIC FULL 11 CHARACTERS. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C316

	
MPI INVALID OR MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C317

	
SEX INVALID. MUST BE ‘M’ OR ‘F’. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C319

	
BIRTH_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C319.2

	
BIRTH_DATE INVALID. IT CANNOT BE IN THE FUTURE BASED ON EXTRACT DATE.

	
C319.3

	
BIRTH_DATE INVALID. IT CANNOT BE GREATER THAN 150 YEARS AGO BASED ON EXTRACT DATE.

 

	
C319.4

	
BIRTH_DATE INVALID. IT MUST BE EQUAL OR EARLIER THAN ADM_DATE.

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
C320

	
PRIMARY_CENTER MISSING. MUST BE PRESENT ON CLAIMS OF PLAN TYPE 01.

	
C320.2

	
PRIMARY_CENTER INVALID. MUST MATCH A VALID ENTRY ON IPA TABLE.

	
C321

	
DATE_ACCIDENT INVALID. MUST BE EQUAL OR GREATER THAN BIRTH_DATE.

	
C321.2

	
DATE_ACCIDENT INVALID. MUST BE EQUAL OR EARLIER THAN ADM_DATE.

	
C322

	
REC_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C322.2

	
REC_DATE INVALID. MUST BE EQUAL OR GREATER THAN DIS_DATE.

	
C323

	
ENTRY_DATE MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C323.2

	
ENTRY_DATE INVALID. MUST BE EQUAL OR GREATER THAN REC_DATE.

	
C324

	
PCP_PROV MISSING. REQUIRED WHEN PLAN_TYPE = ‘01’.

	
C324.2

	
PCP_PROV INVALID. MUST BE A VALID PROVIDER_ID FOR PRIMARY CARRIER.

	
C325

	
ATT_PROV MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C326

	
BILL_PROV MISSING. THIS IS A REQUIRED FIELD WHEN TRANS_CODE IS I.

	
C326.2

	
BILL_PROV INVALID. MUST BE A VALID PROVIDER_ID FOR CARRIER.

	
C328

	
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.

	
C328.2

	
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN ADM_DATE.

	
C328.3

	
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN DIS_DATE.

	
C328.4

	
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN DATE_ACCIDENT.

	
C328.5

	
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN REC_DATE.

	
C328.6

	
EXTRACT_DATE INVALID. MUST BE LATER OR EQUAL THAN ENTRY_DATE.

	
C329

	
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.

	
C330

	
PRIMARY_CARRIER_ID INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C331

	
CLAIM FOUND WITHOUT A CORRESPONDING VALID SERVICE. EVERY CLAIM MUST HAVE AT LEAST ONE SERVICE.

	
C332

	
DIS_STAT MISSING OR INVALID. THIS IS A REQUIRED FIELD ON UB-92 CLAIMS.

	
PROVIDER FILE ERRORS

	
C200

	
PROV CARRIER MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C201

	
PROV_ID MISSING. THIS IS A REQUIRED FIELD.

	
C202

	
PROV_LNAME MISSING. THIS IS A REQUIRED FIELD ON ALL RECORDS.

	
C203

	
PROV_ADDR1 MISSING. THIS IS A REQUIRED FIELD.

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
C204

	
PROV_CITY MISSING. THIS IS A REQUIRED FIELD.

	
C205

	
PROV_STATE MISSING. THIS IS A REQUIRED FIELD.

	
C206

	
PROV_ZIP MISSING. THIS IS A REQUIRED FIELD.

	
C207

	
PROV_COUNTRY MISSING. THIS IS A REQUIRED FIELD.

	
C208

	
PROV_TEL MISSING OR WRONG LENGTH. THIS IS A REQUIRED FIELD.

	
C209

	
PROV_TYPE INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID PROVIDER TYPE CODE.

 

	
C210

	
PROV_SPEC1 INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID SPECIALTY CODE.

 

	
C213

	
FEDERAL_TAX_ID MISSING OR WRONG LENGTH. THIS IS A REQUIRED 9 DIGIT FIELD.

 

	
C214

	
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.

	
C215

	
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.

	
IPA FILE ERRORS

	
C100

	
CARRIER_ID MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C101

	
IPA MISSING. THIS IS A REQUIRED FIELD.

	
C102

	
IPA_DESC MISSING. THIS IS A REQUIRED FIELD.

	
C103

	
IPA_ADDR1 MISSING. THIS IS A REQUIRED FIELD.

	
C104

	
IPA_CITY MISSING. THIS IS A REQUIRED FIELD.

	
C105

	
IPA_STATE MISSING. THIS IS A REQUIRED FIELD.

	
C106

	
IPA_ZIP MISSING. THIS IS A REQUIRED FIELD.

	
C107

	
IPA_COUNTRY MISSING. THIS IS A REQUIRED FIELD.

	
C108

	
IPA_WORK_PHONE MISSING OR WRONG LENGTH. THIS IS A REQUIRED FIELD.

 

	
C109

	
FEDERAL_TAX_ID MISSING OR WRONG LENGTH. THIS IS A REQUIRED 9 DIGIT FIELD.

 

	
C110

	
EXTRACT DATE MISSING. THIS IS A REQUIRED FIELD.

	
C111

	
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.

	
CAPITATION FILE ERRORS

	
C500

	
CARRIER_ID MISSING OR INVALID. THIS IS A REQUIRED FIELD AND MUST BE A VALID CARRIER ID AS ASSIGNED BY ASES.

	
C501

	
CAP_ID INVALID. THIS IS A REQUIRED FIELD.

	
C501.2

	
CAP_ID INVALID. CAP_ID CANNOT BE DUPLICATED. THIS IS A REQUIRED FIELD.

	
C502

	
CAP_TYPE INVALID. MUST BE ‘P’ OR ‘S’. THIS IS A REQUIRED FIELD.

	
C503

	
CAP_DATE INVALID. THIS IS A REQUIRED FIELD.

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

File Validation ERROR CODES

 

	
C504

	
EXPR_DATE INVALID. THIS IS A REQUIRED FIELD.

	
C505

	
PROV INVALID. MUST BE A VALID PROVIDER FOR THIS CARRIER. THIS IS A REQUIRED FIELD.

	
C506

	
IPA MISSING. THIS IS A REQUIRED FIELD IF CAP_TYPE = ‘P’ AND CARRIER_ID CORRESPONDS TO PLAN TYPE ‘01’

	
C506.2

	
IPA INVALID. THIS MUST BE A VALID IPA CODE.

	
C507

	
REGION_CODE INVALID. MUST BE ONE = ‘A’, ‘B’, ‘E’, ‘F’, ‘G’, ‘Z’, ‘J’ OR ‘S’. THIS IS A REQUIRED FIELD.

	
C508

	
MUNICIPALITY CODE INVALID. MUST CORRESPOND TO A VALID ASES MUNICIPALITY CODE AND BE WITHIN THE REGION IDENTIFIED BY REGION_CODE. THIS IS A REQUIRED FIELD.

	
C509

	
MEMBER_SSN INVALID. IT MUST BE 9 DIGITS. THIS IS A REQUIRED FIELD.

	
C510

	
FAMILY_ID INVALID. THIS HAS TO BE ALPHANUMERIC FULL 11 CHARACTERS. THIS IS A REQUIRED FIELD.

	
C511

	
MEMBER_SUFFIX INVALID. IT MUST BE 2 DIGITS. THIS IS A REQUIRED FIELD.

	
C512

	
CAP_AMT INVALID. IT MUST BE NUMERIC. THIS IS A REQUIRED FIELD.

	
C513

	
EXTRACT_DATE MISSING. THIS IS A REQUIRED FIELD.

	
C513.2

	
EXTRACT_DATE INVALID. MUST BE EQUAL TO OR LATER THAN CAP_DATE.

	
C513.3

	
EXTRACT_DATE INVALID. MUST BE EQUAL TO OR LATER THAN EXPR_DATE

	
C514

	
FILLER INVALID. MUST BE ‘*’ ON ALL RECORDS.

	
C515

	
MPI INVALID OR MISSING. THIS IS A REQUIRED FIELD.

	
C516

	
INCONSISTENCY BETWEEN TWO OR MORE RECORDS. IF CARRIER ID, CAP TYPE, EXPR DATE, PROV, FAMILY ID & MEMBER SUFFIX MATCH BETWEEN MULTIPLE RECORDS, THERE IS AN INCONSISTENCY IF IPA OR REGION CODE OR MEMBER SSN OR MPI DO NOT MATCH.

 

	
CODE

	
WARNING DESCRIPTION

	
SERVICES FILE WARNINGS

	
W400

	
PROC_CODE MUST BE A VALID HCPCS/CPT CODE. (CMS1500 / UB92 CLAIMS).

	
W400.2

	
PROC_CODE FOR DENTAL CLAIMS MUST BE A VALID DENTAL HCPCS/CDT CODE. (DENTAL CLAIMS)

	
W400.3

	
PROC CODE FOR PHARMACY CLAIMS MUST BE BLANK. (PHARMACY CLAIMS)

	
W401

	
CPT MOD INVALID.

	
W4 02

	
REV_CODE MUST BE A VALID REVENUE CODE. (UB92 CLAIMS)

	
W4 03

	
RX_NDC MUST BE A VALID NDC CODE (PHARMACY CLAIMS)

 

	
CLAIMS FILE WARNINGS

	
W300

	
ICD DIAG 01 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W301

	
ICD DIAG 02 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W302

	
ICD DIAG 03 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W303

	
ICD DIAG 04 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W304

	
ICD DIAG 05 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W305

	
ICD DIAG 06 MUST BE A VALID ICD OR DSM IV DIAGNOSIS CODE. (MUST CARRY HIGHEST DEGREE OF DETAIL 4TH OR 5TH DIGIT). (NOT PHARMACY OR DENTAL).

	
W327

	
DIS STAT MISSING OR INVALID. THIS IS A REQUIRED FIELD FOR UB-92 CLAIMS.

	
PROVIDERS FILE WARNINGS

	
W2 0 0

	
PROV FNAME MISSING. THIS IS AN EXPECTED FIELD FOR INDIVIDUAL PROVIDERS.

 

  

  

  

 

ATTACHMENTS

 

  

  

  

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT I - MUNICIPALITY CODES

 

	
Alphabetical by Municipality

	  	
Ordered By Code

	
MUNICIPALITY

	
REGION

	
CODE

	  	
CODE

	
MUNICIPALITY

	
REGION

	
Adjuntas

	
S

	
0004

	  	
0004

	
Adjuntas

	
S

	
Aguada

	
Z

	
0008

	  	
0008

	
Aguada

	
Z

	
Aguadilla

	
Z

	
0012

	  	
0012

	
Aguadilla

	
Z

	
Aguas Buenas

	
E

	
0016

	  	
0016

	
Aguas Buenas

	
E

	
Aibonito

	
G

	
0020

	  	
0020

	
Aibonito

	
G

	
Anasco

	
Z

	
0024

	  	
0024

	
Anasco

	
Z

	
Arecibo

	
A

	
0028

	  	
0028

	
Arecibo

	
A

	
Arroyo

	
G

	
0032

	  	
0032

	
Arroyo

	
G

	
Barceloneta

	
A

	
0036

	  	
0036

	
Barceloneta

	
A

	
Barranquitas

	
G

	
0040

	  	
0040

	
Barranquitas

	
G

	
Bayamon

	
B

	
0044

	  	
0044

	
Bayamon

	
B

	
Cabo Rojo

	
Z

	
0048

	  	
0048

	
Cabo Rojo

	
Z

	
Caguas

	
E

	
0052

	  	
0052

	
Caguas

	
E

	
Camuy

	
A

	
0056

	  	
0056

	
Camuy

	
A

	
Canovanas

	
F

	
0060

	  	
0060

	
Canovanas

	
F

	
Carolina

	
F

	
0064

	  	
0064

	
Carolina

	
F

	
Catano

	
B

	
0068

	  	
0068

	
Catano

	
B

	
Cayey

	
E

	
0072

	  	
0072

	
Cayey

	
E

	
Ceiba

	
F

	
0076

	  	
0076

	
Ceiba

	
F

	
Ciales

	
A

	
0080

	  	
0080

	
Ciales

	
A

	
Cidra

	
E

	
0084

	  	
0084

	
Cidra

	
E

	
Coamo

	
G

	
0088

	  	
0088

	
Coamo

	
G

	
Comerio

	
B

	
0092

	  	
0092

	
Comerio

	
B

	
 Corozal

	
B

	
0096

	  	
0096

	
Corozal

	
B

	
Culebra

	
F

	
0100

	  	
0100

	
Culebra

	
F

	
Dorado

	
B

	
0104

	  	
0104

	
Dorado

	
B

	
Fajardo

	
F

	
0108

	  	
0108

	
Fajardo

	
F

	
Florida

	
A

	
0112

	  	
0112

	
Florida

	
A

	
Guanica

	
S

	
0116

	  	
0116

	
Guanica

	
S

	
Guayama

	
G

	
0120

	  	
0120

	
Guayama

	
G

	
Guayanilla

	
S

	
0124

	  	
0124

	
Guayanilla

	
S

	
Guaynabo

	
B

	
0128

	  	
0128

	
Guaynabo

	
B

	
Gurabo

	
E

	
0132

	  	
0132

	
Gurabo

	
E

	
Hatillo

	
A

	
0136

	  	
0136

	
Hatillo

	
A

	
Hormigueros

	
Z

	
0140

	  	
0140

	
Hormigueros

	
Z

	
Humacao

	
E

	
0144

	  	
0144

	
Humacao

	
E

	
Isabela

	
Z

	
0148

	  	
0148

	
Isabela

	
Z

	
Jayuya

	
S

	
0152

	  	
0152

	
Jayuya

	
S

	
Juana Diaz

	
G

	
0156

	  	
0156

	
Juana Diaz

	
G

	
Juncos

	
E

	
0160

	  	
0160

	
Juncos

	
E

	
Lajas

	
Z

	
0164

	  	
0164

	
Lajas

	
Z

	
Lares

	
A

	
0168

	  	
0168

	
Lares

	
A

	
Las Marias

	
Z

	
0172

	  	
0172

	
Las Marias

	
Z

	
Las Piedras

	
E

	
0176

	  	
0176

	
Las Piedras

	
E

	
Loiza

	
F

	
0180

	  	
0180

	
Loiza

	
F

	
Luquillo

	
F

	
0184

	  	
0184

	
Luquillo

	
F

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT I - MUNICIPALITY CODES

 

	
Alphabetical by Municipality

	  	
Ordered By Code

	
MUNICIPALITY

	
REGION

	
CODE

	  	
CODE

	
MUNICIPALITY

	
REGION

	
Manati

	
A

	
0188

	  	
0188

	
Manati

	
A

	
Maricao

	
Z

	
0192

	  	
0192

	
Maricao

	
Z

	
Maunabo

	
G

	
0196

	  	
0196

	
Maunabo

	
G

	
Mayaguez

	
Z

	
0200

	  	
0200

	
Mayaguez

	
Z

	
Moca

	
Z

	
0204

	  	
0204

	
Moca

	
Z

	
Morovis

	
A

	
0208

	  	
0208

	
Morovis

	
A

	
Naguabo

	
E

	
0212

	  	
0212

	
Naguabo

	
E

	
Naranjito

	
B

	
0216

	  	
0216

	
Naranjito

	
B

	
Orocovis

	
G

	
0220

	  	
0220

	
Orocovis

	
G

	
Patillas

	
G

	
0224

	  	
0224

	
Patillas

	
G

	
Penuelas

	
S

	
0228

	  	
0228

	
Penuelas

	
S

	
Ponce

	
S

	
0232

	  	
0232

	
Ponce

	
S

	
Puerta de Tierra

	
J

	
0264

	  	
0236

	
Quebradillas

	
A

	
Puerto Nuevo

	
J

	
0270

	  	
0240

	
Rincon

	
Z

	
Quebradillas

	
A

	
0236

	  	
0244

	
Rio Grande

	
F

	
Rincon

	
Z

	
0240

	  	
0248

	
Sabana Grande

	
Z

	
Rio Grande

	
F

	
0244

	  	
0252

	
Salinas

	
G

	
Rio Piedras

	
J

	
0272

	  	
0256

	
San German

	
Z

	
Sabana Grande

	
Z

	
0248

	  	
0264

	
Puerta de Tierra

	  
	
Salinas

	
G

	
0252

	  	
0266

	
San Juan

	  
	
San German

	
Z

	
0256

	  	
0270

	
Puerto Nuevo

	  
	
San Jose

	
J

	
0274

	  	
0272

	
Rio Piedras

	  
	
San Juan

	
J

	
0266

	  	
0274

	
San Jose

	  
	
San Lorenzo

	
E

	
0276

	  	
0276

	
San Lorenzo

	
E

	
San Sebastian

	
Z

	
0280

	  	
0280

	
San Sebastian

	
Z

	
Santa Isabel

	
G

	
0284

	  	
0284

	
Santa Isabel

	
G

	
Toa Alta

	
B

	
0288

	  	
0288

	
Toa Alta

	
B

	
Toa Baja

	
B

	
0292

	  	
0292

	
Toa Baja

	
B

	
Trujillo Alto

	
F

	
0296

	  	
0296

	
Trujillo Alto

	
F

	
Utuado

	
A

	
0300

	  	
0300

	
Utuado

	
A

	
Vega Alta

	
B

	
0304

	  	
0304

	
Vega Alta

	
B

	
Vega Baja

	
A

	
0308

	  	
0308

	
Vega Baja

	
A

	
Vieques

	
F

	
0312

	  	
0312

	
Vieques

	
F

	
Villalba

	
G

	
0316

	  	
0316

	
Villalba

	
G

	
Yabucoa

	
E

	
0320

	  	
0320

	
Yabucoa

	
E

	
Yauco

	
S

	
0324

	  	
0324

	
Yauco

	
S

	
Outside Puerto Rico

	
--

	
0666

	
*

	
0666

	
Outside Puerto Rico

	
--

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT II - CARRIER CODES

 

	
CODE

	
Carrier

	
Type

	
01

	
Triple S

	
MCO

	
03

	
(discontinued)

	
MCO

	
02

	
Humana

	
MCO

	
17

	
MCS

	
MCO

	
25

	
(discontinued)

	
MCO

	
27

	
MCS Life

	
Medicare Platino

	
28

	
Red Medica

	
Medicare Platino

	
29

	
Medicare y Mucho Mas

	
Medicare Platino

	
31

	
Triple S

	
Medicare Platino

	
33

	
Preferred Medicare Choice

	
Medicare Platino

	
34

	
MCS Advantage

	
Medicare Platino

	
35

	
COSVIMed

	
Medicare Platino

	
37

	
Salud Dorada con Medicare

	
Medicare Platino

	
39

	
MAPFRE

	
Medicare Platino

	
41

	
Health Medicare Ultra

	
Medicare Platino

	
42

	
Humana

	
Medicare Platino

	
44

	
Auxilio Platino

	
Medicare Platino

	
47

	
American Health

	
Medicare Platino

	
49

	
FirstPlus

	
Medicare Platino

	
51

	
Triple S

	
TPA - Direct Contract

	
52

	
Humana

	
TPA - Direct Contract

	
53

	
MCS

	
TPA - Direct Contract

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT II - CARRIER CODES

 

	
CODE

	
Carrier

	
Type

	
55

	
COSVI

	
TPA - Direct Contract

	
60

	
Caremark

	
PBM

	
64

	
MC-21

	
PBM

	
70

	
ASSMCA

	
Mental Health Pilot

	
71

	
Plan de Salud Hospital Menonita

	
Government Employee

	
72

	
MMM Healthcare,INC

	
Government Employee

	
73

	
National Life Insurance Company

	
Government Employee

	
74

	
Ryder Health Plan, Inc.

	
Government Employee

	
75

	
Triple-S Salud Inc.

	
Government Employee

	
76

	
(discontinued)

	
MBHO

	
77

	
Humana Health Plan of Puerto Rico, Inc.

	
Government Employee

	
78

	
Humana Insurance of Puerto Rico,Inc.

	
Government Employee

	
79

	
MCS Advantage,Inc.

	
Government Employee

	
80

	
MCS Life Insurance Company

	
Government Employee

	
81

	
Asociacion de Maestros de Puerto Rico

	
Government Employee

	
82

	
First Medical Health Plan, Inc.

	
Government Employee

	
83

	
APS

	
MBHO

	
95

	
FHC

	
MBHO

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT III - SPECIALTY CODES

 

	
CODE

	
Specialty

	
Codes included in this table are designed for completeness and in no way imply coverage of services under the Government Health Insurance Plan

	
01

	
General Practice

	
02

	
General Surgery

	
03

	
Allergy/Immunology

	
04

	
Otolaryngology

	
05

	
Anesthesiology

	
06

	
Cardiology

	
07

	
Dermatology

	
08

	
Family Practice

	
09

	
Interventional Pain Management

	
10

	
Gastroenterology

	
11

	
Internal Medicine

	
12

	
Osteopathic Manipulative Therapy

	
13

	
Neurology

	
14

	
Neurosurgery

	
16

	
Obstetrics / Gynecology

	
18

	
Ophthalmology

	
19

	
Oral Surgery

	
20

	
Orthopedic Surgery

	
22

	
Pathology

	
24

	
Plastic and Reconstructive Surgery

	
25

	
Physical Medicine / Rehabilitation

	
 26

	
Psychiatry

	
28

	
Colorectal Surgery (Formerly Proctology)

	
29

	
Pulmonary Diseases

	
30

	
Diagnostic Radiology

	
32

	
Anesthesiologist Assistant

	
33

	
Thoracic Surgery

	
34

	
Urology

	
35

	
Chiropractic

	
36

	
Nuclear Medicine

	
37

	
Pediatric Medicine

	
38

	
Geriatric Medicine

	
39

	
Nephrology

	
40

	
Hand Surgery

	
41

	
Optometry

	
42

	
Certified Nurse Midwife

	
43

	
Certified Registered Nurse Assistant (CRNA)

	
44

	
Infectious Disease

	
45

	
Mammography Screening Center

	
46

	
Endocrinology

	
47

	
Independent Diagnostics Testing Facility

	
48

	
Podiatry

	
49

	
Ambulatory Surgical Center

	
50

	
Nurse Practitioner

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT III - SPECIALTY CODES

 

	
CODE

	
Specialty

	
51

	
Medical Supply Company with Orthotist

	
52

	
Medical Supply Company with Prosthetist

	
53

	
Medical Supply Company with Orthotist-Prosthetist

	
54

	
Other Medical Supply Company

	
55

	
Individual Certified Orthotist

	
56

	
Individual Certified Prosthetist

	
57

	
Individual Certified Orthotist-Prosthetist

	
58

	
Medical Supply Company with pharmacist

	
59

	
Ambulance Service Provider

	
60

	
Public Health and Welfare Agency

	
61

	
Voluntary Health or Charitable Agency

	
62

	
Psychologist

	
63

	
Portable X-ray Supplier

	
64

	
Audiologist

	
65

	
Physical Therapist

	
66

	
Rheumatology

	
67

	
Occupational Therapy

	
68

	
Clinical Psychologist

	
69

	
Clinical Laboratory

	
70

	
Multi-Specialty Clinic or Group Practice

	
71

	
Registered Dietician / Nutritional Professional

	
72

	
Pain Management

	
73

	
Mass Immunization Roster Billers

	
74

	
Radiation Therapy Center

	
75

	
Slide Preparation Facilities

	
76

	
Peripheral Vascular Disease

	
77

	
Vascular Surgery

	
78

	
Cardiac Surgery

	
79

	
Addiction Medicine

	
80

	
Licensed Clinical Social Worker

	
81

	
Critical Care (Intensivists)

	
82

	
Hematology

	
83

	
Hematology / Oncology

	
84

	
Preventive Medicine

	
85

	
Maxillofacial Surgery

	
86

	
Neuropsychiatry

	
87

	
All Other Suppliers

	
88

	
Unknown Supplier / Provider Specialty

	
89

	
Certified Clinical Nurse Specialist

	
90

	
Medical Oncology

	
91

	
Surgical Oncology

	
92

	
Radiation Oncology

	
93

	
Emergency Medicine

	
94

	
Intervention Radiology

	
96

	
Optician

	
97

	
Physician Assistant

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT III - SPECIALTY CODES

 

	
CODE

	
Specialty

	
98

	
Gynecological Oncology

	
99

	
Unknown Physician Specialty

	
A1

	
Skilled Nursing Facility

	
A2

	
Intermediate Care Nursing Facility

	
A3

	
Other Nursing Facility

	
A4

	
Home Health Agency

	
A5

	
Pharmacy

	
A6

	
Medical Supply Company with Respiratory Therapist

	
A7

	
Department Store

	
A8

	
Grocery Store

	
DD

	
Dentist

	
EN

	
Endodontist

	
HE

	
Health Educator

	
HN

	
Home Health Nurse

	
PE

	
Periodontist

	
RT

	
Respiratory Therapist

	
ST

	
Speech Therapist

	
BB

	
Blood Bank

	
CV

	
Cardiac Catheterization Facility

	
DF

	
Dialysis Facility

	
EC

	
Emergency Care Facility

	
HV

	
HIV Ambulatory Antibiotic Facility

	
HO

	
Hospice

	
IC

	
Intensive Care Unit

	
IT

	
Infusion Therapy

	
LI

	
Lithotripsy

	
NI

	
Neonatal ICU

	
OP

	
Optical

	
PC

	
Clinic - Primary Level

	
PH

	
Private Hospital

	
PP

	
Private Psychiatric Hospital

	
PS

	
Psychiatric Partial Hospital

	
SH

	
State Hospital

	
SP

	
State Psychiatric Hospital

	
XR

	
X-ray Facility

	
Z4

	
Cardiovascular Surgery Program

	
O1

	
Occupational Medicine

	
P1

	
Perinatology

	
N1

	
Neonatolgy

	
G1

	
Geneticist

	
P2

	
Pediatric Surgery

 

  

  

  

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

 

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
Codes included in this table are designed for completeness and in no way imply coverage of services under the Government Health Insurance Plan

	
01

	
Pharmacy

	
A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients.

	
02

	
Unassigned

	
N/A

	
03

	
School

	
A facility whose primary purpose is education.

	
04

	
Homeless Shelter

	
A facility or location whose primary purpose is to provide temporary housing to homeless individuals.

	
05

	
Indian Health Service Free-standing Facility

	
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization

 

	
06

	
Indian Health Service Provider-based Facility

	
A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients.

 

	
07

	
Tribal 638 Free-standing Facility

	
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization.

 

	
08

	
Tribal 638 Provider-based Facility

	
A facility or location owned and operated by a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients.

 

	
09-10

	
Unassigned

	
N/A

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
11

	
Office

	
Location, other than a hospital, Skilled Nursing Facility (SNF), military treatment facility, community health center, State or local public health clinic, or Intermediate Care Facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

 

	
12

	
Home

	
Location, other than a hospital or other facility, where the patient receives care in a private residence.

	
13

	
Assisted Living Facility

	
Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.

 

	
14

	
Group Home

	
A residence, with shared living areas, where clients receive supervision and other services such as social and/or behavioral services, custodial service, and minimal services.

 

	
15

	
Mobile Unit

	
A facility/unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and/or treatment services.

 

	
16-19

	
Unassigned

	
N/A

	
20

	
Urgent Care Facility

	
Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled ambulatory patients seeking immediate medical attention.

 

	
21

	
Inpatient Hospital

	
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

 

	
22

	
Outpatient Hospital

	
A portion of a hospital, which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

 

	
23

	
Emergency Room - Hospital

	
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
24

	
Ambulatory Surgical Center

	
A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.

 

	
25

	
Birthing Center

	
A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of newborn infants.

 

	
26

	
Military Treatment Facility

	
A medical facility operated by one or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF).

 

	
27-30

	
Unassigned

	
N/A

	
31

	
Skilled Nursing Facility

	
A facility, which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

 

	
32

	
Nursing Facility

	
A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

 

	
33

	
Custodial Care Facility

	
A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.

 

	
34

	
Hospice

	
A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.

 

	
35-40

	
Unassigned

	
N/A

	
41

	
Ambulance - Land

	
A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

 

	
42

	
Ambulance - Air or Water

	
An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured.

 

	
43-48

	
Unassigned

	
N/A

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
49

	
Independent Clinic

	
A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.

 

	
50

	
Federally Qualified Health Center

	
A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician.

 

	
51

	
Inpatient Psychiatric Facility

	
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

 

	
52

	
Psychiatric Facility Partial Hospitalization

	
A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility.

 

	
53

	
Community Mental Health Center

	
A facility that provides the following services:

• Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services area who have been discharged from inpatient treatment at a mental health facility.

• 24 hour a day emergency cares services.

• Day treatment, other partial hospitalization services, or psychosocial rehabilitation services.

• Screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission.

• Consultation and education services.

 

	
54

	
Intermediate Care Facility/Mentally Retarded

	
A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF.

 

 

  

  

  

 

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
55

	
Residential Substance Abuse Treatment Facility

	
A facility, which provides treatment for substance (alcohol and drug) abuse to live-in residents who, does not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.

 

	
56

	
Psychiatric Residential Treatment Center

	
A facility or distinct part of a facility for psychiatric care, which provides a total 24-hour therapeutically, planned and professionally staffed group living and learning environment.

 

	
57

	
Non-residential Substance Abuse Treatment Facility

	
A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.

 

	
58-59

	
Unassigned

	
N/A

	
60

	
Mass Immunization Center

	
A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting.

 

	
61

	
Comprehensive Inpatient Rehabilitation Facility

	
A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services.

 

	
62

	
Comprehensive Outpatient Rehabilitation Facility

	
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services.

 

	
63-64

	
Unassigned

	
N/A

	
65

	
End-Stage Renal Disease Treatment Facility

	
A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis.

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT IV - PLACE OF SERVICE CODES

 

	
CODE

	
Name

	
Description

	
66-70

	
Unassigned

	
N/A

	
71

	
State or Local Public Health Clinic

	
A facility maintained by either State or local health departments that provide ambulatory primary medical care under the general direction of a physician.

 

	
72

	
Rural Health Clinic

	
A certified facility, which is located in a rural medically, underserved area that provides ambulatory primary medical care under the general direction of a physician.

 

	
73-80

	
Unassigned

	
N/A

 

	
81

	
Independent Laboratory

	
A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office.

 

	
82-98

	
Unassigned

	
N/A

 

	
99

	
Other Place of Service

	
Other service facilities not specified above.

 

 

  

  

  

 

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT V

THIS ATTACHMENT HAS BEEN REMOVED

 

  

  

  

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

ATTACHMENT VI - PROVIDER TYPE CODES

 

	
CODE

	
Description

	
Codes included in this table are designed for completeness and in no way imply coverage of services under the Government Health Insurance Plan

	
AM

	
Ambulance

	
AS

	
Ambulatory Surgical Center

	
BB

	
Blood Bank

	
CL

	
Clinical Facility

	
DE

	
Dentist

	
DM

	
Durable Medical Equipment (DME)

	
EM

	
Emergency Facility

	
HH

	
Home Health Agency

	
HO

	
Hospital

	
HS

	
Hospice

	
LA

	
Laboratory

	
MD

	
Medical Doctor (Physician)

	RX	Pharmacy 
	SN	Skilled Nursing Facility (SNF)
	UF	Urgent Care facility
	XR	Radiology Facility
	ZZ	Other

 

  

  

  

 

  

  

  

 

Milliman

650 California Street, 17th Floor

San Francisco, California 94108·2702

USA

Tel +1 415 403 1333

Fax +1 415 403 1334

milliman.com

Actuarial Certification for Admlnistraci6n de Seguros de Salud

Mi Salud Program: Metro North, North, Northeast, San Juan, and West Regions

July 1, 2013 through June 30, 2014

I, Susan E. Pantely, Principal and Consulting Actuary, am an employee of Milliman, Inc. Consultants and Actuaries. I am a Member of the American Academy of Actuaries, and meet its Qualification Standards for issuing Actuarial Statements of Opinion for Medicaid premium rate development. I have been retained by Administraci6n de Seguros de Salud (ASES) to develop the capitation rates for the Mi Salud program for the period July 1, 2013 through June 30, 2014. This memorandum has been prepared in conformity with all applicable Actuarial Standards of Practice, including ASOP no. 8.

This actuarial certification covers the fixed payments for the Preferred Medical Group (PMG) fund and administrative fee for these regions.

In developing the fixed payment rates, I relied on data provided by ASES and managed care organizations under the Government Health Insurance program (GHIP) regarding:

	
  

	
●

	
Claims incurred November 2011 through December 2012, paid through February 2013

	
  

	
●

	
Data concerning capitations, administrative costs, and other program costs for the period November 2011 through December 2012.

	

        ●

	
 

 

The conclusions reached as a result of my review are contingent on the accuracy of the data provided. The data was used without Independent audit, having been evaluated for reasonableness and consistency by comparing to financial statements and other control totals reported by the managed care organizations. To the extent that the underlying data and information is inaccurate, the fixed payment rates certified here may also be Inaccurate.

The fixed payment rates were developed based on GHIP claims, utilization and membership data, and Include allowance only for benefits covered under the Ml Salud program. Adjustments were made to account for such factors as medical trend, incomplete data, and program changes. Separate rates were not developed by other categories including age, gender, or eligibility category, consistent with past practice. Demographic profiles for regions studied previously did not vary materially, and the adjustments would be modest relative to the fixed payment rates developed.Use of the single rate approach Is considered actuarially sound.

The conclusions reached as a result of my review are contingent on the accuracy of the data provided. The data was used without Independent audit, having been evaluated for reasonableness and consistency by comparing to financial statements and other control totals reported by the managed care organizations. To the extent that the underlying data and Information is Inaccurate, the premium rates certified here may also be inaccurate.

I hereby certify that, to the best of my knowledge and judgment, the methodologies used to develop the PCP capitation rate, PMG fund, and administrative per member per month (PMPM) fee for the Ml Salud program are appropriate and developed in accordance with generally accepted actuarial principles and practices and are not excessive, inadequate, or unfairly discriminatory in relation to benefits. In my opinion, The primary care physician (PCP) capitation, PMG fund, and administrative fees are actuarlally sound, as defined In 42 CFR § 438.6(c), were developed in accordance with generally accepted actuarial principles and practices, and are appropriate for the populations to be covered and the services to be furnished under the contract. The administrative fee and PMG fund payments can be found in Attachment~ 1 and 2, respectively.

 

  

  

  

 

This certification is intended for ASES and CMS and should not be relied on by other parties. The reader should be advised by actuaries or other professionals competent in the area of actuarial projections of the type in this certification, so as to properly interpret the projection results.

It should be emphasized that fixed payment rates are a projection of future costs based on a set of assumptions. These assumptions may not be appropriate for all organizations. Each organization should consider a number of factors, Including but not limited to, provider contracts, medical management, and administrative requirements. Actual experience will differ from projected amounts to the extent that the actual experience deviates from the projected experience.

This opinion has been prepared specifically for the Mi Salud program rates and may not be appropriate for other purposes. This certification is intended for ASES and CMS and should not be relied on by other parties.

(signed)

Susan E. Pantely, FSA, MAAA

June 28, 2013

415-394-3756

 

  

  

  

Overview

There are eight distinct regions for the Ml Salud program: Southeast, East, North, San Juan, Metro North, Northeast, and Southwest plus the Virtual region. These regions have distinct utilization and cost patterns and the capitated rates reflect these regional variations. Medical services within a region are provided by one MCO and one MBHO. As the regions reflect large stable populations, the capitation rate development does not explicitly consider age, gender or eligibility category. This actuarial certification covers the fixed payment components for the Triple S regions of North, Metro North, San Juan, West, and Northeast. Projected fixed payments under the contract are approximately $691,606,000.

 

Milliman has relied on the following data sources as provided by Adminlstracl6n de Seguros de Salud (ASES):

	
●

	
Detailed claim-level covering claims Incurred during the period November 2011 through December 2012. This information was used to prepare claims lag reports (monthly paid claims by month of service) and to generate actuarial cost models by type of service (Inpatient, outpatient, etc.).

	
●

	
Monthly enrollment for the period November 2011 through December 2012.

	
●

	
Information from the carrier regarding net capitated payment rates.

	
●

	
Financial Reports as reported by the carrier.

	
●

	
Incurred claims as reported by the carrier.

Although the above data was reviewed for reasonableness, Milliman did not audit the data. After accumulating all of the information to be used in the rate setting process, a comparison of the various sources of claims data was performed to check for consistency. We compared (i) the claim lag reports provided by the HMOs, (II) the claim amounts reported by ASES and (ill) the claim amounts in the financial statements. There was satisfactory consistency between the three claims data sources.

The actuarial model used to derive the July 1, 2013 to June 30, 2014 (Contract Period) PMG fund payments relies primarily on health plan experience. The historical claims experience by region for the Mi Salud program was analyzed and actuarial cost models for the Base Period were developed. The Base Period is claims Incurred January 1, 2012- December 31, 2012.

Therefore, the Base Period reflects services that are both eligible State Plan Services and provided to member eligible for Mi Salud (Checklist AA2.0)

We had historical claims paid through February 2013. For claims Incurred in the Base Period, we expect the medical claims data is Incomplete. We reviewed the historical claims lag triangles by region. We adjusted the base period PMPM to account for claims Incurred but not paid. The completion factors can be found in Attachment 2. (Checklist M3.14)

These estimates were then projected forward to the Projection Period {July 1, 2013- June 30, 2014) using assumed trend rates. Administrative expenses were added to the claims component in order to project the total Contract Period costs under the plan. The services used in the analysis include the following:

● Medical

● Prescription Drug

The analysis of Base Period claims experience attempted to Identify and adjust for any distortions In the data. Significant variations In experience, including the Impact from unusually large Individual claims, were Investigated. No adjustments for large claims were deemed necessary. (Checklist AA5.0)

These regions were transitioned from the previous Managed Care Organization (MCO) to Triple 5 In November 2011. Medical claims Incurred for the first few months of the Triple 5 contract were low due to the transition. We added an adjustment to Increase the incurred 2012 claims to account for the low incurred claims In the months of January and February 2012. This adjustment can be found In Attachment 2.

 

  

  

  

The total projected medical costs for this population are comprised of fee-for-service (FFS) medical expenses and the PMG capitated expenses only. This memorandum addresses the PMG capitated medical expenses only.

Member Months

Members move In and out of the program. Partial members are paid a pro rata portion of the premium. We Increased the member months by 2% based on the assumption that partial month members are covered for one-half month. (Checklist AA3.4)

Trend Factors

The rating methodology uses trend factors to adjust the Base Period claims cost to the Projection period. The cost trend factors used In this analysis are a combination of utilization and Inflation components. We developed the projected cost trend rate assumptions based on an analysis of recent experience and professional judgment regarding future cost Increases. Annual utilization trends were set at 0.0% and 2.1% for medical and prescription drug, respectively. Annual average charge trend was set at 0.0% and 4.0% for medical and prescription drug, respectively. (Checklist M3.11)

Mi Salud Changes

There were no programmatic changes from the Base Period to the Projection Period.

Administrative Fees

ASES pays a fixed monthly administrative fee for claims processing. The amount allocated for administrative expenses ranges from 4.6% to 5.9% of total projected medical expenses. The administrative fees are shown in Attachment 1.

*    *    *

 

Certified Rates

Attachment 1 to this report provides the administrative fees. Attachment 2 provides a buildup of the PMG fund payments by Region. These rate are only appropriate for the period July 1, 2013 to June 30, 2014.

 

  

  

  

ATTACHMENT 1

ADMINISTRATIVE FEES PER MEMBER PER MONTH

 

	Region	 	Per Member Per Month Administrative Fee
	 	 	 
	Metro North	 	$5.82
	North	 	$5.51
	Northeast	 	$6.17
	San Juan 	 	$8.21
	Virtual	 	$0.00
	West	 	$5.08

 

  

  

  

ATTACHMENT 2 – DEVELOPMENT OF PMG FUND

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	  	  	  	  Midpoint	  	  	  	  	  	  	  	  
	
Base Period = January 1, 2012 – December 31, 2012

	  	  	  7/1/2012	  	  	  	  	  	  	  	  
	
Base Period FFS. non-Rx = January 1, 2012- December 31, 2012

	  	  	  7/1/2012	  	  18.0	  	  	  	  
	
Projection Period = July 1, 2013 – June 30, 2014

	  	  	  1/1/2014	  	  18.0	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  

	  	  	
North

	  	
Metro

	  	
Northeast

	  	
San Juan

	  	
West

	  	
Total

	
(1) Base Period PMG non-Rx Paid PMPM

	  	
$35.40

	  	
$39.33

	  	
$32.50

	  	
$42.31

	  	
$32.63

	  	
$31.84

	
(2) Completion Factor 0.920

	  	  	  	
0.959

	  	
0.965

	  	
0.951

	  	
0.947

	  	
0.964

	
(3) Completed Base Period PMG non-Rx PMPM (1)/(2)

	  	
$36.92

	  	
$40.76

	  	
$34.18

	  	
$44.70

	  	
$33.85

	  	
$34.59

	
(4) Adjustment for Jan-Feb 2012 Understatement

	  	
1.027

	  	
1.027

	  	
1.027

	  	
1.000

	  	
1.031

	  	
1.016

	
(5) Base Period PMG non-Rx PMPM (3) x (4)

	  	
$37.91

	  	
$41.85

	  	
$35.10

	  	
$44.70

	  	
$34.90

	  	
$35.14

	
(6) Annual Utilization Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(7) Annual Average Charge Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(8) Projected PMG Rx (5) x [(1+ (6))^(18/12)] x [(1+ (7))^(18/12)]

	  	
$37.91

	  	
$41.85

	  	
$35.10

	  	
$44.70

	  	
$34.90

	  	
$35.14

	  	  	  	  	  	  	  	  	  	  	  	  	  
	
(9) Base Period capitation Paid PMG

	  	
$9.94

	  	
$9.94

	  	
$12.50

	  	
$9.94

	  	
$9.94

	  	
$13.75

	
(10) Annual Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(11) Projected Capitation Paid PMG

	  	
$9.94

	  	
$9.94

	  	
$12.50

	  	
$9.94

	  	
$9.94

	  	
$13.75

	  	  	  	  	  	  	  	  	  	  	  	  	  
	
(12) Base Period PMG Rx Paid PMPM

	  	
$9.39

	  	
$9.06

	  	
$8.22

	  	
$9.23

	  	
$6.08

	  	
$9.35

	
(13) Completion Factor

	  	
1.000

	  	
1.000

	  	
1.000

	  	
1.000

	  	
1.000

	  	
1.000

	
(14) Completed Base Period FFS non-Rx PMPM (12) / (13)

	  	
$9.39

	  	
$9.06

	  	
$8.22

	  	
$9.23

	  	
$6.08

	  	
$9.35

	
(15) Annual Utilization Trend

	  	
2.1%

	  	
2.1%

	  	
2.1%

	  	
2.1%

	  	
2.1%

	  	
2.1%

	
(16) Annual Average Charge Trend

	  	
4.0%

	  	
4.0%

	  	
4.0%

	  	
4.0%

	  	
4.0%

	  	
4.0%

	
(17) Projected FFS non-Rx

	  	
$10.28

	  	
$9.91

	  	
$9.00

	  	
$10.10

	  	
$6.65

	  	
$10.28

	
(14) x [(1+ (15))^(18/12)] X [(1+(16))^(18/12]

	  	  	  	  	  	  	  	  	  	  	  	  
	
(18) Total PMG Risk (8) + (11) + (17)

	  	
$58.13

	  	
$61.70

	  	
$56.59

	  	
$64.74

	  	
$51.49

	  	
$59.18

 

  

  

  

Milliman

650 California Street, 17th Floor

San Francisco, California 94108·2702

USA

Tel +1415 4031333

Fax +1 416 403 1334

milliman.com

Actuarial Certification for Admlnlstracf6n de Seguros de Salud

Ml Salud Program: East, Southeast, and Southwest Regions

October 1, 2013 through June 30, 2014

I, Susan E. Pantely, Principal and Consulting Actuary, am an employee of Milliman, Inc. Consultants and Actuaries. I am a Member of the American Academy of Actuaries, and meet Its Qualification Standards for Issuing Actuarial Statements of Opinion for Medicaid premium rate development. I have been retained by Admlnlstracl6n de Seguros de Salud (ASES) to develop the capitation rates for the Mi Salud program for the period October 1, 2013 through June 30, 2014. This memorandum has been prepared In conformity with all applicable Actuarial Standards of Practice, including ASOP no. 8.

This actuarial certification covers the fixed payments for the Preferred Medical Group (PMG) fund and administrative fee for these regions.

In developing the fixed payment rates, I relied on data provided by ASES and managed care organizations under the Government Health Insurance program (GHIP) regarding:

	
●

	
Claims Incurred January 2010 through December 2012, paid through December 2012

	
●

	
Data concerning capitations, administrative costs, and other program costs for the period January 2010 through December 2012.

	
●

 

The conclusions reached as a result of my review are contingent on the accuracy of the data provided. The data was used without Independent audit, having been evaluated for reasonableness and consistency by comparing to financial statements and other control totals reported by the managed care organizations. To the extent that the underlying data and information Is inaccurate the fixed payment rates certified here may also be Inaccurate.

The fixed payment rates were developed based on GHIP claims, utilization and membership data, and Include allowance only for benefits covered under the Mi Salud program. Adjustments were made to account for such factors as medical trend, incomplete data, and program changes. Separate rates were not developed by other categories including age, gender, or eligibility category, consistent with past practice. Demographic profiles for regions studied previously did not vary materially, and the adjustments would be modest relative to the fixed payment rates developed. Use of the single rate approach is considered actuarially sound.

The conclusions reached as a result of my review are contingent on the accuracy of the data provided. The data was used without Independent audit, having been evaluated for reasonableness and consistency by comparing to financial statements and other control totals reported by the managed care organizations. To the extent that the underlying data and Information is inaccurate, the premium rates certified here may also be inaccurate.

I hereby certify that, to the best of my knowledge and judgment, the methodologies used to develop the PCP capitation rate, PMG fund, and administrative per member per month {PMPM) fee for the Mi Salud program are appropriate and developed In accordance with generally accepted actuarial principles and practices and are not excessive, inadequate, or unfairly discriminatory in relation to benefits. In my opinion, The primary care physician (PCP) capitation, PMG fund, and administrative fees are actuarially sound, as defined In 42 CFR § 438.6(c), were developed In accordance with generally accepted actuarial principles and practices, and are appropriate for the populations to be covered and the services to be furnished under the contract. The administrative fee and PMG fund payments can be found In Attachments 1 and 2, respectively.

 

  

  

  

This certification is intended for ASES and CMS and should not be relied on by other parties. The reader should be advised by actuaries or other professionals competent In the area of actuarial projections of the type In this certification, so as to properly interpret the projection results.

It should be emphasized that fixed payment rates are a projection of future costs based on a set of assumptions. These assumptions may not be appropriate for all organizations. Each organization should consider a number of factors, Including but not limited to, provider contracts, medical management, and administrative requirements. Actual experience will differ from projected amounts to the extent that the actual experience deviates from the proJected experience.

This opinion has been prepared specifically for the Ml Salud program rates and may not be appropriate for other purposes. This certification is intended for ASES and CMS and should not be relied on by other parties.

(signed)

Susan E. Pantely, FSA, MAAA

June 28, 2013

415-394-3756

 

  

  

  

 

	Milliman	
Actuarial Certification -

Administración de Seguros de Salud

                                                                                                                                                                                            

Overview

There are eight distinct regions for the Mi Salud program: Southeast, East, North, San Juan, Metro North, Northeast, and Southwest plus the Virtual region. These regions have distinct utilization and cost patterns and the capitated rates reflect these regional variations. Medical services within a region are provided by one MCO and one MBHO. As the regions reflect farge stable populations, the capitation rate development does not explicitly consider age, gender or eligibility category. This actuarial certification covers the fixed payment components for the Triple S regions of East, Southeast, and Southwest. Projected fixed payments under the contract are approximately $323,981,000. Milliman has relied on the following data sources as provided by Admlnlstracion de Seguros de Salud (ASES):

	
  

	
●

	
Detailed claim-level covering claims Incurred during the period January 2010 through

	
  

	
●

	
December 2012. This Information was used to prepare claims lag reports (monthly paid claims

	
  

	
●

	
by month of service) and to generate actuarial cost models by type of service (inpatient,

	
  

	
●

	
outpatient, etc.).

	
  

	
●

	
Monthly enrollment for the period January 2010 through December 2012.

	
  

	
●

	
Information from the carrier regarding net capltated payment rates.

	
  

	
●

	
Financial Reports as reported by the carrier.

	
  

	
●

	
Incurred claims as reported by the carrier.

Although the above data was reviewed for reasonableness, Milliman did not audit the data. After accumulating all of the information to be used in the rate setting process, a comparison of the various sources of claims data was performed to check for consistency. We compared (i) the claim lag reports provided by the HMOs, (ii) the claim amounts reported by ASES and (Ill) the claim amounts In the financial statements. There was satisfactory consistency between the three claims data sources.

The actuarial model used to derive the October 1, 2013 to June 30, 2014 (Contract Period) PMG fund payments relies primarily on health plan experience. The historical claims experience by region for the Mi Salud program was analyzed and actuarial cost models for the Base Period were developed. The Base Period Is claims Incurred January 1, 2012- December 31, 2012.

Therefore, the Base Period reflects services that are both eligible State Plan services and provided to member eligible for Mi Salud (Checklist AA2.0)

We had historical claims paid through December 2012. For claims incurred In the Base Period, we expect the medical claims data is Incomplete. We reviewed the historical claims lag triangles by region. We adjusted the base period PMPM to account for claims Incurred but not paid. The completion factors can be found In Attachment 2. (Checklist AA3.14)

These estimates were then projected forward to the Projection Period (October 1, 2013- June 30, 2014) using assumed trend rates. Administrative expenses were added to the claims component in order to project the total Contract Period costs under the plan. The services used In the analysis Include the following:

● Medical

● Prescription Drug

The analysis of Base Period claims experience attempted to identify and adjust for any distortions in the data. Significant variations in experience, including the Impact from unusually large Individual claims, were investigated. No adjustments for large claims were deemed necessary. (Checklist AA5.0)

The total projected medical costs for this population are comprised of fee-for-service (FFS) medical expenses and the PMG capitated expenses. This memorandum addresses the PMG capitated medical expenses only.

 

  

  

  

Member Months

Members move in and out of the program. Partial members are paid a pro rata portion of the premium. We increased the member months by 2% based on the assumption that partial month members are covered for one-half month. (Checklist AA3.4)

Trend Factors

The rating methodology uses trend factors to adjust the Base Period claims cost to the Projection period. The cost trend factors used in this analysis are a combination of utilization and Inflation components. We developed the projected cost trend rate assumptions based on an analysis of recent experience and professional judgment regarding future cost increases.

Annual utilization trends were set at 0.0% and 2.1% for medical and prescription drug, respectively. Annual average charge trend was set at 0.0% and 4.0% for medical and prescription drug, respectively. (Checklist AA3.11)

Ml Salud Changes

There were no programmatic changes from the Base Period to the Projection Period.

Administrative Fees

ASES pays a fixed monthly administrative fee for claims processing. The amount allocated for administrative expenses ranges from 3. 7% to 4.6% of total projected medical expenses. The administrative fees are shown In Attachment 1.

 

*    *    *

Certified Rates

Attachment 1 to this report provides the administrative fees. Attachment 2 provides a buildup of the PMG fund payments by Region. These rates are only appropriate for the period October 1, 2013 to June 30, 2014.

 

  

  

  

 

ATTACHMENT 1

ADMINISTRATIVE FEES PER MEMBER PER MONTH

 

	Region	 	Per Member Per Month Administrative Fee
	 	 	 
	East	 	$5.21
	Southeast 	 	$5.50
	Southwest	 	$5.44

 

  

  

  

ATTACHMENT 2 – DEVELOPMENT OF PMG FUND

 

	 	  	  	  	  	  	  	  	  
	  	Midpoint	  	  	  	  	  	  
	
Base Period = January 1, 2012 – December 31, 2012

	7/1/2012	  	  	  	  	  	  
	
Base Period FFS. non-Rx = January 1, 2012- December 31, 2012

	7/1/2012	  	  18.0	  	  
	
Projection Period = October 1, 2013 – June 30, 2014

	2/15/2014	  	  19.5	  	  
	  	  	  	  	  	  	  	  	  
	  	  	
East

	  	
Southeast

	  	
Southwest

	  	
Total

	
(1) Base Period PMG non-Rx Paid PMPM

	  	
$29.89

	  	
$25.61

	  	
$24.20

	  	
$25.34

	
(2) Completion Factor

	  	
0.840

	  	
0.841

	  	
0.846

	  	
0.824

	
(3) Completed Base Period PMG non-Rx PMPM (1)/(2)

	  	
$30.82

	  	
$30.47

	  	
$28.59

	  	
$30.10

	
(4) Annual Utilization Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(5) Annual Average Charge Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(6) Projected PMG Rx (3) x [(1+ (4))^(19.5/12)] x [(1+ (5))^(19.5/12)]

	  	
$30.82

	  	
$30.47

	  	
$28.59

	  	
$30.10

	  	  	  	  	  	  	  	  	  
	
(7) Base Period capitation Paid PMG

	  	
$27.81

	  	
$15.92

	  	
$11.27

	  	
$19.51

	
(8) Annual Trend

	  	
0.0%

	  	
0.0%

	  	
0.0%

	  	
0.0%

	
(9) Projected Capitation Paid PMG

	  	
$27.81

	  	
$15.92

	  	
$11.27

	  	
$19.51

	  	  	  	  	  	  	  	  	  
	
(10) Base Period PMG Rx Paid PMPM

	  	
$12.29

	  	
$10.34

	  	
$10.75

	  	
$11.25

	
(11) Completion Factor

	  	
0.988

	  	
0.989

	  	
0.987

	  	
1.000

	
(12) Completed Base Period FFS non-Rx PMPM (10) / (11)

	  	
$12.44

	  	
$10.46

	  	
$10.89

	  	
$11.39

	
(13) Annual Utilization Trend

	  	
2.1%

	  	
2.1%

	  	
2.1%

	  	
2.1%

	
(14) Annual Average Charge Trend

	  	
4.0%

	  	
4.0%

	  	
4.0%

	  	
4.0%

	
(15) Projected FFS non-Rx

	  	
$13.71

	  	
$11.53

	  	
$12.00

	  	
$12.55

	
(12) x [(1+ (13))^(19.5/12)] X [(1+(14))^(19.5/12]

	  	  	  	  	  	  	  	  
	
(16) Total PMG Risk (6) + (9) + (15)

	  	
$72.35

	  	
$57.91

	  	
$51.87

	  	
$62.17

 

  

  

  

 

ATTACHMENT 11

MI Salud

Administrative Fees Per Member Per Month Per Region

Fiscal Year 2013-2014

	
Region

	 	
Per Member Per Month 

Administrative Fee

	 	
Estimated Membership

	
Metro North

	 	
$

	
5.82

	 	
212,042  

	
Northeast

	 	
$

	
6.17

	 	
136,961  

	
North

	 	
$

	
5.51

	 	
201,062  

	
West

	 	
$

	
5.08

	 	
226,086  

	
San Juan

	 	
$

	
8.21

	 	
99,733  

	
Virtual

	 	
$

	
Included Above

	 	
4,967  

	
Composite

	 	
$

	
5.85

	 	
880,851  

 

 

	
Region

	
Per Member Per Month 

Administrative Fee

	
Estimated Membership

	
East

	
$

	
5.21

	
212,940  

	
Southeast

	
$

	
5.50

	
164,988  

	
Southwest

	
$

	
5.44

	
162,984  

	
Composite

	
$

	
5.37

	
540,912  

 

  

  

  

Administration of Health Insurance of Puerto Rico

TPA Contract

Deliverables

Attachment 12

	  Contract 

Section	  Deliverable	  Contractor 

delivery date	Approval

Yes/No	  Status
	 	
 

6.4.5

	 	
 

Enrollee Handbook

(Universal Guide)

 

	 	
 

November 1, 2013

	 	  	 	  
	 	
 

6.6.6

	 	
 

Provider Directory

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

6.7.5

	 	
 

Front and back sample of Enrollee ID Card

 

	 	
 

October 20, 2013

	 	  	 	  
	 	
 

6.8.13

	 	
 

Scripts addressing the questions expected to arise most often for both the Information Service and Medical Advice Services

 

	 	
 

October 20, 2013

	 	  	 	  
	 	
 

6.8.14;

6.8.14.1-4

	 	
 

Tele Mi Salud Policies and Procedures, Quality Criteria and Protocols, Outreach Program, Scripts and Training materials for Tele MI Salud Call Center Employees

 

	 	
 

October 20, 2013

	 	  	 	  
	 	
 

6.9.5

	 	
 

Website screenshots

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

6.10.2

	 	
 

Cultural Competency Plan

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

6.12

	 	
 

Enrollment  Outreach Plan for the Homeless Population

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

6.14.5.1

	 	
 

Marketing Plan and copies of all Marketing Materials (written and oral)

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

7.5.3.4.5

	 	
 

Wellness Plan

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

7.5.8.3.12

	 	
 

Pre-Natal and Maternal Wellness Plan

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

7.7.6.6

	 	
 

Summary of the Strategy for the identification of populations with special health care needs

 

	 	
 

November 15, 2013

	 	  	 	  
	 	
 

7.7.6;  

7.7.6.1-6

	 	
 

Protocols for screening and registering Enrollees for Special Coverage

 

	 	
 

November 1, 2011

	 	  	 	  
	 	
 

7.7.9.1

	 	
 

Plan for Coordination with the MBHO to meet the integration requirements for autism

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

7.8.2.6

	 	
 

Case Management Policies and Procedures

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

7.8.3.5

	 	
 

Disease Management Policies and Procedures

 

	 	
 

December 1, 2011

	 	  	 	  

 

  

  

  

 

Administration of Health Insurance of Puerto Rico

TPA Contract

Deliverables

Attachment 12

 

	 	
 

7.9.1.3

	 	
 

EPSDT Plan including procedures for for tracking gaps in care and follow for annual dental examinations and visits.

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

8.8

 

 

	 	
 

Integration Plan incorporating the elements in Article 8, to ensure cooperation between TPA and MBHO

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

9.6.1.6

	 	
 

Policies and procedures for Enrollee selection of PCP

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

9.11.3

	 	
 

Policies and Procedures for Enrollee selection of PCP

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

9.14.2

	 	
 

Protocols  for screening Enrollees for participation in Case Management and Disease Management Programs

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

9.19.4

	 	
 

Policies and procedures for determining the adequacy of Providers’ available hours

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

9.21.3

	 	
 

Policies and procedures for monitoring (PPN) Provider performance, measuring access to care, and identifying Provider compliance issues

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

9.1.1;

9.22.1

 

	 	
 

Assurances concerning adequacy of Provider Network

	 	
 

TBD -Certifications Due Upon Request

	 	  	 	  
	 	
 

10.1.6.1

	 	
 

Model for each type of Provider Contract

 

	 	
 

Within Thirty Days Upon Execution

 

	 	  	 	  
	 	
 

10.1.6.1

	 	
 

Compact disk with copies of provider contract templates

 

	 	
 

Within Thirty Days Upon Execution

	 	  	 	  
	 	
 

10.2.1.3

	 	
 

Provider Guidelines

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

10.2.2.1

	 	
 

Continuing Education Curriculum for Providers

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

10.5.1.5

	 	
 

Capitation Methodology

 

	 	
 

October 28, 2013

	 	  	 	  
	 	
 

10.8.1

	 	
 

Electronic file and a list of all participating providers, listed by municipality, indicating the capacity of each Provider, as well as the specialty or subspecialty of physicians

 

	 	
 

File Submission Monthly based on Execution Date

 

	 	  	 	  
	 	
 

10.8.5

	 	
 

Control sheet of provider files including:

-    General description of the content of each file

-    The total number of record in each file

 

	 	
 

File Submission Monthly based on Execution Date of the Fifth Day After End of the Month

	 	  	 	  
	 	
 

11.1.2

	 	
 

Utilization Management Policies and Procedures

 

	 	
 

October 17, 2013

	 	  	 	  

 

  

  

  

 

Administration of Health Insurance of Puerto Rico

TPA Contract

Deliverables

Attachment 12

 

	 	
 

12.2.4;

12.3;

12.5.1

 

	 	
 

QAPI Program

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

13.1.3

	 	
 

Fraud and Abuse Policies and Procedures, proposed compliance plan, and Program Integrity Plan

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

14.1.3

	 	
 

Grievance System Policies and Procedures

 

	 	
 

October 24, 2013

	 	  	 	  
	 	
 

14.1.14

	 	
 

Grievance System Forms

 

	 	
 

October 24, 2013

	 	  	 	  
	 	
 

15.3.2

	 	
 

Staff Training Plan and a current organizational chart

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

15.5.1-2

	 	
 

Implementation Plan

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

10.5.1.8; 

16.5.1

	 	
 

Provider Payment Schedule

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

22.1.7

	 	
 

Payment Procedures and controls

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

22.4.1.9

	 	
 

Plan for Routine Audits to prevent duplicate payments for third party billable services

 

	 	
 

December 1, 2013

	 	  	 	  
	 	
 

28.2

	 	
 

Certification that the Contractor does not contract with entities that have been under investigation for, accused of, convicted of, or sentenced to imprisonment, in Puerto Rico, the United States of America, or any other country, for any crime involving corruption, fraud, embezzlement, or unlawful appropriation of public funds, pursuant to Act 458, as amended, and Act 84 of 2002

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

30.1

	 	
 

Insurance license issued by PRICO

 

	 	
 

October 17, 2013

	 	  	 	  
	 	
 

31.1

	 	
 

Certifications from government agencies, a list of Contractor’s contracts with government agencies, and other documents relating to Contractor’s compliance with federal and Puerto Rico law.

 

	 	
 

Within 15 days of execution of contract

	 	  	 	  
	 	
 

38.2

	 	
 

Conflict of Interest Disclosure Form

 

	 	
 

October 17, 2013

	 	  	 	  

 

  

  

  

 

ATTACHMENT 13

Commonwealth of Puerto Rico

OFFICE OF THE INSURANCE COMMISSIONER

 

	 	February 21, 1991
	 	NORMATIVE LETTER  CA-I-2-1232-91

 

TO ALL THE HEALTH SERVICE ORGANIZATIONS AND THEIR PROVIDERS

 

	 	RE: Per Capita Contracting

 

Gentlemen:

Via Circular Letter No. E-2-917-83 of February 10, 1983, this Office forbid the different health service organizations the contracting of health service providers on a per capita basis and/or of set amounts.

The so-called per capita basis, represents the set payment of a determinate amount of money per subscriber made by the organization to the provider, regardless of whether said subscriber utilizes the services rendered by the provider or not.

We have reexamined said concept in light of the provisions of the Insurance Code of Puerto Rico and we find that an absolute transfer of risk under the most liberal terms that would permit a per capita contract, constitutes the offering of a care plan on the part of the service provider, who is generally not authorized by this Office to carry out such business.

Notwithstanding the above, within certain limitations, a type of per capita contracting can be carried out on the part of the medical service provider, which does not constitute insurance business.

The essential characteristics of a contract such as the aforementioned one, are the following: the health service organization retains the primary responsibility toward the subscriber and the transfer of the economic risk is done in a prudent and reasonable manner, based on the real experience of the utilization of the services.  In addition, it must provide the necessary guaranties of quality and sufficiency in the rendering of the services.

To such effect, this Office will allow contracting on set basis or per capita, as long as the following conditions are fulfilled:

1) The health service organization may contract in a per capita manner those services where, because of its geographical location or service area, it cannot count with its own facilities.

2) The health service organization may contract with any medical-hospital group, hospital, insurer or medical service corporation, duly accredited, the supplying of those services that appear in their evidence of coverage in harmony with the capacity and in accordance with the limitations of said provider to facilitate its services.  All per capita contracts shall forbid the provider from, in turn, subcontracting in a per capita fashion.

3) The per capita contract or the one on set bases shall require the provider to supply to the health service organization statistical data about the utilization, costs, days-patients, average stay, etc. and will faculty it to reasonably watch out for the quality of the services rendered to its subscribers.  The health service organization shall be entitled access to the provider’s books for the purpose of auditing the same, with regard to the contracting between both and will take the necessary steps to correct those related defects or faults that it finds with the provider with what was contracted.  The provider shall supply the organization with its annual financial statements and any reasonable and necessary information about costs and utilization.

 

  

  

  

 

4) The per capita contract must require the provider to maintain records of all the subscribers to which it renders service, classifying these on the basis of each health service organization to which it provides service.  Said information will be accessible to the health service organizations and to any public entity.  The provider shall conserve said records for the period that the health service organization requires it to by means of the contract, but in no case whatsoever shall it be for less than five (5) years.

5) The provider shall be responsible and must have the capacity to provide the health care services for a period no lesser than 30 days in the event that the organization is liquidated, is pending liquidation or in a collection proceeding.

6) All health service organizations shall submit to the Office of the Insurance Commissioner a copy of each contract for evaluation and approval of per capita rate or on set bases that it wishes to grant, with no less than 60 days prior to the execution of the same, (including the payment of rights for $250.  payable to the order of the Secretary of the Treasury), it being provided that the violation of this guideline shall imply the sanctions that proceed in conformity with what is established by the Insurance Code of Puerto Rico.

For the purpose of determining whether the provisions of the Insurance Code of Puerto Rico and of this normative letter  are being complied with, this Office shall evaluate the compliance of the requirements of this letter within sixty (60) days counted from the date when it is submitted.  To carry out said evaluation, the provider as well as the health service organization shall supply information about the provider’s facilities, the services that its personnel shall offer and the ratio of costs during the past two years, as well as any other information which this Office requires from it.

7) The per capita contract between the Organization and the provider shall be formalized in writing and its duration cannot be more than one (1) year.  It shall contain, among other things, the following clauses and conditions:

a) A declaration about what is the provider’s capacity in terms of hours-patients, days-beds and other similar unit and that said capacity is in agreement with the expected utilization for the number of per capita subscribers that the contract will cover.

b) The health service organization shall submit annually to this Office, on or before March 31, a comparative report about the experience in the per capita contracting.

c) The per capita contract must have as minimum 50 subscribers, without exceeding the capacities of the provider.

d) The provider will render a medical service of excellence, on an equal footing with the norms of medical technology in this jurisdiction.  THe organization will handle all the grievances or complaints due to the lack of services, incompetence, poor service quality and any other complaint related to the rendering of services presented by the subscribers.

e) The provider commits itself to make accessible to this Office statistical data about the utilization, costs, the average stay of the patients, the services to the subscribers, the personnel, the annual financial statements, its books with regard to the contracting with the organization and any reasonable and necessary information regarding costs and utilization of services.

8) In the per capita contract, the rate per capita shall not be lesser than the actuarial amount  necessary to cover the cost of the medical service.

9) The per capita contracting shall not undermine the organization’s obligation with regard to the subscriber. The provider’s lack of compliance shall be considered as violation on the part of the organization.

10) The resolution or termination of a per capita contract shall only be effective by means of the notice of a written warning by any of the parties, with no less than thirty (30) days of advance notice to the date of effectiveness.

 

  

  

  

 

11) The per capita provider cannot carry out marketing, subscription or administration of the health care plan in the name of the health service organization.

By means of the present document, you are required strict compliance with what is ordered in this normative letter, which shall enter into effect immediately.  The health service organizations shall have until June 30 of 1991, to finalize any effective agreement that is not in conformity with what is expressed herein and they shall submit evidence to the Insurance Commissioner on or before August 30, 1991 regarding the compliance required by this letter.

Each health service organization must present annually to the Commissioner on or before March 31, a report certified and sworn by its President.  Said report shall contain:

1.  The name and the address of all the per capita providers.

2.  A statement of costs and of income of the per capita contracts.

3.  A statement of new or resigning subscriptions and its utilization for each per capita contract.

4.  A statement of claims payable reported and not reported of the per capita provider.

The filing of this report implies the payment of $50. for rights payable in the name of the Secretary of the Treasury.

If you have any doubt about the contents of this normative letter, you must get in touch with this Office immediately.

 

	 	Respectfully,
	 	 
	 	(signed)
	 	Miguel A. Villafañe Neriz
	 	Insurance Commissioner

 

  

  

  

 

ASES

HEALTH INSURANCE ADMINISTRATION

Commonwealth of Puerto Rico

 

	Circular Letter	 	2010-2011 Fiscal Year
	No.  10-10-06	 	October 6, 2011

To the Secretaries, Directors of

Dependencies and Mayors of the

Commonwealth of Puerto Rico

Re: Medical Services Contracted for the year 2011

As part of Reorganization Plan No. 3 of 2010, the functions exercised previously by the Public Insurance Area of the Department of the Treasury related to Act No. 95 of June 29, 1963 passed on to the Health Insurance Administration (ASES), it being understood to mean the faculty to negotiate, contract and endeavor the health benefits for public employees.

In Circular Letter No. 1300-07-09, issued by the Department of the Treasury, there are established the general instructions to be followed for the handling and payment of the health service plans for Government personnel.  In accordance to the provisions of Act No. 95, the health service contracts for the year 2011 were formalized with effectiveness from January 1 to December 31, 2011.

SPECIFIC PROVISIONS

1.             Any eligible personnel that is interested in joining some health service plan contracted by ASES must send the original of the application form to the insuring entity no later than November 30, 2010 with return receipt requested.  The employee shall retain a copy as evidence and shall send a copy to the Human Resources Office of his/her agency.  The personnel who joins a health service plan sponsored by an employee organization must endeavor his/her application form through said organization.  It, after having verified that the employee belongs to the organization, shall be responsible for sending the original of the same to the insuring entity within the limit date indicated.  It shall be the responsibility of the insured person to pay the insuring entity directly for the part of the premium corresponding to him/her if he/she hands in his/her application after the limit date established.

2.             The agency’s Office of Human Resources shall be responsible for retaining the copies of the application forms of the personnel to verify the invoices received by the insuring entity.

3.             The personnel that have a temporary appointment, whose appointment contract is less than six months, is eligible to join the health service plans contracted by ASES, but will not be entitled to the employer contribution established in Circular Letter 1300-07-09.  In these cases, when filling out the application form, there must be indicated in a visible area of the same the phrase NOT ENTITLED TO EMPLOYER CONTRIBUTION.  These applications must be delivered to the insuring entity and copy to the Office of Human Resources of his/her agency.

The Office of Human Resources for each agency will utilize the copies of the applications received to prepare a personnel listing, by insuring entity and organization of employees.  Said list shall include the name and social security number of the principal insured person and shall identify temporary personnel not entitled to employer contribution.  Under no circumstance will there be included in the magnetic media the temporary employees whose appointments are less than six months.

4.             The insuring entities authorized to send the changes directly to the Information Technology Area (ATI) of this Department in the different magnetic media shall have until 4:00 p.m.  of December 3, 2010 to hand them in.  Under no circumstance shall they include in the same the temporary employees whose appointment is less than six months.

 

  

  

  

 

5.             In Attachment 1, there are indicated the keys assigned by ATI to identify the discounts for the concept of health services to be effected in favor of the insuring entities and employee organizations under Act 95 contracted by the Secretary of the Treasury.  ATI shall use these keys to identify in the payroll record the insuring entity or employee organization with which the functionary has his/her medical service insurance.

 

6.             The agencies interested in having ATI process for them the changes automatically for the first biweekly period of the month of January of 2011, shall request it in writing to ATI, before the closing to process the same.  The agencies shall have until 4:00 of the afternoon of December  3, 2010 to submit their application and authorization so that ATI processes their changes automatically.  If the agency does not participate in said process, the agency shall be responsible for making the changes directly in the RHUM system (Mechanized Human Resources). The agencies shall be responsible for entering the transactions of temporary personnel whose appointment is less than six months.

7.             In the contracts formalized with the employee organizations, it was agreed that the payment corresponding to the premiums shall be issued in the name of the insuring entity through which the services shall be rendered.  In Attachment 1 we indicate in favor of whom will the corresponding payments be issued.

8.             Automatic renewals are not authorized, with the exception of the Advantage and Part D of Medicare coverages.  Any retired personnel with the Advantage and Part D of Medicare coverages who does not wish to continue with the health plan after the automatic renewal and those who belong to Medicare’s Complementary Coverage shall have until February 7 of 2011 to change companies or renew their coverage.

If this clause were to be violated, the employee shall notify ASES and the health service Plan shall be obligated to the payment of a penalty of five thousand ($5,000) per occurrence payable to ASES.

9.             When the functionary hands in more than one copy of the application form to the government agency, said agency shall acknowledge the first application received as valid.

10.           The insuring entity must issue the identification cards to the insured person, which shall include the Plan’s date of effectiveness, no later than 15 days after receiving the employee’s application.  As evidence that the cards were sent, it shall utilize PS Form 3877, Certificate of Mailing, supplied by the office at the post office.  In the same, it shall indicate the name and address of the insured person and must be certified by the post office functionary.  In the cases where the sending of the aforementioned cards cannot be carried out, it shall send a certification of coverage to the insured person, no later than 15 days after having received the application, and shall complete PS Form 3877, as evidence of having sent the same.

When the insured person does not receive the cards or certifications, it shall get in touch with the insuring entity to request the reimbursement or the non-invoicing for the month or the months in which the entity is late in issuing the cards or certifications.  In these cases, evidence must be presented as to the application endeavors made by him/her to the insuring entity.

11.           The health service contracts shall have effectiveness until December 31, 2011.  Notwithstanding, those functionaries who are interested in getting out of the health service plan due to any reason that is not that of joining another health service plan, may do so at any moment within said period, by means of Model SC 1330, Cancellation Request, (Attachment 2).  In these cases, the employee cannot join the other health plan of the ones contracted by ASES until the next negotiation, nor will the employer contribution be available to him/her.

Model SC 1330 shall be completed in the original and two copies.  It shall be the responsibility of the insured person to send the original of the aforementioned Model to the insuring entity so that the same can be endeavored and the copy to the Office of Human Resources of the entity for which he/she works. He/she shall retain the last copy as evidence of the application.

12.           The only reason for the insuring entity to not to proceed to cancel the health plan contract shall be that the functionary owes premiums.  As soon as the insuring entity receives the Cancellation Request they shall have 5 days in which to notify the insured person, if said cancellation does not proceed.

 

  

  

  

 

The insuring entity shall notify the employee that first, he/she has to pay for the cancellation to proceed.  Otherwise, he/she has to remain in the plan until the effective period of the contract.

13.           If during the effective period of the contract, the employee or his/her dependents are eligible to join another group health plan, they may request to withdraw from the plan contracted by ASES. In these cases, the cancellation shall be effective the first day of the following month if it is submitted on or before the 10th.  If the petition for withdrawal is made after the 10th, the cancellation shall have effectiveness on the first day of the month following the one in which the request is submitted.

 

14.           If during the effective period of this contract, an employee or his/her dependents stop being eligible for another health plan, they may apply to join the plan contracted by ASES.  In this case, they shall have thirty (30) days from the date of the notice of the cancellation in which to request the change.  They must present evidence as to the date of effectiveness of the cancellation.  The income in these cases shall have effectiveness on the first day of the month following that one in which the same is submitted, as long as the person requests it prior to the tenth (10th) day of the month.  If the person submits the application after the tenth (10th) day of the month, the same shall have effectiveness on the first day of the month following that one in which the application was submitted.

15.           The agencies have the obligation to send the necessary documents that justify any adjustment made in the payment to the insurance company.

16.           The agencies may not utilize the RHUM system to carry out reimbursement of health service plans to employees or to entities, once its contracting period is ended.

17.           In the cases of those employees with sick leave, the agencies are obligated to pay the employer contribution as soon as the health plan invoices and not wait for the employee to be reinstated to his/her duties.

18.           The joint family plan does not apply to personnel and their relatives who belong to the Teachers’ Association of Puerto Rico.  Neither does it apply to personnel from public corporations or government entities whose health services are not contracted under the provisions of the aforementioned Act No. 95.  However, for the unions that contract under Act No. 158, the joint liability will be allowed.

ACT NO. 158 OF AUGUST 10, 2006

Said Act provides that the unions that are under Act No. 45 of February 25, 1998, as amended, better known as the Public Employee Unionization Act, shall be entitled to having the exclusive representative negotiate directly in their names, everything concerning the benefits relating to the health service plan.  For the year 2008, several organizations presented to the Secretary of the Treasury their negotiations with a single plan.  The agencies to which said negotiation applies shall have to take the following measures:

1.             The union shall notify the agency and its union members officially that they are going to be under said Act No. 158 and the name of the health plan selected.

2.             The agency shall request from the union copy of the application of each union member under said plan.  Said agency may not have all the union members join in said plan in a block fashion, it shall only have join in those for which the union presents copy of the application.

3.             The agency shall agree with the union the manner in which the discount shall be made.  The payment of these discounts shall be made in the name of the insuring entity or the Health Plan.

4.             The agency shall agree with ASES the manner in which the changes are to be made and shall be responsible for sending the same directly to ATI in the different magnetic media.  The norms, dates and calendar to be followed shall be ruled by Act 95.

5.             The union shall watch out that the discounts and the services are rendered to the union members.

6.              The union member shall handle any grievance or claim directly with the union.

 

  

  

  

 

7.            The Health Plan selected shall be compulsory for all the union members, excepting the following conditions:

	
  

	
a.    That the employee present evidence of disaffiliation from the union.

	
  

	
b.    That the employee belong to Mi Salud as a Medically Indigent Person or ELA Puro, (it being understood that they are going to join the plan through their employer contribution without being certified by the Office of the Medical Assistance Program of their municipality of residence).  If interested in joining the union’s health plan, they must withdraw at the corresponding Office of Medical Assistance Program prior to the date of effectiveness of the Plan selected.  If the public employee is in Mi Salud as a medically indigent person and loses this benefit outside of the dates established, he/she must complete their affiliation as ELA Puro until the time of coverage ends.  The employee may not join any other plan of the ones contracted by ASES nor will he/she have the employer contribution at his/her disposal. Said cancellation shall be effective as of December 31 of the contract year.

	
  

	
c.    In a family or joint couple plan, that the union member is not the principal insured person.

	
  

	
d.    The employee is a member of the Teachers’ Association.  If interested in joining the union’s health plan, the employee shall get in touch with the Teachers’ Association before filling out the union’s application so that they will orient him/her regarding the process for his/her cancellation from his/her plan with the Association.

	
  

	
e.    The employee does not wish to join the Health Plan selected.  If that is so, he/she cannot utilize his employer contribution for any other Health Plan contracted by ASES.

8.            The employee may not make changes to another Health Plan during the year.

9.            If, during the effective period of the contract, the employee is reclassified from union member to managerial, he/she will stop being eligible for the Health Plan under Act No. 158.  In these cases,  the employee shall have 30 days from the date when they obtain knowledge about the change to join one of the plans contracted by ASES under Act No. 95.  The employee must present the health plan with a certification from the agency that indicates that he/she is no longer a member of the union under this Act.

That managerial employee who belongs to any Employee Organization under Act No. 158 and who goes on to become a union member shall have 30 days to join the plan that corresponds to said Organization.  They must present to the union a certification from the agency that indicates that he/she is no longer a managerial employee.

10.          The effective period of this contract shall be equal to the date established by ASES, as well as any other date established by its Executive Director.

ADVANTAGE PROGRAMS FOR RETIRED PERSONS

The effective period of the plans contracted for the Medicare retired persons with Medicine coverage 9.2, Medicare Part D or Advantage shall be from January 1, 2011 to December 31, 2011.

  

  

  

INSURING ENTITIES FOR ADVANTAGE PROGRAMS FOR RETIRED PERSONS - YEAR 2011

	
Name

	
Deduction Code

	
FIRST MEDICAL HEALTH PLAN, INC.

	
A27

	
HUMANA INSURANCE

	
A17

	
MCS LIFE INSURANCE

	
A14

	
MEDICARE Y MUCHO MAS

	
A35

	
TRIPLE S, INC.

	
A01

INSURING ENTITIES FOR MEDICINE PROGRAMS - PART D FOR RETIRED PERSONS - YEAR 2011

	
Name

	
Deduction Code

	
TRIPLE S, INC

	
D01

	
MCS LIFE INSURANCE

	
D14

	
FIRST MEDICAL HEALTH PLAN, INC.

	
D27

GENERAL   PROVISIONS

	
1.

	
The insurers shall be responsible for offering orientations and information to their representatives and to the functionaries during the orientation campaigns.  In addition, they shall be responsible for notifying the insured persons the changes that occur in the coverage and maintaining evidence of these.

	
2.

	
The handling and payment of the health plans shall be governed by the provisions of Circular Letter No. 1300-07-09 issued by the Department of the Treasury.

	
3.

	
The Office of Human Resources of each agency, shall request an up-to-date Marriage Certificate.

	
4.

	
We authorize the agencies to reproduce Model SC 1330, Request for Cancellation, at their own facilities.

	
5.

	
It’s important that you give a copy of the same to each one of the employees from your agency.

	
6.

	
Soon there will be issued a Circular Letter to inform you the Employee Organizations under Act 95 and Act 158 with which ASES will formalize Health contracts for the year 2011, as well as the keys that will identify the same.

This Circular Letter repeals Circular Letter No. 1330-21-10 of January 15, 2010.

The text of this circular letter is available in our Internet page at the address:

www.ases.gobierno.pr/publicaciones/cartas_circulares_cont.html.

It is the responsibility of the agencies to have the provisions of this Circular Letter reach every one of your personnel, especially those from the Office of Human Resources in charge of the health plans.

Cordially,

(signed)

Domingo Névarez-Ramírez, MHSA

Executive Director

(signed)

Mr. Carlos Guzmán

Service Representative

Attachments

  

  

  

 

	CC-10-10-06 	 
	October 1, 2010 	Attachment 1

 

INFORMATION TO JOIN OR RENEW HEALTH PLANS YEAR 2011

1.             The entry applications to the health plans must reach the insuring entity no later than November 30, 2010, to guarantee the effectiveness as of January 1, 2011.

2.             The personnel that have a temporary appointment whose appointment contract is lesser than six months is eligible to join the health service plans, but not entitled to the employer contribution.  In this case, they shall indicate in their entry application NOT  ENTITLED  TO EMPLOYER  CONTRIBUTION.

3.             The insured person shall sent the application for entry to the insuring entity and copy to the Office of Human Resources of his/her agency.  The personnel that joins a health service plan sponsored by an employee organization shall endeavor its application for entry via said organization.

4.             The insuring entity must issue the identification cards to the insured person and commits itself to work the requests for cancellations or resignations no later than 15 days after receiving the employee’s request.

5.             If the cards or certifications of coverage are not received, within the period established in point 4, the insured person must get in touch with the insuring entity.  The insured person may request the reimbursement or non-invoicing for the month or months where the entity is late in issuing the cards or certifications and shall present evidence of the efforts made on his/her part with the insuring entity.

6.             When filling out the application for entry, all of its parts must be completed with the information, as it appears at the Agency.

7.             When an employee is interested in joining a joint health plan and his/her spouse renders services at another entity, they shall fill out Model SC 1335, Certification to Join the Joint Health Pla.  The joint family plan does not apply to the personnel and their relatives who belong to the Teachers’ Association of Puerto Rico.  Neither does it apply to personnel from the public corporations or government entities whose health services are not contracted under the provisions of the aforementioned Act No. 95.  However, for the unions that contract under Act No. 158, the joint obligation will be permitted.

The Office of Human Resources of the agency, shall request a copy of the up-to-date Certificate of Marriage.

8.             After November 30, 2010, no entry application whatsoever shall be endeavored, with the following exceptions:

a.             Newly appointed personnel.  These shall have 60 days from the date of effectiveness of their appointment.

b.             Personnel that joins in one of the employee organizations, with which contracts have been effected, for the purpose of joining the health plans offered by said organizations.

c.             Personnel, that after November 30 enjoys the retirement benefits, from any of the Retirement Systems, who are interested in continuing or joining one of the health plans contracted by the Secretary of the Treasury.  Said applications must be processed at the corresponding insuring entity with no less than 60 days prior to the date when it shall cease.

9.             If the insured person were to cease in his/her functions, he/she shall have the option to continue with his/her health plan, via direct payment or not continuing with the same.  If they were to continue with their health plan, they shall retain their cards, inform their decision to their immediate supervisor and to the Area of Human Resources of their agency and fill out Model SC 1339, Certificate of Conversion of Health Plan in the event of Resignation or Lay-off.  If he/she is not to continue with the health plan, the employee is responsible for notifying it to the insuring entity.  In addition, they must hand over to their immediate supervisor, their card and that of their dependents, including the one corresponding to their spouse if they had a joint health plan.  The supervisor shall send Model SC 1339 and copy of the resignation to the Agency’s Human Resources Area, which, in turn, shall send it to the insuring entity.

  

  

  

 

10.           When the principal insured ceases, but rendered services during a period lesser than 15 days during any month, except due to authorized leave, said period shall not be counted as worked for the purpose of the payment of the employer contribution.  The premium shall be paid in its entirety by the insured person.

11.           The insured person is obligated to notify, in writing, his/her health plan the following changes:

a.             Dismissal and suspension of employment or salary - shall indicate the date of effectiveness of the dismissal or suspension and his/her address.  In addition, in the cases of suspension, it shall indicate the expiration date of the same.  If he/she has a joint health plan, he/she shall send copy of the communication to the dependency where his/her spouse is rendering services for the corresponding action.  The spouse of the insured principal shall have the deduction of the insured principal made during the time period that the dismissal or suspension of employment and salary lasts.

In the case of unconfirmed suspension or dismissal, if the contract were to be continued with, the functionary shall pay his/her premiums, including the employer part, directly to the insuring entity or employee organization.  When the functionary reincorporates himself/herself to work, if the insurance is continued, the adjustments will be made to reimburse him/her for the employer contribution for the period of his/her lay-off or suspension, in accordance to Section 9 © of Act No. 95.  In the case of joint plans, when the spouse of the insured principal returns to work, the insuring entity shall make the adjustments to reduce the discount to the insured principal and invoice the dependency where his/her spouse renders services.

b.             Leave without Salary, Military Leave without Salary or Family and Medical Leave (Model SC 1334) - shall indicate the date the same begins and ends and whether will continue with the contract or not.  In addition, if he/she has a joint plan, shall send copy of said communication to the dependency where his/her spouse in rendering services, for the corresponding action.

If he/she continues with the contract, the coverage shall continue in effect for a period that shall not exceed one year for leaves under Act No. 95, or for a period that shall not exceed 12 weeks in the cases of leaves under the Family and Medical Leave Act of 1993, (Public Law 103-3), and shall be entitled to the payment of the corresponding employer contribution for the aforementioned period.  If the functionary is reinstated to public service after the leave has ended and has not joined a health plan, he/she shall have 60 days following the date of his/her reinstatement to apply to join to one of the health plan contracted by the Secretary of the Treasury.

When an employee subscribed to a health benefit plan takes a leave without salary and determines to continue with the insurance contract, he/she shall be entitled to the payment of the employer contribution for a period that shall not exceed 12 months, as long as he/she reinstates himself/herself to public service at the end of said period.  If, after one year has elapsed from the date when the leave without salary is granted, the employee has not reinstated himself/herself to his/her duties, having enjoyed the payment of the Government contribution to the health benefit plan, he shall be obligated to reimburse said amount to his/her agency. However, the Secretary of the Treasury may exclude from the obligation to reimburse the aforementioned contributions, to any employee that receives retirement benefits for a health condition.

When a person in the military subscribed to a health benefit plan takes a military leave without salary and determines to continue with the insurance contract, he/she must notify the insuring entity and the Office of Human Resources of his/her agency.  The military leave without salary is until the person returns and he/she does not have to return the employer contribution as long as he/she has been activated for a specific need.

12.           The functionaries shall endeavor in writing any claim for errors in discounts directly to the insuring entity or employee organization within the 30 days following the receipt of the voucher or some notice of collection.

 

  

  

  

 

13.           In the cases of resignation of the spouse of  the insured principal in a joint plan, it shall be processed just like in cases of dismissal.

14.           If during the effectiveness of a contract, the functionary or his/her dependents are eligible to join another health plan, he/she may request the termination of the plan contracted by the Secretary of the Treasury.  In these cases, the cancellation shall be effective on the first day of the following month if it is submitted  before the 10th.  If the request for termination of plan is made after the 10th, the cancellation shall be effective on the first day of the month following the one in which the request was submitted.

 

15.           The functionaries who join a health plan sponsored by a public employee organization must channel their request for income directly to the corresponding organization.

16.           The claims for services shall be handled in writing directly to the insuring entity or corresponding employee organization, within the 60 days after having received any service covered by the policy.

  

  

  

June 29. 2011

NORMATIVE LETTER #11-06-29

TO ALL PROVIDERS THAT OFFER HEALTH SERVICES FOR THE MI SALUD PLAN

 

RE: Topic: Auto-Enrollment

 

Dear Provider:

 

Any person who on or after July 1, 2011 is certified as eligible to the Health Plan of the Government of Puerto Rico will be automatically insured by MI Salud and enrolled in said plan according to their Region of residence.

 

The insured will be able to begin receiving health services starting on the same day that the Medicaid Office of the Puerto Rico Department of Health gives the insured the MA-10 form. The title of this document is “Notice of Action Taken Regarding Application and/or Reevaluation,” a copy of which is enclosed so you may become familiar with form MA-10 and to help you understand this Normative Letter. The date to determine when the person’s insurance coverage started is that which appears under the section titled “Date of Certification” on the MA-10 form (upper right). The insured will also be given the MI Salud Welcome Letter (a Model Letter is enclosed).

 

If the insured visits your office or health service facility and requests any health service and he or she has not received the MI Salud Plan ID card, the provider must ask the insured for a copy of form MA-10 and the Welcome Letter. This Letter, when presented with form MA-10, will continue in effect for 30 days starting on the “Date of Certification” specified on form MA-10.

 

The insured must present both documents when seeking a health service covered by the MI Salud Plan to evidence that (i) his or her name appears on form MA-10 and the beneficiary’s identity must validated with some type of identification card or other means, (ii) the insured is enrolled in the MI Salud Plan, (iii) 30 days have not elapsed from the Date of Certification on form MA-10 (iv) and he or she may begin to receive services. In addition, the provider must verify that the Welcome Letter and the MA-10 form are in effect at the time of rendering the services, since they will not be in effect if 30 days have elapsed.

 

It is important for the provider to call the insurer of the beneficiary’s region to verify if this beneficiary has been assigned a primary physician, Primary Medical Group and a Preferred Network. Even if the insured does not have a primary physician, the provider may render health services and submit a claim to Humana or MCS-HMO for physical or dental health, and to APS Healthcare for mental health services. These entities are responsible for the payment of your services, in accordance with the terms and conditions of the contract between you and the appropriate entities and the provisions set forth in this Normative Letter.

 

To simplify the claims and payment process for the services rendered by the provider, there is a section on form MA-10 labeled “MPI/SS.” The insured’s identification number appears in this section.

 

It is important to state that what is set forth in this Normative Letter does not apply to beneficiaries who: (1) Are enrolled in a Medicare Platino Plan and (2) Have an MA-10 form with a Date of Certification prior to July 1, 2011. In the latter case, the beneficiary must visit the Insurer’s Office in their region (Humana or MCS-HMO) to obtain the MI Salud Plan card to begin receiving covered services.

 

ASES requires that MCS-HMO, Humana and APS Healthcare, within a non-extendable term of five (5) calendar days, send each of their participating providers for the MI Salud Plan a true and exact copy of this Normative Letter. The entities must send to the attention of Executive Director of ASES an Affidavit signed by their Corporate President to certify that they have faithfully complied with all which is hereby required.

 

  

  

  

 

We require faithful compliance with this normative letter in order to continue providing the excellent and quality services under the MI Salud Plan of the Government of Puerto Rico.

 

As always, we are certain that we can count on the support of providers.

 

Cordially,

 

(signed)

Frank R. Díaz-Ginés, MHSA

Executive Director

  

  

  

ASES

 

Administration of Health Insurance

Commonwealth of Puerto Rico

February 13, 2004

TO ALL THE INSURERS, MENTAL HEALTH SERVICE COMPANIES, ADMINISTRATOR OF SERVICES FOR DIRECT CONTRACTING, MEDICAL GROUPS OF THE DEMONSTRATIVE OF DIRECT CONTRACTING, PRIMARY CENTERS, INDEPENDENT PRACTICE ASSOCIATIONS AND PROVIDERS PARTICIPANTS OF THE HEALTH INSURANCE OF THE COMMONWEALTH OF PUERTO RICO

(signed)

Enrique A. Vicéns Rivera

Executive Director

Normative Letter No. 04-0130

PAYMENT OF CLAIMS IN EMERGENCY ROOMS FOR PHYSICAL AND MENTAL HEALTH SERVICES AT MEDICAL-SURGICAL HOSPITALS

During the course of the 2003 fiscal year and of the present one, the Administration of Health Insurance (ASES) has received a significant amount of complaints originating from hospital medical-surgical institutions.  In particular, said institutions ask us which one is the entity responsible for the payment of the claims for services rendered in emergency rooms of said institutions when physical procedures are carried out to stabilize a mental health beneficiary or when examinations and physical diagnosis tests are carried out but the final diagnosis turns out to be covered by the mental health service companies (MBHOs).

For the purpose of clearing up the confusion in existence with regard to the matter, this Normative Letter provides the construction of ASES with regard to the matter, which has been previously communicated to MBHOs and Insurers:

When a beneficiary is admitted to a medical-surgical hospital or receives services in emergency rooms from said hospitals, the insurers will handle the payment of the corresponding fund for any physical procedure which can reasonably be carried out to stabilize a beneficiary regardless of whether the final diagnosis will be a mental health one.  In like manner, the insurers shall be responsible for handling the payment of the corresponding fund via examinations and physical diagnostic tests that could, reasonably, be carried out on the basis of the symptoms with which a beneficiary shows up in conformity to the definition of medical emergency condition in the contracts, which establishes the federal regulation.  For example, it is the responsibility of the insurer to pay providers for claims for stomach wash or for suturing the wrists of a beneficiary with a suicide attempt.  Simultaneously, the MBHO has to be contacted in accordance its protocol for the psychiatric consultation and corresponding referral.

If a psychiatric consultation or evaluation were needed, the medical-surgical hospital or its emergency room will coordinate the same utilizing the MBHO protocols and the Uniform Sheet of Referral for Mental Health Services.  The MBHO shall be responsible only for the offering of those mental health services, services related to the treatment of alcoholism and/or controlled substance dependency, which exclude physical stabilization procedures or diagnosis procedures in said institutions.

In conformity to the contract between ASES and the MBHOs, these would have available psychiatrists with privileges at medical-surgical hospitals, which shall take care of the consultations of beneficiaries admitted in said hospitals.    If at the moment of requiring the mental health services at the hospital unit, the MBHO does not have physicians available, the beneficiary may receive treatment for his/her condition on the part of the psychiatrist facultatives coordinated via the hospital and who fulfill the requirements of credentials (usual ones) for that type of provider.  This until the patient can be transferred to a psychiatric institution, after authorization from the MBHO.  It’s important to point out that in these cases the following exclusion considered in our contractual agreement (between ASES and the MBHOs) shall apply:

 

  

  

  

 

	
●

	
Services ordered and/or rendered by providers who are not participants of mental health services, except in cases of real and proven emergency or via prior authorization from the mental health service company (MBHO).

For purposes of payment, the MBHO shall verify the usual credentials of the facultative and shall compensate him/her for an amount that not be lesser than the one contracted with the MBHO providers to offer the psychiatric consultation services at medical-surgical hospitals.  In the event that the patient is a beneficiary of Medicare and of the Health Insurance, the reimbursement to the facultative shall be carried out in accordance to the contract with ASES.

  

  

  

Commonwealth of Puerto Rico

Department of Health

 

December 23, 2008

Minerva Rivera, Esq.

Executive Director of ASES

(Signed)

Johnny V. Rullán, MD, FACPM

Secretary of Health

LISTING OF DIAGNOSES OF CHILDREN WITH SPECIAL HEALTH NEEDS (NNES)

The Listing of Diagnoses of Children with Special Health Needs was revised in response to your request.

It’s necessary to point out that at the beginning this listing was provided to ASES as a guide; therefore, it’s important that a child who does presents some  condition which is in the listing not be excluded from the benefits of the coverage of the Health Card of the Government of Puerto Rico. If the child fulfills the definition of Children with Special Health Needs of the Bureau for the Child-Maternal Health, he/she must receive the services even before a diagnosis is established.

In addition, we submit our recommendations for the identification, diagnosis and treatment of the children and youth with special health needs to as assure access to the services which this population needs.  These have the purpose of ensuring some uniform needs for all the children with special health needs regardless of the insurer.

Thank you for your attention to this matter.

 

NNES Diagnosis Listing

d/several 2008-06

  

  

  

CHILDREN WITH SPECIAL HEALTH NEEDS

DEFINITION:

Children who have or are at a greater risk of developing a chronic physical, conduct, emotional or developmental condition, who also need health services and other related services of a type or in an amount that goes beyond what children in general need.

STANDARD OF MEDICAL NEED SPECIFIC TO CHILDREN

●              Medically necessary services are those necessary for the prevention and maintenance of health or for the diagnosis and treatment of a physical or mental condition, or if they were necessary to prevent the deterioration of that condition or to promote the development or the maintenance of appropriate functioning for the age.

NNES SPECIAL  COVERAGE

In the “Special Coverage”, the Insurance Companies, with whom ASES contracts the services, assume the risks of the services for the conditions classified with Diagnoses of Conditions of Children with Special Needs. (See list of ASES diagnoses).

In this list of conditions there are included the most frequent diagnoses, but it is not limited to or excludes other conditions that fulfill the definition.  With this purpose there should be utilized a screener to determine its applicability.

It is the responsibility of the primary physician to request the coverage, and register the insured person utilizing the corresponding form for Children with Special Health Needs that is found in the Manual of the Provider.  The certification process may also be initiated by one of the Pediatric Centers of the Department of Health.

To be able to evaluate and certify these cases it is necessary to include, together with the form, the necessary information: Ex:

● Summary of the case: Up-to-date history record and physical examination

● Evaluations and consultations from specialists

● Results of diagnostic procedures and tests

● Results of diagnostic laboratory tests

● Necessary follow-up plan

● Treatment plan

This information and the registration form must be sent to the Case Handling Program (PMC) of the Insurer.  The PMC will evaluate the application for certification and the documentary information included.  Each case is evaluated individually by the Handler of cases and consulting the Program’s advisory team.  This depend on the coverage negotiated.  The agreement with the insurance companies must be uniform and that it obligates all the companies equally.

The family and the primary physician are notified directly by letter as to whether the application for inclusion of his/her patient in the NNE registry has been accepted or denied; or if there is information missing for the consideration of the case.  The physician and/or the family may appeal in writing any denial decision, with the necessary additional information.

  

  

  

Index by Diagnosis and Condition

	
ICD 9

	  
	
 

	
Metabolic Disorders

	  	  
	
270

	
Disorders of the metabolism of aromatic amino acids

	
270.0

	
Disorders of the transport of amino acids

	
270.0

	
Cystinosis

	
270.0

	
Cystinuria

	
270.0

	
Fanconi

	
270.0

	
Hartnup’s

	
270.0

	
Lowe’s

	
270.1

	
Phenylketonuria (PKU)

	
270.2

	
Disorders of metabolism of tyrosine

	
270.2

	
Alcaptonuria

	
270.2

	
Hyperthyrosinemia

	
270.2

	
Ocronosis

	
270.2

	
Tyrosinosis

	
270.2

	
Tyrosinuria

	
270.2

	
Albinism

	
270.3

	
Maple-Syrup disease

	
270.3

	
Other metabolic disorders of chained amino acids

	
270.3

	
Hyperleukina-isoleukinemia

	
270.3

	
Hypervalinemia

	
270.3

	
Isovaleric  acidemia

	
270.3

	
Methylmalonic  acidemia

	
270.3

	
Propionic  acidemia

	
270.3

	
Metabolic disorders with amino acids with sulfide

	
270.4

	
Homocystinuria

	
270.4

	
Deficiency of sulfite oxidase

	
270.4

	
Homocystine cystathionine

	
270.5

	
Other metabolic disorders of aromatic amino acids

	
270.5

	
Disorder of:

	
270.5

	
Histidine metabolism

	
270.5

	
Tryptophan metabolism

	
270.5

	
Metabolic disorders of chain amino acids and fatty acids

	
270.6

	
Metabolic disorders of the citrulinemia urea cycle

	
270.6

	
Hyperammonemia

	
270.6

	
Argininosuccinic acid

	
270.7

	
Metabolic disorders of lysine and hydroxilisine

	
270.7

	
Glutaric aciduria

	
270.7

	
Hydroxilisinemia

	
270.7

	
Hyperlisinemia

	
270.7

	
Metabolic disorders of glycine

	
270.7

	
Non-ketosic hyperglysinemia

	
270.8

	
Deomitine metabolic disorders

	
270.8

	
Omitinemia type I, II

	
270.8

	
Hyperhydroxyprolinemia

	
270.8

	
Hyperprolynemia types I, II

	
270.8

	
Sarcosinemia

	
270.8

	
Other specific amino acid metabolic disorders

	
270.9

	
Other non-specific metabolic and amino acid transport disorders

	
271

	
Carbohydrate transport and metabolism disorders

 

  

  

  

 

	
271.0

	
Glycogenosis

	
271.0

	
Amylopectinosis

	
271.0

	
Deficiency of glucose-6-phosphatase

	
ICD9

	
Index by Diagnosis and Condition

	  	  
	
271.0

	
Cardiac glycogenosis

	
271.0

	
Disease:

	
271.0

	
Andersen

	
271.0

	
Cori

	
271.0

	
Forbes

	
271.0

	
Hers

	
271.0

	
McArdle

	
271.0

	
Pompe

	
271.0

	
Tauri

	
271.0

	
Von Gierke

	
271.0

	
Deficiency of hepatic phospholirase

	
271.1

	
Metabolic disorder of Galactosemia galactose

	
271.2

	
Metabolic disorder of fructose, Fructosemia

	
271.3

	
Intolerance to lactose

	
271.3

	
Other disorders of intestinal absorption of carbohydrates

	
271.4

	
Other specific metabolic disorders of carbohydrates Pentosuria, renal Glycosuria

	
271.8

	
Metabolic disorders of pyruvate and gluconeogenesis

	
271.8

	
Defects in degradation of glycoprotein

	
271.9

	
Non-specific disorder of the transport and metabolism of carbohydrates

	
272

	
Metabolic disorder of lipids

	
272.0

	
Hypercholesterolemia

	
272

	
Gangliosidosis

	
272.0

	
Hypercholesterolemia

	
272.1

	
Hyperglycerinemia

	
272.4

	
Other non-specific hyperlipidemias

	
272.7

	
Other gangliosidosis

	
272.7

	
Lipidosis

	
272.7

	
Anderson’s

	
272.7

	
Fabry’s

	
272.7

	
Gaucher’s

	
272.7

	
Krabbe

	
272.7

	
Neimman-Pick

	
272.7

	
Faber’s

	
272.7

	
Metachromatic leukodystrophia

	
272.7

	
Mucopolysaccaridosis, type I

	
272.7

	
Hurler’s

	
272.7

	
Hurler-Scheie

	
272.7

	
Scheie

	
272.7

	
Mucopolysaccaridosis, type II

	
272.7

	
Hunter’s

	
272.7

	
Other mucopolysaccaridosis

	
272.7

	
Maroteaux-Lamy

	
272.7

	
Morquio’s

	
272.7

	
Sanfilippo

	
273

	
Metabolic disorders of plasma protein

	
274.9

	
Unspecific gout

	
275

	
Metabolic disorder of minerals

	
275.0

	
Metabolic disorders of iron

	
275.1

	
Metabolic disorders of copper

	
275.1

	
Wilson’s

	
275.2

	
Metabolic disorders of magnesium

 

  

  

  

 

	  	  
	
275.3

	
Metabolic disorders of phosphorus

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	  	  
	
275.4

	
Metabolic disorders of calcium

	
275.9

	
Other metabolic disorders of minerals

	
276.2

	
Lactic Acidosis

	
277

	
Other metabolic disorders

	
277.00

	
Cystic Fibrosis

	
277.1

	
Metabolic disorders of purine and pyrimidine

	
277.1

	
Hereditary eritropoietic porphyria

	
277.2

	
Other metabolic disorders of purine and pyrimidine

	
277.2

	
Lesch-Nyhan

	
277.2

	
Hereditary Xantinuria

	
277.3

	
Amyloidosis

	
277.4

	
Gilbert’s

	
277.4

	
Crigler-Najjar

	
277.4

	
Other metabolic disorders of bilirubin

	
277.4

	
Dubin-Johnson

	
277.4

	
Rotor’s

	
277.6

	
Antitrypsin alpha-1 deficiency

	
277.8

	
Other specific metabolic disorders

	
277.81

	
Primary carnitine deficiency

	
277.82

	
Carnitine deficiency

	
277.85

	
Disorders of the oxidation of fatty acids

	
277.85

	
CPT1, CPT2, LCHAD, VLHAD, MCAD, SCAD

	
277.87

	
Mitochondrial metabolic disorders

	
277.89

	
Other specific disorders of the metabolism

	
277.89

	
Hans Schuler Christian, Hystiocitosis, Hystiocitosis

	
277.9

	
Other non-specific metabolic disorders

	
Hereditary and degenerative diseases of the Nervous System

	
330

	
Cerebral degeneration

	
330.0

	
Sphingolipidosis (Leukodystrophia)

	
330.1

	
Cerebral Lipidosis

	
330.8

	
Other cerebral degenerations

	
330.8

	
Alper’s

	
330.8

	
Leigh’s

	
330.8

	
Sub-acute necrotizing encelopathy

	
331.4

	
Obstructive hydrocephalia, acquired

	
333.1

	
Essential shakes

	
333.2

	
Myoclonus

	
333.4

	
Huntington’s chorea

	
334.0

	
Spinocerebral disease

	
334.0

	
ereditary ataxia

	
334.0

	
Friedreich’s ataxia

	
334.1

	
Hereditary spastic paraplegia

	
334.2

	
Primary cerebellar degeneration

	
334.2

	
Marie’s

	
334.2

	
Sanger’s-Brown

	
334.8

	
Telangiectasia-ataxia

	
335

	
Spinal muscular atrophy and kindred syndromes

	
335.0

	
Infantile spinal muscular atrophy, type I (Werdnig-Hoffman)

	
335.1

	
Other hereditary spinal muscular atrophies

  

  

  

 

	
ICD9

	
Index by Diagnosis and Condition

	
335.10

	
Spinal muscular atrophy:

	
335.10

	
Infantile, type II

	
335.11

	
Juvenile, type II (Kugelberg-Welander)

	
340

	
Multiple sclerosis

	
341.0

	
Other demyelinant diseases of the central nervous system

	
341.1

	
Diffuse sclerosis

	
341.1

	
Periaxial encephalitis

	
341.1

	
Schiller’s disease

	
341.8

	
Other demyelinant diseases of the central nervous system

	
341.8

	
Central demyelination of the corpus callosum

	
341.8

	
Pontine central myelinosis

	
341.8

	
Acute transverse myelitis in demyelinant disease of the central nervous system

	
341.8

	
Subacute necrotizing myelitis

	
341.9

	
Non-specific demyelinant diseases of the central nervous system

	
345

	
Epilepsy

	
345.1

	
Generalizes epilepsy without convulsions

	
345.1

	
Generalized epilepsy with convulsions

	
345.1

	
· clonic

	
345.1

	
· myoclonic

	
345.1

	
· tonic

	
345.1

	
· tonic-clonic

	
345.1

	
Lennox-Gastaut syndrome

	
345.2

	
Epileptic petit mal state

	
345.3

	
Epileptic grand mal state

	
345.3

	
Tonic-clonic epileptic state

	
345.4

	
Partial epilepsy, with loss of consciousness

	
345.4

	
Epileptic absence state

	
345.4

	
Complex partial epileptic mal state

	
345.5

	
Partial epilepsy, without loss of consciousness

	
345.6

	
Salaam attacks

	
345.6

	
Infantile spasms

	
345.7

	
Continuous partial epilepsy (Kozhevnikof)

	
345.8

	
Other epileptic states

	
345.9

	
Non-specified type epileptic mal state

	
342.0

	
Flaccid hemiplegia

	
342.1

	
Spastic hemiplegia

	
342.3

	
Infantile monoplegia

	
342.9

	
Non-specified hemiplegia

	
343

	
Infantile cerebral paralysis

	
343.0

	
Spastic diplegia

	
343.1

	
Congenital hemiplegia

	
343.2

	
Non-specified, quadriplegia

	
343.4

	
Infantile hemiplegia

	
343.8

	
Congenital spastic paralysis (cerebral)

	
343.9

	
Non-specific infantile cerebral paralysis

	
344

	
Other infantile spastic paralysis syndromes, non-congenital

	
356

	
Motor and sensory hereditary neuropathy

	
356.0

	
Idiopathic hereditary neuropathies

	
356.0

	
Dejerine-Sottas disease

	
356.1

	
Peroneal muscular atrophy, Charcot-Marie-Tooth disease

	
356.2

	
Sensory hereditary neuropathy, types I-IV

  

  

  

	
ICD9

	
Index by Diagnosis and Condition

	
356.8

	
Roussy Levy syndrome

	
348

	
Other conditions of the brain

	
348.0

	
Cerebral cyst

	
348.30

	
Unspecified encephalopathy

	
356.3

	
Resfsum disease

	
356.3

	
Neuropathy associated with hereditary ataxia

	
356.4

	
Idiopathic progressive neuropathy

	
356.6

	
Other hereditary and idiopathic neuropathies

	
356.9

	
Hereditary and idiopathic neuropathy, without another specification

	
357

	
Inflammatory polyneuropathy

	
357.0

	
Guillain-Barre syndrome

	
357.0

	
Acute infectious polyneuritis (post)

	
359

	
Muscular dystrophy and other neuropathies

	
359.0

	
Hereditary congenital muscular dystrophy

	
359.1

	
Progressive hereditary muscular dystrophy

	
359.1

	
* autosomic recessive, infantile type, similar to Duchenne or Becker

	
359.1

	
· benign (Becker)

	
359.1

	
· waist-pelvic

	
359.1

	
· distal

	
359.1

	
· scapuloperoneal

	
359.1

	
· benign scapuloperoneal with precocious contractures [Emery-Dreituss]

	
359.1

	
· fascioscapulohumeral

	
359.1

	
· gravis [Duchenne]

	
359.1

	
· ocular

	
359.1

	
· oculopharyngea

	
359.2

	
Motonic disorders

	
359.2

	
Myotonic disorders [Steiner]

	
359.2

	
Congenital myotonia:

	
359.2

	
· dominant [Thomsen]

	
359.2

	
· recessive [Becker]

	
359.9

	
Myopathies, without specifying

	  	  
	
Musculo-skeletal disorders

	
723.5

	
Torticollis, non-specific

	
732.1

	
Juvenile osteochondritis of the pelvis and hip

	
732.1

	
Plana coxa

	
732.1

	
Legg-Calve-Perthes

	
732.1

	
Scheuermann disease

	
732.4

	
Juvenile osteochondritis of the tibia and peroneus

	
732.4

	
Proximal of the tibia (Blount)

	
732.4

	
Tuberosity of the tibia (Osgood-Schlatter)

	
732.4

	
Vara tibia

	
736.7

	
Other acquired deformities of the limbs

	
736.71

	
Acquired equinovarus deformity

	
736.79

	
Other equine deformities of the foot, acquired

	
737

	
Curvature of the spine

	
737.1

	
Acquired cifosis

	
737.2

	
Acquired lordosis

	
737.3

	
Idiopathic scoliosis

	
754.1

	
Torticollis of the sternocleidomastoid muscle

  

  

  

 

	
ICD9

	
Index by Diagnosis and Condition

	 	 
	
Congenital Anomalies

	
Congenital Anomalies of the nervous system

	
740.0

	
Anencephaly

	
740.1

	
Craniorachischisis

	
740.2

	
Iniencephaly

	
741

	
Spina bifida

	
741.00

	
Spina bifida with hydrocephalia, non-specific region

	
741.01

	
Spina bifida with hydrocephalia, cervical region

	
741.02

	
Spina bifida with hydrocephalia, dorsal (thoracic)

	
741.03

	
Spina bifida with hydrocephalia, lumbar region

	
741.9

	
Spina bifida, non-specified

	
741.91

	
Spina bifida without mentioning hydrocephalia, cervical region

	
741.92

	
Spina bifida without hydrocephalia, dorsal region (thoracic)

	
741.93

	
Spina bifida without hydrocephalia, lumbar region

	
742.0

	
Encephalocele

	
742.1

	
Microcephalia

	
742.2

	
Congenital malformations of the corpus callosum

	
742.2

	
Agenesia of the corpus callosum

	
742.2

	
Arrinencephaly

	
742.2

	
Holoprosencephaly

	
742.2

	
Other hypoplastic anomalies of the encephalus: agenesia, hypoplasia, lisencephaly...

	
742.3

	
Congenital hydrocephalia

	
742.3

	
Malformations of the cerebral aqueduct (“Silvio”): Anomaly, stenosis, obstruction

	
742.4

	
Other congenital malformations of the encephalus

	
742.4

	
Megaencephalia

	
742.4

	
Congenital cerebral cysts:

	
742.4

	
Schizencephaly

	
742.4

	
Porencephaly

	
742.4

	
Macrogiria

	
742.51

	
Diastematomyelia

	
742.53

	
Hydromyelia

	
742.59

	
Other congenital anomalies of the spinal cord

	
742.8

	
Other congenital anomalies of the spinal cord, specific

	
742.8

	
Other congenital anomalies of the nervous system

	
742.8

	
Arnold-Chiari syndrome

	
742.9

	
Congenital anomalies of the brain, spinal cord and nervous system non-specific

	
743

	
Congenital malformations of the eye, of the ear, of the face and the neck

	
743

	
Anophthalmia, microphthalmia and macrophthalmia

	
743.03

	
Cystic ocular globe

	
743.1

	
Microphthalmia

	
743.2

	
Buphthalmos, congenital glaucoma

	
743.2

	
Congenital glaucoma

	
743.3

	
Congenital malformations of the crystalline

	
743.3

	
Congenital cataract

	
743.35

	
Congenital aphaquia

	
743.36

	
Other congenital malformations of the crystalline

	
743.37

	
Congenital displacement of the crystalline

	
743.39

	
Coloboma of the crystalline

	
743.4

	
Congenital malformations of the anterior segment of the eye

	
743.41

	
Anomaly of the size and shape of the cornea

 

  

  

  

 

	
743.42

	
Congenital corneal opacity

	
743.43

	
Other congenital malformations of the cornea

	
743.44

	
Other congenital malformations of the anterior segment of the eye

	
ICD9

	
Index by Diagnosis and Condition

	
743.44

	
Rieger’s anomaly

	
743.45

	
Absence of iris, Aniridia

	
743.46

	
Coloboma of the iris

	
743.46

	
Other congenital malformations of the iris

	
743.47

	
Blue sclerotia

	
743.48

	
Congenital malformation of the anterior segment of the eye, non-specified

	
743.51

	
Congenital malformations of the posterior segment of the eye

	
743.51

	
Congenital malformation of the vitreous humor

	
743.52

	
Other congenital malformations of the posterior segment of the eye

	
743.52

	
Coloboma of the bottom of the eye

	
743.53

	
Congenital malformation of the choroid

	
743.56

	
Congenital malformation of the retina

	
743.57

	
Congenital malformation of the optic disk

	
743.57

	
Coloboma of the optic disk

	
743.59

	
Congenital malformation of the posterior segment of the eye, non-specified

	
743.6

	
Congenital malformations of the eyelids, of the tear sac and of the orbit

	
743.61

	
Congenital ectropion

	
743.62

	
Congenital entropion

	
743.62

	
Other congenital malformations of the eyelids

	
743.64

	
Absence and agenesia of the lacrimal sac

	
743.65

	
Congenital stenosis and narrowing of the lacrimal conduit

	
743.65

	
Other congenital malformations of the lacrimal sac

	
743.66

	
Congenital malformation of the orbit

	
743.8

	
Other congenital malformations of the eye, specified

	
743.9

	
Congenital malformations of the eye, not specified

	
744

	
Congenital malformations of the ear that alter audition

	
744.01

	
Congenital absence of the pavilion of the ear

	
744.02

	
Congenital absence, atresia or narrowing of the external auditive conduit

	
744.03

	
Other congenital malformations of the middle ear

	
744.04

	
Congenital malformation of the small bones of the ear

	
744.04

	
Fusion of the small bones of the ear

	
744.05

	
Congenital malformation of the internal ear

	
744.09

	
Congenital absence of the ear SAI

	
744.09

	
Congenital absence of the auricular lobule

	
744.1

	
Accessory auricle

	
744.2

	
Other congenital malformations of the ear

	
744.21

	
Other congenital malformations of the ear, specified

	
744.22

	
Macrotia

	
744.23

	
Microtia

	
744.24

	
Absence of the Eustachian tube

	
744.3

	
Congenital malformation of the ear, not specified

	
744.4

	
Sinus, fistula or cyst of the branchial cleft

	
744.43

	
Cervical ear

	
744.47

	
Sinus and preauricular cyst, fistula:

	
744.49

	
Other malformations of the branchial clefts

	
744.5

	
Pterigion of the neck

	
744.8

	
Other specified congenital malformations of the face and neck

	
744.81

	
Macrocheilia

	
744.82

	
Microcheilia

	
744.83

	
Macrostomy

	
744.84

	
Microstomy

 

  

  

  

 

	
744.9

	
Congenital malformation of the face and neck, not specified

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	
745

	
Congenital malformations of the circulatory system

	
745

	
Congenital malformations of the chambers of the heart and its connections

	
745.0

	
Common truncus arteriosus

	
745.0

	
Persistence of the truncus arteriosus

	
745.10

	
Transposition (complete) of the large vessels

	
745.11

	
Transposition of the large vessels in right ventricle

	
745.11

	
Taussig-Bing syndrome

	
745.11

	
Transposition of the large vessels in left ventricle

	
745.12

	
Corrected transposition

	
745.2

	
Fallot’s tetralogy

	
745.3

	
Common ventricle

	
745.3

	
Sole ventricle

	
745.4

	
Defect of the ventricular septal

	
745.4

	
Eisenmenger syndrome

	
745.5

	
Defect of the auricular septal

	
745.5

	
Oval hole

	
745.5

	
Ostium secundum (type II)

	
745.6

	
Defect of the aurioventricular septal

	
745.6

	
Defect of the endocardial pillow

	
745.6f

	
Defect of the auricular septal ostium primum (type I)

	
745.69

	
Common auriculoventricular channel

	
745.7

	
Biauricular trilocular heart

	
745.8

	
Other congenital malformations of the cardiac septals

	
745.9

	
Congenital malformation of the cardiac septal, unspecified

	
746

	
Congenital malformations of the pulmonary and tricuspid valves

	
746.00

	
Anomaly of the pulmonary valve, unspecified

	
746.01

	
Atresia of the pulmonary valve

	
746.02

	
Congenital stenosis of the pulmonary valve

	
746.09

	
Congenital insufficiency of the pulmonary valve

	
746.1

	
Stenosis, congenital atresia of the tricuspid valve

	
746.2

	
Ebstein’s anomaly

	
746.3

	
Congenital stenosis of the aortic valve

	
746.4

	
Congenital insufficiency of the aortic valve

	
746.5

	
Congenital mitral stenosis

	
746.6

	
Congenital mitral insufficiency

	
746.7

	
Syndrome of left hypoplasia of the heart

	
746.7

	
Syndrome of left hypoplasia of the heart

	
746.81

	
Congenital subaortic stenosis

	
746.82

	
Triauricular heart

	
746.83

	
Stenosis of the pulmonary infundible

	
746.84

	
Other congenital malformations of the heart, specified

	
746.85

	
Malformation of the coronary vessels

	
746.86

	
Congenital heart block

	
746.87

	
Other congenital malformations of the heart

	
746.87

	
Dextrocardia

	
746.87

	
Levocardia

	
746.89

	
Congenital diverticule of the left ventricle

	
746.9

	
Congenital malformation of the heart, unspecified

	
747

	
Congenital malformations of the large arteries

	
747.0

	
Permeable arterius ductus

	
747.0

	
Open Botalli conduit (hole)

 

  

  

  

 

	
747.0

	
Persistence of the arterius ductus

	
747.1

	
Coarctation of the aorta

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	
747.2

	
Other anomalies of the aorta

	
747.21

	
Anomaly of the arch of the aorta

	
747.22

	
Atresia and stenosis of the aorta

	
747.22

	
Absence of the aorta

	
747.22

	
Aplasia of the aorta

	
747.29

	
Other congenital malformations of the aorta

	
747.29

	
Aneurism of the Vaisaiva sinus (with rupture)

	
747.29

	
Congenital aunerism

	
747.3

	
Anomalies of the pulmonary artery

	
747.40

	
Congenital malformations of the large veins

	
747.41

	
Total anomalous connection of the pulmonary veins

	
747.42

	
Partial anomalous connection of the pulmonary veins

	
747.49

	
Anomalous connection of the pulmonary veins, without other specification

	
747.5

	
Congenital absence and hypoplasia of the umbilical artery

	
747.5

	
Sole umbilical artery

	
747.60

	
Other congenital malformations of the peripheral vascular system

	
747.6

	
Peripheral arteriovenous malformation

	
747.62

	
Congenital stenosis of the renal artery

	
747.62

	
Other congenital malformations of the renal artery

	
747.8

	
Other congenital malformations of the vascular system, specified

	
747.81

	
Anomalies of the cerebrovascular system

	
747.82

	
Spinal vascular anomaly

	
747.83

	
Persistent fetal circulation

	
747.9

	
Congenital malformation of the vascular system, unspecified

	
748

	
Congenital malformations of the respiratory system

	
748.0

	
Atresia of the choanas

	
748.1

	
Agenesia or hypoplasia and other malformations of the nose

	
748.2

	
Pterygium of the larynx

	
748.3

	
Congenital malformations of the larynx, trachea and bronchii

	
748.3

	
Congenital bronchomalacia

	
748.4

	
Congenital malformations of the lung

	
748.4

	
Congenital pulmonary cyst

	
748.5

	
Agenesia, hypoplasia and dysplasia of the lung

	
748.5

	
Sequestration of the lung

	
748.6

	
Other congenital malformations of the lung

	
748.61

	
Congenital bronchioectasia

	
748.8

	
Other specific anomalies of the respiratory system

	
749

	
Cleft lip and palate

	
749.00

	
Cleft palate

	
749.01

	
Cleft palate, unilateral complete

	
749.02

	
Unilateral cleft palate, incomplete

	
749.03

	
Bilateral cleft palate, complete

	
749.04

	
Bilateral cleft palate, incomplete

	
749.10

	
Cleft lip

	
749.11

	
Cleft lip, unilateral complete

	
749.12

	
Cleft lip, unilateral incomplete

	
749.13

	
Cleft lip, bilateral complete

	
749.14

	
Cleft lip, bilateral incomplete

	
749.20

	
Cleft palate with cleft lip

	
749.21

	
Cleft of the hard palate with cleft lip, unilateral

	
749.21

	
Cleft of the hard palate and of the soft palate with lip

 

  

  

  

 

	
749.22

	
Cleft of the soft palate with cleft lip, unilateral

	
749.23

	
Cleft of the hard palate with cleft lip, bilateral

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	
749.23

	
Cleft of the hard palate and of the soft palate with cleft lip, bilateral

	
749.24

	
Cleft of the soft palate with cleft lip, bilateral

	
749.25

	
Cleft of the palate with cleft lip, without other specification

	
750

	
Other congenital malformations of the digestive system

	
750.0

	
Anquiloglosia, short lingual fraenum

	
750.1

	
Other congenital malformations of the tongue

	
750.15

	
Macroglosia

	
750.2

	
Other congenital malformations of the mouth and the pharynx

	
750.2

	
Congenital malformations of the salivary glands and ducts

	
750.26

	
Other congenital malformations of the mouth

	
750.27

	
Pharyngeal diverticula

	
750.29

	
Other congenital malformations of the pharynx

	
750.3

	
Atresia of the esophagus without mention of fistula

	
750.3

	
Atresia of the esophagus with tracheoesophagic fistula

	
750.3

	
Congenital tracheoesophagic fistula without mention of atresia

	
750.3

	
Congenital narrowness or stenosis of the esophagus

	
750.4

	
Congenital malformations of the esophagus

	
750.4

	
Pterigion of the esophagus, congenitally dilated esophagus, diverticula, duplication

	
750.5

	
Congenital hypertrophic pyloric stenosis

	
750.6

	
Congenital hiatal hernia

	
750.7

	
Other congenital malformations of the stomach, specified

	
750.8

	
Other congenital malformations of the top part of the digestive tube

	
751.0

	
Meckel diverticula, persistence of the duct

	
751.1

	
Congenital absence, atresia and stenosis of the small intestine

	
751.1

	
Congenital absence, atresia and stenosis of the duodenum

	
751.1

	
Congenital absence, atresia and stenosis of the jejunum

	
751.2

	
Congenital absence, atresia and stenosis of the large intestine, unspecified part

	
751.2

	
Congenital absence, atresia and stenosis of the rectum and anus

	
751.3

	
Hirschsprung disease, Aganglionosis, congenital megacolon (aganglionar)

	
751.5

	
Other congenital malformations of the intestine

	
751.6

	
Congenital malformations of the gallbladder, of the biliar ducts and the liver

	
751.61

	
Agenesia, aplasia and hypoplasia of the gallbladder

	
751.61

	
Atresia of the biliar ducts

	
751.62

	
Cystic disease of the liver

	
751.69

	
Cyst of the choledocal

	
751.7

	
Agenesia, aplasia and hypoplasia of the pancreas

	
751.7

	
Anular pancreas

	
751.7

	
Congenital cyst of the pancreas

	
751.9

	
Other congenital malformations of the digestive system

	
752

	
Congenital malformations of the genital organs

	
752.0

	
Anomalies and congenital absence of ovary

	
752.1

	
Congenital malformations of the Eustachian tubes and of the broad ligaments

	
752.2

	
Congenital malformations of the uterus

	
752.2

	
Duplication of the uterus with duplication of the uterine neck and of the vagina

	
752.3

	
Agenesia and aplasia of the uterus and Other anomalies of the uterus

	
752.3

	
Other congenital malformations of the uterus

	
752.40

	
Anomalies of the uterine neck, vagina and external feminine genitalia

	
752.41

	
Embryonic cyst of the uterine neck

	
752.42

	
Unperforated hymen

	
752.49

	
Agenesia and aplasia of the uterine neck

	
752.49

	
Other congenital malformations of the feminine genital organs

 

  

  

  

 

	
752.49

	
Congenital absence of the vagina

	
752.51

	
Cryptordchidism

	
752.6

	
Hypospadias, epispadias and other anomalies of the penis

	
ICD9

	
Index by Diagnosis and Condition

	
752.64

	
Aplasia and congenital absence of the penis

	
752.69

	
Other congenital malformations of the penis

	
752.7

	
Indeterminate sex and pseudohermaphroditism

	
752.7

	
Indeterminate sex, without other specification, ambiguous genitals

	
752.8

	
Other congenital malformations of the masculine genital organs

	
752.8

	
Other congenital malformations of the deferent ducts, of epididymis

	
753

	
Congenital malformations of the urinary system

	
753.0

	
Renal agenesia and other hypoplastic malformations of the kidney

	
753.0

	
Renal agenesia, unilateral

	
753.0

	
Renal agenesia, bilateral

	
753.0

	
Renal agenesia, without other specification

	
753.0

	
Renal hypoplasia, unilateral

	
753.0

	
Renal hypoplasia, bilateral

	
753.0

	
Renal hypoplasia, not specified

	
753.0

	
Potter syndrome

	
753.1

	
Polycystic kidney, infantile type

	
753.11

	
Solitary renal cyst, congenital

	
753.12

	
Polycystic kidney, unspecified type

	
753.15

	
Renal displasia

	
753.16

	
Medular cystic kidney

	
753.17

	
SAI spongioid kidney

	
753.19

	
Other cystic renal diseases

	
753.2

	
Congenital obstructive defects of the pelvis, renal and congenital malformations of the ureter

	
753.23

	
Other obstructive defects of the renal pelvis and the ureter

	
753.23

	
Congenital ureterocele

	
753.29

	
Congenital hydronephrosis

	
753.29

	
Atresia and stenosis of the ureter

	
753.29

	
Congenital megaloureter

	
753.29

	
Agenesia of the ureter

	
753.29

	
Duplication of the ureter

	
753.29

	
Bad position of the ureter

	
753.29

	
Congenital vesico-ureteral-renal reflux

	
753.3

	
Other congenital malformations of the kidney

	
753.3

	
Supernumerary kidney

	
753.3

	
Lobulated, fused and horseshoe kidney

	
753.3

	
Ectopic kidney

	
753.3

	
Renal hyperplasia and giant kidney

	
753.4

	
Other specific anomalies of the ureter

	
753.5

	
Bladder exstrophy

	
753.6

	
Congenital posterior urethral valves

	
753.6

	
Other atresias and stenosis of the urethra and bladder neck

	
753.7

	
Anomalies of the urachus

	
753.8

	
Congenital absence of the bladder and of the urethra

	
753.8

	
Congenital diverticula of the bladder

	
753.8

	
Other congenital malformations of the bladder and the urethra

	  	  
	
754

	
Congenital malformations and deformities of the osteomuscular system

	
754.0

	
Congenital osteomuscular deformities of the head, of the face

	
754.0

	
Facial asymmetry

	
754.0

	
Compressed fancies

  

  

  

 

	
ICD9

	
Index by Diagnosis and Condition

	 	 
	
754.0

	
Dolicocephalia

	
754.0

	
Plagiocephalia

	
754.0

	
Other congenital deformities of the cranium, of the face and of the jaw

	
754.0

	
Congenital flattening of the nose

	
754.0

	
Hemifacial atrophy or hypertrophy

	
754.0

	
Depressions in the cranium

	
754.0

	
Congenital deviation of the nasal septum

	
754.10

	
Congenial torticollis

	
754.2

	
Congenital deformity of the vertebral column

	
754.2

	
Congenital scoliosis:

	
754.3

	
Congenital deformities of the hip

	
754.30

	
Congenital luxation of the hip, unilateral

	
754.3

	
Congenital acetabular displasia

	
754.31

	
Congenital luxation of the hip, bilateral

	
754.32

	
Congenital subluxation of the hip, unilateral

	
754.33

	
Congenital subluxation of the hip, bilateral

	
754.35

	
Unstable hip

	
754.4

	
Congenital deformity of the knee

	
754.4

	
Congenital recurvatum genu

	
754.41

	
Congenital luxation of the knee

	
754.42

	
Congenital curvature of the femur

	
754.43

	
Congenital curvature of the tibia and the perone

	
754.44

	
Congenital curvature of the long bones de the lower limb, without other specification

	
754.5

	
Congenital deformity of the feet

	
754.51

	
Talipes equinovarus

	
754.53

	
Metatarsus varus

	
754.59

	
Other congenital varus deformities of the feet

	
754.61

	
Congenital piano foot

	
754.62

	
Calcaneovalgus talipes

	
754.69

	
Valgus metatarsus

	
754.71

	
Cavus foot

	
754.79

	
Calcaneovarus talipes

	
754.79

	
Congenital varus hallux

	
754.79

	
Other congenital deformities of the feet

	
754.81

	
Pectus excavatum

	
754.81

	
Pectus curvatum

	
754.82

	
Pectus carinatum (shaped like the keel of a boat)

	
754.82

	
Pectus carinatum (pigeon chest)

	
754.89

	
Other congenital deformities of the extremities

	
754.89

	
Congenital arthrogriposis multiple

	
754.89

	
Congenital deformed finger

	
754.89

	
Hand on shovel (congenital)

	
755.0

	
Polydactyly

	
755.02

	
Supernumerary toe(s) of the foot

	
755.1

	
Sindactyly

	
755.13

	
Interdigital membrane of the foot

	
755.14

	
Fusion of the toes of the foot

	
755.2

	
Defects due to reduction of the superior extremity

	
755.21

	
Complete congenital absence of the limb(s)

  

  

  

 

	
ICD9

	
Index by Diagnosis and Condition

	
755.23

	
Congenital absence of the forearm and the hand

	
755.26

	
Defect due to longitudinal reduction of the radius

	
755. 27

	
Defect due to longitudinal reduction of the cubit

	
755.29

	
Congenital absence of the hand and the finger(s)

	
755.3

	
Defects due to reduction of the lower limb(s)

	
755.3

	
Other defects due to reduction of the lower limb(s)

	
755.31

	
Congenital complete absence of the lower limb(s)

	
755.34

	
Defect due to longitudinal reduction of the femur

	
755.35

	
Defect due to longitudinal reduction of the tibia

	
755.37

	
Defect due to longitudinal reduction of the peroné

	
755.4

	
Other defects due to reduction of the superior limb(s)

	
755.4

	
Complete absence of the non-specified limb(s)

	
755.4

	
Phocomelia, non-specified limb(s)

	
755.5

	
Other congenital malformations of the superior limb(s), including the shoulder girdle

	
755.54

	
Deformity of:

	
755.56

	
Supernumerary bones of the carpus

	
755.57

	
Macrodactyly (fingers of the hand)

	
755.58

	
Lobster claw hand

	
755.59

	
Cleidocranial dysostosis

	
755.59

	
Triphalangic thumb

	
755.6

	
Other congenital malformations of the inferior limb(s), including the pelvis girdle

	
755.64

	
Congenital malformation of the knee

	
756.0

	
Congenital malformations of the bones of the cranium and of the face

	
756.0

	
Craniosynostosis

	
756.0

	
Acrocephalia

	
756.0

	
Imperfect fusion of the cranium

	
756.0

	
Oxycephaly

	
756.0

	
Trigonocephaly

	
756.0

	
Craniofacial dysostosis

	
756.0

	
Crouzon disease

	
756.0

	
Hypertelorism

	
756.0

	
Macrocephaly

	
756.0

	
Maxillofacial dysostosis

	
756.0

	
Oculomaxillar dysostosis

	
756.0

	
Absence of bone(s) of the cranium, congenital

	
756.0

	
Congenital deformity of the forehead

	
756.0

	
Platybasia

	
756.1

	
Congenital malformations of the vertebral column and the bony thorax

	
756.10

	
Anomalies of the vertebral column, without specifying

	
756.11

	
Spondylolysis, L-S

	
756.12

	
Congenital spondylolystesis

	
756.14

	
Hemivertebra, congenital lordosis

	
756.15

	
Cervical fusion syndrome

	
756.16

	
Klippel-Feil syndrome

	
756.17

	
Spina bifida occulta

	
756.2

	
Cervical rib

	
756.3

	
Congenital malformation of the sternum

	
756.4

	
Osteochondrodysplasia with growth defect

	
756.4

	
Acondrogenesis

	
756.4

	
Tanatophoric dwarfism

	
756.4

	
Achondroplasia

	
756.51

	
Osteopetrosis

 

  

  

  

 

	
756.52

	
Other specified ostechondrodiyplasias; Osteopoichylosis

	
756.54

	
Fibrous polyostotic dysplasia

	
ICD9

	
Index by Diagnosis and Condition

	
756.55

	
Chondroectodermic dysplasia, Ellis-van Creveld syndrome

	
756.56

	
Progressive diafisaria displasia

	
756.56

	
Metafissary dysplasia

	
756.59

	
Other osteochondrodysplasias

	
756.59

	
Albright syndrome (-McCune)(-Sternberg)

	
756.6

	
Congenital malformations of the diaphragm

	
756.6

	
Absence

	
756.6

	
Eventration

	
756.71

	
Fructose malabsorption

	
756.79

	
Exomphalos

	
756.79

	
Omphalocele

	
756.79

	
Gastroschisis

	
756.79

	
Other congenital malformations of the abdominal wall

	
756.83

	
Ehlers-Danlos syndrome

	
757

	
Congenital malformations of the skin, hair and nails

	
757.0

	
Hereditary Lymphedema

	
757.1

	
Congenital ichthyosis

	
757.1

	
Vulgar ichthyosis

	
757.1

	
Ichthyosis linked to chromosome X

	
757.1

	
Lamellar ichthyosis

	
757.1

	
Colloidon baby

	
757.1

	
Congenital vesicular ichthyoiform eritrodermia

	
757.1

	
Harlequin fetus

	
757.2

	
Other congenital malformations of the skin, specified

	
757.31

	
Ectodermic dysplasia (anhydrotic)

	
757.32

	
Vascular hamartomas, non-neoplasic nevus, congenital

	
757.33

	
Other congenital malformations of the skin

	
757.33

	
Pigmentous congenital anomalies, pigmentous xeroderma

	
757.33

	
Mastocytosis, pigmentous urticary

	
757.39

	
Epidermolysis bullosa

	
757.39

	
Supernumerary cutaneous appendices

	
757.4

	
Congenital alopecia, other congenital malformations of the hair

	
757.5

	
Anonychia, other congenital malformations of the nails

	
757.6

	
Congenital malformations of the mamma

	
759

	
Other non-specific congenital anomalies

	
759.0

	
Congenital malformations of the spleen

	
759.0

	
Asplenia (congenital)

	
759.0

	
Congenital splenomegaly

	
759.1

	
Congenital malformations of the adrenal glands

	
759.2

	
Congenital malformations of the other endocrine glands

	
759.2

	
Persistent thyroglosal duct

	
759.2

	
Congenital malformation of thyroid or parathyroid gland

	
759.2

	
Thyroglosal cyst

	
759.3

	
Situs inversus

	
759.3

	
Dextrocardia with situs inversus

	
759.3

	
Auricular disposition in mirror image with situs inversus

	
759.3

	
Situs inversus or transversus

	
759.3

	
Transposition of bowels

	
759.4

	
Siamese twins

	
759.5

	
Tuberous sclerosis

	
759.6

	
Other congenital hamartosis, without classifying

	
759.6

	
Peutz-Jeghers

 

  

  

  

 

	
759.6

	
Sturge-Weber

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	
759.7

	
Multiple congenital anomalies, as described

	
759.81

	
Prader Willi syndrome

	
759.82

	
Marfan’s syndrome

	
759.83

	
Fragile X syndrome

	
759.89

	
Other syndromes of congenital malformations

	
758.89

	
Russell-Silver syndrome

	
759.89

	
Alport syndrome

	
759.89

	
Lawrence-Moon-(Bardet)- Biedl syndrome

	
759.89

	
Zeilweger syndrome

	
759.89

	
Carpenter’s syndrome

	
759.89

	
Angleman’s syndrome

	
759.89

	
Jarcho-Levin syndrome

	
758

	
Chromosomic anomalies; unclassified in another part

	
758.0

	
Down syndrome

	
758.0

	
Trisomy 21, due to lack of meioitic disjunction

	
758.0

	
Trisomy 21, mosaic (due to lack of mitotic disjunction)

	
758.0

	
Trisomy 21, due to translocation

	
758.0

	
Down syndrome, unspecified

	
758.1

	
Edwards syndrome

	
758.1

	
Trisomy 18, due to lack of meioitic disjunction

	
758.1

	
Trisomy 18, mosaic (due to lack of mitotic disjunction)

	
758.1

	
Trisomy 18, due to translocation

	
758.2

	
Patau syndrome

	
758.2

	
Trisomy 13, due to lack of meioitic disjunction

	
758.2

	
Trisomy 13, mosaic (due to lack of mitotic disjunction)

	
758.2

	
Trisomy 13, due to translocation

	
758.3

	
Other suppressions on the part of an autosomic chromosome

	
758.3

	
Suppression of the short arm of chromosome 4

	
758.3

	
Wolff-Hirschorn syndrome

	
758.31

	
Suppression of the short arm of chromosome 5

	
758.31

	
Criduchat syndrome

	
758.32

	
Velo-cardio-facial syndrome

	  	  
	
758.5

	
Other conditions due to anomalies in autosomic chromosomes

	
758.5

	
Suppression of the autosomes, unspecified

	
758.6

	
Turner syndrome

	
758.7

	
Klinefelter’s syndrome

	
758.6

	
Caryotype 45, X

	
758.81

	
Other conditions resulting from anomalies in sexual chromosomes

	
758.89

	
Other conditions resulting from anomalies in non-specific chromosomes

	
760

	
Conditions in the perinatal period

	
760.71

	
Fetal syndrome due to consumption of alcohol

	
765.00

	
Prematurity

	
767.6

	
Injury of the brachial plexus

	
768.9

	
Perinatal hypoxia, asphyxia or anoxia

	
772.1

	
Intraventricular hemorrhage (Grade III-IV)

	
774.7

	
Kernicterus

	
779.7

	
Cystic periventricular leukomalacia

	
779.7

	
Cystic periventricular leukomalacia

	  	  
	
Disorders of the Sensory organs

	
360

	
Disorders of the eye and attachments

 

  

  

  

 

	
362.2

	
Retinopathy of the Premature

	
369

	
Blindness and loss of vision

	
ICD9

	
Index by Diagnosis and Condition

	
369.2

	
Moderate to severe blindness, both eyes

	
369.4

	
Legal blindness

	
369.6

	
Blindness in one eye (the other one is normal)

	
378.0

	
Strabism (alternating, congenital, non-paralytic)

	
378.00

	
Esotropia, non-specific

	
378.10

	
Exotropia

	
378.6

	
Mechanic

	
378.60

	
Paralytic

	
378.71

	
NCOP specified (Duane’s syndrome)

	
389

	
Loss of hearing

	
389.00

	
Bilateral conductive loss of hearing

	
389.10

	
Neurosensorial loss of hearing, non-specific

	
389.2

	
Conductive and neurosensorial loss of hearing, mixed

	
478.4

	
Polyps in the vocal chords

	
784.4

	
Alterations in the voice

	
784.41

	
Aphonia

	
748.49

	
Dysphonia

	  	  
	
Burns and traumas

	
709.2

	
Scars and fibrosis of the skin

	
709.2

	
Disfiguring scar

	
709.2

	
Disabling scar

	
906.9

	
Delayed defects of burns

	
949.0

	
Burns and corrosions

	
952.9

	
Damage to the spinal cord

	  	  
	
Lack of normal physiological development

	
783.4

	
Delays in physiological development, not specific

	
783.41

	
Failure to thrive, failure in gaining weight

	
783.42

	
Delay in general development (non-specific area)

	
783.43

	
Short height, failure in growth

	  	  
	
Bronchial asthma

	
493.00

	
Asthma

	
493.0

	
Extrinsec predominantly allergic asthma

	
493.1

	
Non-allergic asthma

	
493.9

	
Asthma, non-specified

	  	  
	
Mental and Conduct disorders

	
295.00

	
Schizophrenia

	
296.0

	
Depression

	
298.9

	
Psychosis

	
299.0

	
Autism

	
300.9

	
Neurosis

	
300.9

	
Self-damaging conduct (suicidal conduct)

	
312.00

	
Conduct disorders (conduct disorders in children and adolescents)

	
313.81

	
Oppositional defiant disorder

	
314.00

	
Activity and attention disorder (ADD)

	
314.01

	
Attention deficit with hyperactivity

	  	  
	
315

	
Developmental delays and disorders

	
315.3

	
Disorder in language development

 

  

  

  

 

	
315.4

	
Delay in motor development and coordination

	  	  
	
ICD9

	
Index by Diagnosis and Condition

	
315.5

	
Delay in development, mixed

	
315.9

	
Delay in development, not specific

	  	  
	
Mental Retardation

	
317.00

	
Slight, intellectual coefficient of 50 to 70

	
318.0

	
Moderate, intellectual coefficient of 35 to 49

	
318.1

	
Severe, intellectual coefficient of 20 to 34

	
318.2

	
Deep, intellectual coefficient under 20

	
319.0

	
Mental retardation, not specified

	
319.0

	
William syndrome

	  	  
	
Endocrine and nutritional disorders

	
243.0

	
Congenital hypothyroidism                  224.0 244.9               Acquired hypothyroidism

	
246.8

	
Other specific disorders of the thyroid gland

	
250.01

	
Insulin Dependent Diabetes Mellitus, Type I, Juvenile

	
250.02

	
Juvenile non-insulin dependent Diabetes Mellitus

	
252.0-252.08

	
Hyperparathyroidism 252.1 Hypoparathyroidism

	
252.8

	
Other specific disorders of the parathyroid gland

	
253.0

	
Acromegalia and giantism

	
253.3

	
Dwarfism due to deficiency of the growth hormone

	
255.2

	
Adrenal  congenital  hyperplasia

	
255.8

	
Other specific disorders of the adrenal glands

	
259.1

	
Precocious sexual development, precocious puberty

	
259.4

	
Dwarfism, NOS

	
278.01

	
Morbose obesity

	  	  
	
Immunological and hematological disorders

	
42

	
Disease of the Human Immunodeficiency Virus (HIV)

	
279.0

	
Deficiency of humoral immunity

	
279.1

	
Deficiency of cellular immunity

	
279.3

	
Deficiency of non-specific immunity

	
279.4

	
Autoimmune disorder, not classified

	
282.4

	
Major Thalassemia

	
282.6

	
Sickle cell anemia

	
283.9

	
Hemolitic anemia

	
284.9

	
Aplastic anemia

	
286.0

	
Hemophilia

	
279.2

	
Combined immunity deficiency

	  	  
	
710

	
Diseases of the connective tissue and collagen

	
710

	
Systemic eritematous lupus

	
710.1

	
Sclerosis, scleroderma

	
710.2

	
Sicca Syndrome

	
710.3

	
Dermatomyositis

	
710.4

	
Poliomyositis

	
714

	
Juvenile rheumatoid arthritis

	  	  
	
Cancer and Tumors

	
140-239

	
Neoplasms

	  	
Malignant tumors

	  	
Invasive tumors

	
208.9

	
Leukemia

	  	  

  

  

  

 

ATTACHMENT 14

 

Commonwealth of Puerto Rico Puerto Rico

Puerto Rico Health Insurance Administration

 

Guidelines for the

 Development of Program

Integrity Plan

 

2013 -2014

 

(This document is to be used by all contracted companies participating in the Commonwealth of Puerto Rico “Mi Salud”. The purpose of sharing information with contracted companies is to provide them guidelines with minimum requirements to formulate their own Plan Integrity Program for the Health Care Delivery System sponsored by the Commonwealth of Puerto Rico)

 

  

  

  

 

The Insurer shall comply with the following Medicaid Integrity requirements:

 

	  	
A.

	
60 days after the dated of the agreement the Company must submit to ASES Compliance Office copy of the policies and procedures for identifying and tracking potential provider fraud cases, for conducting preliminary and full investigation and for referring cases of suspected fraud to an appropriate law enforcement agency. The Compliance Plan should be developed in accordance with 42 CFR 438.608.

 

	  	
B.

	
Each company must submit to the Administration's Compliance Office on a quarterly basis a report with the following information: preliminary and full investigations, audits performed, administrative actions against providers, overpayments identified and providers referred to the Department of Justice (if not submit a certification signed by the Compliance Director and the President or CEO).

 

	  	
C.

	
Each company must submit to the Compliance Office on a quarterly basis a report with the following information: fraud investigations pending, fraud investigations in process, fraud investigations finished and referrals to the Department of Justice or U.S. Attorney's Field Office (if there were no investigations, submit a certifications signed by the Compliance Director and the President or CEO).

 

	  	
D.

	
Each Company has five (5) days to notify ASES about the referrals made to the US Attorney's Field Office and HHS-OIG.

 

	  	
E.

	
Each company must submit to the Compliance Office a certification signed by the Compliance Director and the President or CEO indicating that all full investigations were made in accordance with 42 CFR 455.15.

 

	  	
F.

	
Each Company has five (5) days to notify ASES about any adverse or negative action that the MCO has taken on provider application (upon initial application or application renewal) or actions which limit the ability of providers to participate in the program.

 

	  	
G.

	
Each Company must review the credentialing forms of all providers and any fiscal agents they may use to ensure that they are in accordance with federal regulation 42 CFR 455.104.

 

	  	
H.

	
Each Company must require providers to fill out a complete ownership and control disclosures form. The Company is responsible to ensure compliance with regulation.

 

	  	
I.

	
Each Company must review providers agreement to incorporate appropriate business transaction language to ensure accordance with federal regulation 42 CFR 455.105.

 

	  	
J.

	
Each Company must request providers to fulfill a business transactions form and verify compliance with regulation.

 

	  	
K.

	
Each Company must establish a method to capture criminal conviction information on owners, persons with control interest, agents, and managing employees of providers to ensure that is in accordance with federal regulation 42 CFR 455.106.

 

	  	
L.

	
Each Company must review the enrollment packages for all provider types to request criminal conviction information as stated before.

 

	  	
M.

	
Each Company should develop and implement procedures to report to HHS-OIG and ASES within 20 working days any criminal conviction disclosures made during the MCO credentialing process. Copy of the policies should be submitted to ASES Compliance Office.

 

	  	
N.

	
Each Company must submit to the Compliance Office a certification signed by the Compliance Director and the President or CEO stating compliance with 42 CFR 455.106.

 

  

  

  

 

	  	
O.

	
Each Company must comply with requirement in 42 CFR 455.20 and must document in a quarterly report compliance with regulation.

 

	  	
P.

	
Each Company must comply with requirement in 42 CFR 455.101.

 

	  	
Q.

	
Each Company must review the enrollment form and credentialing packages for all provider types to capture the identity of agents and managing employees.

 

  

  

  

 

TABLE OF CONTENTS

 

	
Integrity Program Basis and Scope

	  
	
Definitions

	  
	
Other applicable regulations

	  
	
Guidelines for Sub-Parts A, B

	
Sub-Part A: Fraud Detection and Investigation Program

	
PI A001: State plan requirement. § 455.12

	
PI A002: Methods for identification, investigation, and referral. § 455.13

	
PI A003: Preliminary investigation. § 455.14

	
PI A004: Full investigation. § 455.15

	
PI A005: Resolution of full investigation. § 455.16

	
PI A006: Reporting requirements. § 455.17

	
PI A007: Provider’s statements on claims forms. § 455.18

	
PI A008: Provider’s statement on check. § 455.19

	
PI A009: Recipient verification procedure. § 455.20

	
PI AO 10: Cooperation with State Medicaid fraud control units. § 455.21

	
PI A011: Withholding of payments in cases of fraud or willful misrepresentation (§ 455.23)

	  
	
Sub-Part B: Disclosure of Information by Providers and Fiscal Agents

	
PI B001: Purpose § 455.100

PI B002; Definitions.§ 455.101

	
PI B003: Determination of ownership or control percentages.§ 455.102

PI B004: State Plan requirements § 455.103

	
PI B005: Disclosure by providers and agents: Information on ownership and control. § 455.104

	
PI B006: Disclosure by providers: Information related to business transactions. § 455.105

PI B007: Disclosure by providers: Information on persons convicted of crimes. § 455.106

 

  

  

  

 

Introduction

 

Under the authority of Sec. 1102 of the Social Security Act (42 U.S.C. 1302); as detailed in the 43 FR 45262, Sept. 29, 1978, the Medicaid Program must have a program to detect and investigate fraud, waste and abuse.

 

The Commonwealth of Puerto Rico Department of Health and its Office for the Medically Indigent, acting as the single state agency are responsible for the management of the Medicaid and SCHIP grant funds. These funds are transferred to the Puerto Rico Health Insurance Administration (ASES), to be combined with state funds to provide health benefit coverage to the medically indigent population under a managed care fully capitated health plan. Acting as a sub-grantee to the Office for the Medically Indigent Medicaid program, ASES establishes contracts with insurance companies and other organizations to facilitate the beneficiaries' access to the benefit coverage through out their provider's networks.

 

Integrity Program Basis and Scope

 

This document sets forth guidelines with minimum criteria for the compliance with Program Integrity Policies and Procedures that each organization (grantee, sub-grantee, insurance companies) must have for the administration of the Commonwealth of Puerto Rico's Medicaid and State Health Plans. This document includes guidelines for the elaboration of the 3 main sections in the organizations Program Integrity Plan (PIP):

 

1.      Fraud Detection and Investigation

2.      Providers and Fiscal Agents Disclosure of Information on Ownership and Control

3.      Integrity Program

 

Regulation Citation

 

Sections 1902(a)(4) [42 USC 1396(a)(4)l, (61)2, (64)3); 1903(i)(2) [42 USC 1396(b)(i)(2)]4 1936[42 USC 1396u-6]5) and regulations at 42 CFR Parts 438,455,1001 and 1002

 

Overall Requirement

 

All providers/contractors are required to comply with the CMS Medicaid Integrity Group State Medicaid Director Letters #08-003 and #09-001, which explain what all states and contractors should do in terms of checking for excluded parties. The letters provide guidance on where to check for excluded individuals as well as the consequences of contracting with individuals and entities that have been excluded from participating in federally funded programs.

 

Companies are also required to notify to the Department of Health and Human Services- Office of Inspector General (HHS-OIG) of any action it takes to limit the ability of an individual or entity to participate in its program as stated in 42 CFR 1002.3.

 

Each contracted company must report actions it takes when it denies a provider enrollment based on program integrity concerns. Companies should report on each provider whom it has disenrolled, suspended, terminated or otherwise restricted from participation in the Medicaid program based on program integrity concerns. Companies are required to report affected providers directly to HHS-OIG while copying ASES.

 

  

  

  

 

Definitions

 

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

 

Agent means any person who has been delegated the authority to obligate or act on behalf of a provider

 

Conviction or Convicted means that a judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending.

 

Disclosing Entity means a Medicaid provider (other than an individual practitioner or group of practitioners) or a fiscal agent

 

Exclusion means that items or services furnished by a specific provider who has defrauded or abused the Medicaid program will not be reimbursed under Medicaid.

 

Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.

 

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit for him/her or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

 

Furnished refers to items and services provided directly by, or under the direct supervision of, or ordered by, a practitioner or other individual (either as an employee ^ or in his or her own capacity), a provider, or other supplier of services. (For purposes of denial of reimbursement within this part, it does not refer to services ordered by one party   but billed for and provided by or under the supervision of another.)

 

Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

 

Health insuring organization (HIO) has the meaning specified in §438.2.

 

Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

 

Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

 

Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. This includes:

 

(a)     Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);

 

(b)    Any Medicare intermediary or carrier; and

 

  

  

  

 

(c)    Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title XX of the Act.

 

Person with an ownership or control interest means a person or corporation that—

 

(a)     Has an ownership interest totaling 5 percent or more in a disclosing entity;

 

(b)    Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

 

(c)     Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;

 

(d)     Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

 

(e)     Is an officer or director of a disclosing entity that is organized as a corporation; or

 

(f)      Is a partner in a disclosing entity that is organized as a partnership.

 

Practitioner means a physician or other individual licensed under State law to practice his or her profession.

 

Program Integrity Plan (PIP) means the program, process or policy that each contracted company has to comply with integrity requirements. The plan should be developed in accordance with federal regulation.

Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total operating expenses.

 

Subcontractor means-

 

a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

 

(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreeement.

 

Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).

 

Stakeholder means the single state agency, the sub-grantee and all organizations contracted to provide health care management and services to Medicaid beneficiaries

 

Suspension means that items or services furnished by a specified provider who has been convicted of a program-related offense in a Federal, State, or local court will not be reimbursed under Medicaid.

 

Termination means—

 

(1)      For a—

 

  

  

  

 

(i) Medicaid or CHIP provider, a State Medicaid program or CHIP has taken an action to revoke the provider's billing privileges, and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired; and

 

(ii) Medicare provider, supplier or eligible professional, the Medicare program has revoked the provider or supplier's billing privileges, and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired.

 

(2) (i) In all three programs, there is no expectation on the part of the provider or supplier or the State or Medicare program that the revocation is temporary.

 

(ii) The provider, supplier, or eligible professional will be required to reenroll with the applicable program if they wish billing privileges to be reinstated.

 

(3) The requirement for termination applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing privileges revoked for cause which may include, but is not limited to—

 

(i) Fraud;

 

(ii) Integrity; or

 

(iii) Quality.

 

Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider

 

  

  

  

 

	
 Section A

 

Fraud Detection and Investigation sub part represents each one of the elements that must be included as part of the integrity program activities, although they are not necessarily the only elements that come into play.

 

All contracted plans must have an integrity program with their own structure, policies and procedures. Among other areas, they should have written policies and procedures on methods for the identification, investigation and referral of suspected cases; procedure to perform preliminary investigations as well as full investigations; procedures to address resolution of full investigations; procedures to comply with reporting requirements; provider's statements on claims form (if applicable); provider's statement on checks; cooperation with the Commonwealth of Puerto Rico Office for the Medically Indigent fraud control unit and procedure to withhold payments in case of fraud or willful misrepresentation. Contracted companies are required to submit to ASES Compliance Office copy of their integrity programs for evaluation. The plan should be developed in accordance with 42 CFR 438.608.

 

Each one of the Guidelines under section A includes the name or title of the guideline, scope, purpose, process and general information to identify the creation date, creator, and revisions or updates. This document will be attached to the contract each organization holds with the Puerto Rico Insurance Administration; while each one of the   contracted organization should have at least a minimum set of policies and procedures to address the guidelines included.

 

The Program Integrity Plan (PIP) of each organization is to be monitored by the sub- grantee on periodic basis. An annual report will be issued reporting data and findings.

 

  

  

  

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA1.1

	
State Plan Requirements

	 
	
Scope

	
Applies to Single State Agency and Sub-Grantee

	 
	
Purpose

	
This guideline describes the commitment of the single state agency and the sub-grantee in adhering to the statue rules and regulations and the implementation of a Program Integrity Plan for the Medicaid Program

	 
	
General

	
The grantee and the sub-grantee will abide bye the following guidelines on how to manage the integrity program activities in the whole service delivery system.

	 
	
Guidelines

	
The PIP must include an explicit definition of methods to perform identification of cases suspected of fraud, waste and abuse

	 
	  	  	
1.

	
The single state agency and sub-grantee acknowledge the need to adhere to a Medicaid Integrity Program as defined in the state plan.

	 
	  	  	
2.

	
The grantee and sub-grantee agree to establish a structure to manage Program Integrity Plan (PIP) activities.

	 
	  	  	
3.

	
The organization structure to perform above mentioned activities is furnished with a Program Integrity Plan (PIP) of members representing the single state agency, the sub-grantee and each contracted organization.

	 
	  	  	
4.

	
The PIP leads the efforts toward achieving compliance with state plan requirements regulation by establishing the minimum criteria of required PI program policies and procedures.

	 
	  	  	
5.

	
The PIP monitors contracted companies plan compliance on regular basis.

	 
	  	  	
6.

	
The PIP chairman develops the meeting calendar each year, develops the committee agenda, and keeps minutes of all meetings and call for meetings.

	 
	  	  	
7.

	
Sub-grantee facilitates the development and update of the Program Integrity Plan guidelines, reports and notification to guarantees its distribution and final acceptance among contracted companies and regulatory agencies.

	 
	  	  	
8.

	
Sub-grantee review performance of each organization, level of adherence to policies and recommend corrective action plan development for areas that must be improved.

	 
	  	  	
9.

	
Sub-grantee develops an annual report that is to be submitted to the Medicaid Program Integrity Group and to the CMS region 2. The report will include the areas and companies reviewed during the period and the findings of each company, if any.

	 
	  	  	
10.  

	
The PIP provides guidance and guarantees that each contracted companies develop and implement policies and procedures in their organizations.

	 
	  	  	
11.

	
The PIP guidelines are integrated into each contracted organization Program Integrity Plan Policies and Procedures; and are assumed as a standard operating procedure to prevent fraud, waste and abuse

	 

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA02.1

	
Methods for identification, investigation, and referral

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
This guide describes what the organization must include in their PIP to guarantee the use of methods for the identification, investigation, and referral of suspected fraud and abuse cases.

	
General

	
The organization must establish methods for the identification, investigation and referral of suspected cases, that guarantees the use of a consistent and objective approach to address fraud, waste and abuse when performing PIP activities.

	
Guidelines

	
The PIP must include an explicit definition of methods to perform identification of cases suspected of fraud, waste and abuse

	  	  	
a. 

	
what is fraud, waste and abuse

	  	  	
b.

	
how is detected fraud, waste and abuse

	  	  	
c.

	
who performs the identification

	  	  	
d. 

	
when preliminary, full investigation and resolutions are done

	  	  	  	  
	  	
The PIP must have a detailed process to perform investigations on each suspected case guaranteeing objective methods to identify potential cases and perform investigations

	  	  	
a. 

	
open and documents the case

	  	  	
b.

	
initiate data gathering process

	  	  	
c.

	
follow a protocol to verify information

	  	  	
d.

	
issue a report of findings

	  	  	
e.

	
refer case to next level

	  	  	
f.

	
close the case

	  	  	  	  
	  	
The PIP must include a variety of methods for the identification, investigation and referral of suspected cases, accepted in the industry and without infringing provider or beneficiary rights. Methods might include

	  	  	
a.

	
electronic data exchanges

	  	  	
b.

	
data mining

	  	  	
c. 

	
claims registries / reconciliation

	  	  	
d.

	
targeted procedures

	  	  	
e.

	
profiling

	  	  	  	  
	  	
The PIP must include a systematic approach of data analysis by:

	  	  	
a.

	
flagging the case

	  	  	
b.

	
 identifying cause for flagging (i.e. over-under payment)

	  	  	
c.

	
establishing actions and sanctions

	  	  	  	  
	  	
The PIP must have procedures in placed for referring suspect fraud cases to law enforcement officials, at a minimum:

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Guidelines

	  	
a. 

	
an organizational structure to address the reports.

	  	  	
b.

	
a due process that includes but is not limited to: case identification, complete record with supporting materials, notification letter to suspect, notification letter to single state agency, documentation of entrance and exit interviews, and if necessary copy of referral letters and case resolution letter to and from legal authorities.

	  	  	
c.

	
a flowchart to work in cooperation with the grantee and sub-grantee as well as with the state legal authorities such as: Organization’s Legal Affairs Department, ASES, Single State Agency - Department of Health Legal Department, State Department of Justice, and the Office of Inspector General.

	  	  	
d. 

	
a follow up process to work with legal authorities each case of fraud, waste and abuse suspicion until final disposition and notification to the single state agency.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA03

	
Preliminary Investigations

	 
	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	 
	
Purpose

	
To provide guidance on how to perform a preliminary investigation when the agency receives a complaint of fraud or abuse from any source or identifies any questionable practices.

	 
	
General

	
The organization must conduct a preliminary investigation to determine whether there is sufficient basis to warrant a full investigation.

	 
	
Guidelines

	
The PIP defines a standard operating procedure to complete a preliminary investigation of all suspect cases of fraud, waste and abuse.

	 
	  	  	 
	  	
The PIP identifies the requirements to complete the preliminary investigation when evaluating providers and beneficiaries. It should include at least:

	 
	  	  	
a. 

	
Source of information

	 
	  	  	
b.

	
Identification method (how the case is detected)

	 
	  	  	
c.

	
Cause for investigation

	 
	  	  	
d. 

	
Case documentation

	 
	  	  	
e.

	
Analysis of Data and documents

	 
	  	  	
f.

	
Report of Findings

	 
	  	  	
g.

	
Action Taken (Recommended Action)

	 
	  	  	  	  	 
	  	
The PIP includes a mechanism to keep tracking of all preliminary investigations and results.

	 
	  	  	  	  	 
	  	
The PIP establishes a mechanism to report preliminary investigations activity to the sub-grantee (ASES) which will be in charge of reporting activity to the single state agency (Office for the Medically Indigent).

	 

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA04

	
Full Investigations

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
To provide guidance and minimum set of elements in the PIP to perform full investigations on incidents of fraud and abuse.

	
General

	
If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occur in the Medicaid program, the organization must take the appropriate actions.

	
Guidelines

	
The PIP must define the process to conduct a full investigation and specify when a case requires the full investigation. Full investigations must be done in accordance with federal regulation and based in the company written policy. The company must submit copy of the written policies to ASES for review and approval.

	  	  
	  	
The PIP must define the process to refer the cases to the companies fraud liaison (i.e. companies compliance office), the appropriate law enforcement agency / sub-grantee when there is a reason:

	  	  	
a. 

	
to suspect a provider has engaged in fraud or abuse of the program.

	  	  	
b.

	
to suspect a recipient is defrauding the program.

	  	  	
c.

	
to suspect a recipient has abused the Medicaid program.

	  	  	  	  
	  	
The PIP must have a mechanism to keep tracking of all full investigations performed in progress and closed.

	  	  	  	  
	  	
The PIP must have a mechanism to report the sub-grantee (ASES) informed full investigations in progress, conducted and results.

 

  

  

  

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA05

	
Resolution of full investigation

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
To provide guidance on minimum actions that must be taken in order to complete the process of a full investigation.

	
General

	
The full investigations must continue until the cases are referred, solved or closed.

	
Guidelines

	
The PIP must include the process to guarantee that a full investigation must continue until:

	  	  	
a. 

	
appropriate legal action is initiated.

	  	  	
b.

	
the case is closed or dropped because of insufficient evidence to support the allegations of fraud or abuse.

	  	  	
c.

	
the matter is resolved between the organization and the provider or recipient

	  	  	  	
ü

	
the resolution may include but is not limited to:

	  	  	  	  	
1)

	
Sending a warning letter to the provider or recipient, giving notice that continuation of the activity in question will result in further action;

	  	  	  	  	
2)  

	
Suspending or terminating the provider from participation in the Medicaid program;

	  	  	  	  	
3)

	
Seeking recovery of payments made to the provider; or

	  	  	  	  	
4)

	
Imposing other sanctions provided under the organization PIP plan.

	  	  	  	  
	  	
The PIP must have a mechanism to report the sub-grantee (ASES) informed full investigations in progress, conducted and results.

 

  

  

  

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA06

	
Reporting Requirements

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
To provide guidance on how to adhere to a minimum set of elements that must be included in the process to report fraud and abuse information to the appropriate organizations officials.

	
General

	
The organization must submit a progress report the fraud and abuse information and statistics to the appropriate department / grantee / sub- grantee on quarterly basis.

	
Guidelines

	
The PIP must describe the mechanism to report fraud and abuse data to the appropriate fraud liaison, organization structure, sub-grantee (ASES) and grantee (Office for the Medically Indigent).

	  	  
	  	
The PIP progress report must include at least the following information:

	  	  	
a. 

	
# of complaints on fraud and abuse received.

	  	  	
b.

	
.# of complaints that warrant preliminary investigation.

	  	  	
c.

	
Detailed information for each case of suspected provider fraud and abuse that warrants a full investigation:

	  	  	  	
ü

	
Provider’s name and id number

	  	  	  	
ü

	
Source of the complaint

	  	  	  	
 ü

	
Type of the provider

	  	  	  	
ü

	
Nature of the complaint

	  	  	  	
 ü

	
Estimate amount of money involved

	  	  	  	
 ü

	
Legal and administrative disposition of the case and actions taken by the law enforcement officials to whom the case has been referred.

	  	  	  	  
	  	
Suspected fraud cases must be reported immediately in a written format to ASES Compliance Office.

	  	  
	  	
The PIP reports must be submitted in electronic format to facilitate its inclusion in the Commonwealth of Puerto Rico Medicaid Program PI Annual Report.

 

  

  

  

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA07

	
Provider’s statements on claims forms

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
To provide guidance on how to comply with regulation on provider’s statements on claims forms.

	
General

	
The organization may print that all provider claims forms be imprinted in boldface type with the following statement, or with alternate wording that is approved by the Regional CMS Administration.

	
Guidelines

	
The PIP must include that providers are required to attest in the claim forms that they agree with the following statement:

	  	  
	  	  	
ü

	
“This is to certify that the foregoing information is true accurate and complete”.

	  	  	
ü

	
“I understand that payment of this claim will be from federal and state funds and that any falsification or concealment of a material fact maybe prosecutes under federal and state laws”.

	  	  	  	  
	  	
For electronic claims, providers must attest that they agree with the following statements:

	  	  	  	  
	  	  	
ü

	
“This is to certify the truthfulness of the foregoing information and certify that is true, accurate, complete and that the service was provided”.

	  	  	  	  
	  	
The statements may be printed above the claimant’s signature or, if they are printed on the revenue of the form, a reference to the statements must appear immediately preceding the claimant’s signature.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA08

	
Provider’s statements on check

	
Scope

	
Grantee, Sub-grantee and Contracted Organizations

	
Purpose

	
To provide guidance on how to comply with regulation on provider’s statements on check.

	
General

	
The organization may print the following wording above the claimant’s endorsement on the reverse of checks or warrants payable to each provider.

	
Guidelines

	
The PIP must include that providers are required to attest (in addition to the statements required in providers claims form) that they agree with the following statement either by having it written on checks or temporarily in a legal document as an affidavit:

	  	  
	  	  	
ü

	
“I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws”.

	  	  
	  	
The above attestation must be included in electronic and checks payment.

	  	  
	  	
The PIP must indicate frequency and responsible for conducting spot checks to guarantee the organization complies with the provider’s statements and / or the provider signature appears on a legal document attesting compliance.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA09

	
Recipient verification procedure

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To verify that the services listed on claims forms have been rendered.

	
General

	
The organization must have a method for verifying with recipients whether services billed by providers were received.

	
Guidelines

	
The PIP must include a description of how the organization performs claims matches with medical records to guarantee adequacy of billing.

 

The PIP must define the mechanism to monitor frequency of encounters and services rendered to patients billed by providers.

 

The PIP will provide periodic up dates on reconciliation findings report to the sub-grantee and grantee.

 

The sub-grantee will select a sample to perform independent reviews to verify that recipient’s services billed by providers (as well as encounters under capitated environment) were indeed rendered. This review will be performed through confirmations to beneficiaries.

 

Note: All contracted companies are required to comply with Law 114 which require that the beneficiaries must receive an Evidence of Medical Benefits with a detailed of the services and expenses incurred during a quarter. ASES compliance office will review the compliance with the Law.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA10

	
Cooperation with Medicaid Fraud Control Units

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To provide guidance on how to communicate findings and to cooperate with any Puerto Rico or federal law enforcement agency. To request that all contracted companies must communicate preliminary findings to ASES.

	
General

	
The organization must have a mechanism to provide information to the regulatory and legal authorities on cases, investigations, schemes and any other activity where intention to commit fraud, abuse and waste of services occur.

	
Guidelines

	
The PIP must demonstrate it has an effective mechanism to cooperate with the Medicaid anti fraud unit as well as with other program divisions in charge of preventing and prosecuting cases related to fraud, waste and abuse of services under the Medicaid program.

	  	  
	  	
The PIP must establish a process to guarantee the organization complies with the following: 

	  	  
	  	  	
ü

	
All cases of suspected provider fraud are referred to the anti fraud / integrity organization’s unit.

	  	  	
ü

	
If the anti fraud / integrity unit determines that it may be useful in carrying out the unit’s responsibilities, promptly comply with a request from the unit for -

	  	  	  	
i.

	
Access to, and free copies of, any records or information kept by the organization or its contractors;

	  	  	  	
ii.

	
Computerized data stored by the organization or its contractors. These data must be supplied without charge and in the form requested by the unit;

	  	  	  	
iii.

	
Access to any information kept by providers to which the organization is authorized access. In using this information, the unit must protect the privacy rights of recipients;

	  	  	
ü

	
Communicate to ASES preliminary findings; and

	  	  	
ü

	
On referral from the unit, coordinate with ASES or appropriate law enforcement agency before initiating any available administrative or judicial action to recover improper payments to a provider.

	  	  	  	  
	  	
The PIP must recommend the organization to have in the provider’s contract a disclaimer that as a contracted provider any data related to services or payments provided must be available for review of the integrity staff.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 – 2014

	
Title SA11

	
Withholding of payments in cases of fraud or willful misrepresentations

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To provide guidance on elements to be considered when withholding of payments to providers who committed fraud or willful misrepresentation.

	
General

	
The organization should consider withholding payments to providers as a mechanism to prevent wrong disbursement of payments when suspect of fraud.

	
Guidelines

	
The PIP will establish a mechanism and adhere to the following recommendations when considering withholding of payments:

	  	  	
(a)

	
Basis for withholding. The organization may withhold capitation or claims payments, in whole or in part, to a provider upon receipt of reliable evidence that the circumstances giving rise to the need for a withholding of payments involve fraud or willful misrepresentation under the Medicaid program. The organization may withhold payments without first notifying the provider of its intention to withhold such payments. A provider may request, and must be granted, administrative review where State law so requires.

	  	  	
(b)

	
Notice of withholding. The organization must send notice of its withholding of program payments within 5 days of taking such action. The notice must set forth the general allegations as to the nature of the withholding action, but need not disclose any specific information concerning its ongoing investigation. The notice must:

	  	  	  	
ü

	
State that payments are being withheld in accordance with this provision;

	  	  	  	
ü

	
State that the withholding is for a temporary period, and cite the circumstances under which withholding will be terminated;

	  	  	  	
ü

	
Specify, when appropriate, to which type or types of payment (capitation or claims) withholding is effective; and

	  	  	  	
ü

	
Inform the provider of the right to submit written evidence for consideration bye the agency.

	  	  	
(c)

	
Duration of withholding. All withholding of payment actions under this section will be temporary and will not continue after:

	  	  	  	
ü

	
The agency or the prosecuting authorities determine that there is insufficient evidence of fraud or willful misrepresentation bye the provider; or

	  	  	  	
ü

	
Legal proceedings related to the provider’s alleged fraud or willful misrepresentations are completed.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA12

	
Disclosure of Information by Providers and Fiscal Agents

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To provide definition of concepts in order to fully adhere to the regulation on providers control and ownership of facilities.

	
General

	
The organization must adhere to standard definitions when dealing with disclosure of information by providers and fiscal agents when establishing mechanism to regulate providers control and ownership of facilities.

	
Guidelines

	
The PIP will adhere to the following definitions of concepts to keep consistency with federal regulation and application of law:  

	  	  
	  	
Agent means any person who has been delegated the authority to obligate or act on behalf of a provider.

	  	  
	  	
Disclosing entity means a Medicaid provider (other than an individual practitioner or group of practitioners), or a fiscal agent.

	  	  
	  	
Other disclosing entity means any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the federal programs (Medicaid, SCHIP, FQHC’s). This includes:

	  	  	  	  
	  	  	
(a)

	
Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);

	  	  	
(b)

	
Any Medicare intermediary or carrier; and

	  	  	
(c)

	
Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health- related services for which it claims payment under any plan or program established under title V or title XX of the Act.

	  	  	  	  
	  	
Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency.

	  	  
	  	
Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

	  	  
	  	
Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Guideline

	
Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

	  	  
	  	
Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity.

	  	  
	  	
Person with an ownership or control interest means a person or corporation that-

	  	  	  	  
	  	  	
(a)

	
Has an ownership interest totaling 5 percent or more in a disclosing entity;

	  	  	
(b)

	
Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

	  	  	
(c)

	
Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;

	  	  	
(d)

	
Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured bye the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

	  	  	
(e)

	
Is an officer or director of a disclosing entity that is organized as a corporation; or

	  	  	
(f)

	
Is a partner in a disclosing entity that is organized as a partnership.

	  	  
	  	
Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total operating expenses.

	  	
Subcontractor means -

	  	  	
(a)

	
An individual, agency or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

	  	  	
(b)

	
An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.

	  	  	  	  
	  	
Supplier means an individual, agency or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).

 

  

  

  

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Guideline

	
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

	
Title SA13

	
Disclosure by disclosing entities: Information on ownership and control.

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To provide guidelines on what information must be disclosed by entities that have ownership and control over facilities.

	
General

	
The organization must have a mechanism to monitor on a timely manner the providers and fiscal agents that owns or control facilities where Medicaid beneficiaries receive services.

	
Guidelines

	
The PIP must require each disclosing entity to disclose the following information in a timely manner:

	  	  	
(a)

	
Type of Information that must be disclosed.

	  	  	  	
ü

	
The name and address of each person with an ownership or control interest in the disclosing entity or in any subcontractor in which the disclosing entity has direct or indirect ownership of 5 percent or more;

	  	  	  	
ü

	
Whether any of the persons named is related to another as spouse, parent, child, or sibling.

	  	  	  	
ü

	
The name of any other disclosing entity in which a person with an ownership or control interest in the disclosing entity also has an ownership or control interest. This requirement applies to the extent that the disclosing entity can obtain this information by requesting it in writing from the person. The disclosing entity must -

	  	  	  	  	
(i)

	
Keep copies of all these requests and the responses to them;

	  	  	  	  	
(ii)

	
Make them available to the Secretary or the Medicaid agency upon request; and

	  	  	  	  	
(iii)

	
Advise the Medicaid agency when there is no response to a request.

	  	  	
(b)

	Time and manner of disclosure.
	  	  	  	  	
ü

	
Any disclosing entity that is subject to periodic survey and certification of its compliance with Medicaid standards must supply the information specified to the organization.

	  	  	  	  	
ü

	
 Any disclosing entity that is not subject to periodic survey and certification and has not supplied the information specified.

	  	
Updated information must be furnished to the Secretary or the State survey or Medicaid agency at intervals between recertification or contract renewals, within 35 days of a written request.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 – 2014

	
Guidelines

	  	
(c)

	
Provider agreements and fiscal agent contracts. The organization shall not approve a provider agreement or a contract with a fiscal agent, and must terminate an existing agreement or contract, if the provider or fiscal agent fails to disclose ownership or control information as required by this section.

	  	  	  	  
	  	
The PIP will include the process to provide an annual report to the grantee and sub-grantee on above information and data.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

	
Title SA14

	
Disclosure by providers: Information related to business transactions.

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
The organization must establish a mechanism to facilitate the providers disclose information related to their business transactions when own or control facilities where Medicaid beneficiaries received services.

	
Guidelines

	
The PIP must describe the mechanism to allow providers owning or controlling facilities disclose information related to business transactions.

	  	  
	  	
The PIP must attest the organization abide by the following regulation:

	  	  
	  	  	
(a)

	
Provider agreements. The organization must enter into an agreement with each provider or provider group under which the provider agrees to furnish to it or to the grantee / sub-grantee on request, information related to business transactions.

	  	  	
(b)

	
Information that must be submitted. A provider must submit, within 35 days of the date on a request by the organization full and complete information about-

	  	  	  	
ü

	
The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and

	  	  	  	
ü

	
Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request.

	  	  	  	  	  
	  	
The PIP must include withholding of payment processes and procedures to enforce above guideline.

 

  

  

  

 

Commonwealth of Puerto Rico

Program Integrity Plan 2013 - 2014

 

	
Title SA15

	
Disclosure by providers: Information on persons convicted of crimes

	
Scope

	
Grantee, Sub-Grantee and Contracted Organizations

	
Purpose

	
To provide guidance on type of information providers must report in compliance with integrity program.

	
General

	
The organization is obliged to request providers to report any conviction of crimes or any other in the program integrity regulation.

	
Guidelines

	
The PIP must include a mechanism to confirm information included below is considered as part of the integrity activities.

	  	  
	  	  	
(c)

	
Information that must be disclosed. Before the organization enters into or renews a provider agreement, or at any time upon written request by the organization, the provider must disclose to the organization the identity of any person who:

	  	  	  	
(1)

	
Has ownership or control interest in the provider, or is an agent or managing employee of the provider; and

	  	  	  	
(2)

	
Has been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the title XX services program since the inception of those programs.

	  	  	
(b)

	
Notification to Inspector General.

	  	  	  	
(1)

	
The organization must notify the Inspector General of the Department of any disclosures made under paragraph (a) of this section within 20 working days from the date it receives the information.

	  	  	  	
(2)

	
The organization must also promptly notify the Inspector General of the Department of any action it takes on the provider’s application for participation in the program.

	  	  	
(c)

	
Denial or termination of provider participation.

	  	  	  	
(1)

	
The organization may refuse to enter into or renew an agreement with a provider if any person who has an ownership or control interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person’s involvement in any program established under Medicare, Medicaid or the title XX Services Program.

	  	  	  	
(2)

	
The organization may refuse to enter into or may terminate a provider agreement if it determines that the provider did not fully and accurately make any disclosure required under paragraph (a) of this section.

 

  

  

  

 

ATTACHMENT 15

ELECTRONIC HEALTH RECORD SPECIFICATIONS

 

1.    Overview: Primary Care Physicians (PCPs) and physician specialists within the Preferred Provider Network (PPN) shall have an operational Electronic Health Record (“EHR”) system in their practice in place on or before July 1, 2013. The EHR system must be certified by (i) an Office of the National Coordinator Authorized Testing and Certification Body (“OCN-ATCB”) and (ii) the Certification Commission for Healthcare Information Technology (“CCHIT”) to participate in the MI Salud Program. The purpose of implementing an EHR is to: (i) become a Meaningful User of Health Information Technology (HIT); (ii) improve quality of care; (iii) maximize cost-efficiency; (iv) connect with a Health Information Exchange (“HIE”) hub; and (v) allow patients to access their personal health information through a mechanism such as a Personal Health Record (PHR).

 2.    EHR System Specifications: To comply with technological as well as MI Salud model of care requirements, the EHR system shall:

 

2.1.    Be certified by an ONC-ATCB

2.2.    Be certified by the CCHIT

2.3.    Be capable to perform SureScripts-certified ePrescribing

2.4.    Be supported by one of the major drug-databases such as:

 

  2.4.1.1.    First DataBank;

  2.4.1.2.    MediSpan; or

  2.4.1.3.    Multum.

 

2.5.    Provide for ePrescribing Clinical Decision Support (“CDS”) interaction checks.

  

2.6.    Meet federal meaningful use objectives and measures in force at any given time. For example, during stage 1, must implement, at minimum, the capacity to detect drug-drug and drug-allergy interactions, as well as drug-formulary checks.

 

2.7.    Support applicable (according to practice) federally mandated transactions and code-sets standards, as follows:

2.7.1.      Transactions CCD, CDA, HL7, X12, NCPDP, and others.

2.7.2.      Code-Sets ICD, CPT, HCPCS, NDC, CDT, LOINC, and SNOMED.

2.8.    Be certified by, and connected to, the Puerto Rico Health Information Network (“PRHIN”), the ONC-supported and the state-designated entity or organization for HIE, as its services are made available. The EHR system must also be able to connect to other alternative hubs and be capable of reading and importing CCD files.

2.9.    Support compliance and reporting of CMS quality measures.

 

  

  

  

 

2.10.    Provide electronic copy of health information or clinical summaries to patients and other providers.

 

2.11.    Support electronic submittal of public health and/or reportable-disease/conditions data as these capabilities are made available in Puerto Rico.

 

2.12.    Be capable of quality monitoring.

 

2.13.    Be capable of prospective-preventive services management.

 

2.14.    Have mental and physical health integration capabilities.

 

2.15.    Have screening capabilities according to age group, gender and risks factors.

 

2.16.    Have an EPSDT prospective tracking system.

 

2.17.    Have the capacity to register members on Special Coverage.

 

2.18.    Have the capacity to generate an electronic referral.

 

2.19.    Have the capacity to update MI Salud’s drug formulary

 

2.20.    Provide electronic referral to the Contractor’s clinical programs

 

2.21.    Document Enrollee’s Advance Directives preferences

 

2.22.    Document Enrollee’s moral or religious objections

 

2.23.    Generate a Prior Authorization request to the Contractor

 

2.24.    Provide access to a Network Provider’s education module

 

3.   Contractor’s Certification Program: The Contractor will develop and implement a Certification Program for Electronic Medical Records (“EMR”) with technological requirements as well as MI Salud model of care requirements. Compliance with the established requirements will be taken into consideration to determine PCP qualification for the Physician Incentive Plan, as defined in Section 10.7 of the Contract.

 

  

  

  

 

ATTACHMENT 16

Procedure to include beneficiaries in the special coverage and identify the risks assumed by ASES, to enter in force as of July 1, 2013 for Mi Salud Plan beneficiaries

This document defines the conditions and procedures through which ASES assumes there economic risk of the services offered to Mi Salud beneficiaries. The information that follows describes the criteria and processes to follow for the transferring of the economic risks to ASES in those cases in which the insured is diagnosed with a condition, or a procedure is performed to the person, that is part of the ASES’s economic risk.

It is of utmost importance that the primary care physician continues providing all the medical assistance according to patient needs, even when the economic risk belongs to ASES.  It is the primary care physician’s role to coordinate all the medical services for the patient assigned to him, regardless of who assumes the economic risk.

If the request for special coverage enrollment is performed within the first 120 days from the date in which the tests and procedures that confirmed the diagnosis were made, the coverage will be effective on the date the diagnosis was confirmed. If enrollment is requested after 120 days from the date the diagnosis was confirmed, the coverage will be effective 90 days after the request was received.

The special coverage request form must be sent by e-mail address, cubiertasespeciales@ssspr.com or by fax to (787) 774-4835.

The information that follows details the medical conditions that may be included in the Special Coverage. For each condition we explain the criteria and the procedure to follow to include a beneficiary in the special coverage registry.

APLASTIC ANEMIA

Medical services related to aplastic anemia, including medications, will be ASES financial risks once the diagnosis is confirmed and the beneficiary is enrolled in the special coverage. To enroll the beneficiary it is required that a hematologist certifies the condition and, provides evidence of the result of the bone marrow and cytogenic biopsies confirming the diagnosis. A complete neutrophils count, platelet count and reticulocyte count must also be provided. The primary care physician, primary medical group or hematologist can request enrollment in the special coverage registry.

RHEUMATHOID ARTHRITIS

All medical services related to rheumatoid arthritis, including medications, will the financial risk of ASES, once there is a confirmed diagnosis and the beneficiary is enrolled in the special coverage registry. To enroll the beneficiary, a certification of the condition by the rheumatologist is required, as well as the results of ESR, CRP, ANA Test laboratory tests and pertinent X-rays confirming the diagnosis. The primary care physician, primary medical group or rheumatologist may request the beneficiary’s inclusion the special coverage registry.

 

  

1

  

 

As of the effective date of the beneficiary inclusion in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation that corresponds to the beneficiary.

 

AUTISM

All medical services, including medications, will be the financial risk of ASES once the condition is diagnosed and the beneficiary is enrolled in the special coverage registry. To include these beneficiaries in the registry, evidence of diagnosis submitted by a neurologist or psychiatrist is required. They must also include the results or interpretation of the M-CHAT and Ages and Stages questionnaires. The primary care physician can use the M-CHAT screening test to perform a test for presumed diagnosis. This test can be obtained through the Internet link www.firstsigns.org. The referral for the inclusion of the beneficiary in the registry may be provided by the physical or mental health provider. Once in the registry these beneficiaries do not require referral for services. However, in case the specialist, laboratory or facility thus requires a referral document for services. The primary care physician will be responsible to provide it and the service will not be discounted of the economic risk of the primary group

As of the effective date of the inclusion of the beneficiary in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation that corresponds to the beneficiary.

CANCER

Services covered related to cancer treatment for beneficiaries with this diagnosis will become ASES’ risk form the moment the biopsy sample that confirms the diagnosis is taken. Hospitalization and the procedure to perform the diagnostic biopsy will be considered to be an ASES’ risk. This coverage will depend on the beneficiary’s inclusion in our Cancer Registry and will be extended until the treatment with chemotherapy and radiotherapy is completed. In those cases in which a pathology confirmation of the diagnosis cannot be obtained, ASES, through Triple-S Salud, will consider other specialized studies performed for the determination of the special coverage.

Skin cancer and carcinoma in situ diagnosis will only be considered under the special coverage at the moment of the surgery. Skin cancer cases such as invasive squamous cells melanoma with evidence of metastasis or which because of their extension require radiotherapy or reconstructive surgery will be included in the special coverage.

Once the tumor is eliminated, and there is no evidence of metastasis, the case is in remission or there is no need to continue with chemotherapy or radiotherapy treatments, the services provided will not be considered ASES’ risk. Cases of beneficiaries that had been diagnosed with cancer in the past and are currently free of the disease, will not be considered ASES risks (e.g. beneficiary diagnosed with colon cancer in 2009, who underwent a colostomy). The follow-up of beneficiaries in remission by the oncologist, urologist, etc. will be the risk of the primary medical group, although the beneficiary will be able to access them without a referral, for they will be part of the preferred network.

It is necessary that when the Primary Medical Group requests the inclusion of a beneficiary with a cancer diagnosis in the registry for the condition, they provide the registration sheet filled out with a copy of the pathology studies and other studies that confirm the diagnosis, the treatment recommended and the time for which the beneficiary will be receiving said treatment. If this information is not provided, the beneficiary will be temporarily included in the registry for four (4) months, while the primary medical group or the specialist sends us the necessary information. Registration may be requested by the primary care physician, surgeon, gynecologist, urologist oncologist or radiotherapist in charge of the beneficiary.

 

  

2

  

 

Reactivation cases will be included in the registry on the date of the reactivation of the condition (evidence of metastasis through biopsy or study that confirms the diagnosis) up to a maximum of six (6) months prior to the date of the request, whichever is earlier.

Chemotherapy and radiotherapy treatments are ASES risk, whether or not the beneficiary is included in the registry for the condition.

CHRONIC KIDNEY DISEASE

Those beneficiaries with chronic renal disease are classified in stages 1 to 5 by their glomerular filtration rate (GRF).

	
Level

	
GFR Measure

	
    ICD-9-CM

	
 Risk:

	
Level 1

	
GFR over 90

	
585.1

	
PMG

	
Level 2

	
GFR between 60 and 89

	
585.2

	
PMG

	
Level 3

	
GFR between 30 and 59

	
585.3

	
ASES Parcial*

	
Level 4

	
GFR between 15 and 29

	
585.4

	
ASES Parcial*

	
Level 5

	
GFR less than 15

	
585.5

	
ASES Total

	
Level 5

	
End Stage Renal

	
585.6

	
ASES Total

* Beneficiaries in levels 1 and 2 will be the risk of the primary medical group.

* Beneficiaries in levels 3 and 4 will be a partial risk for ASES, as detailed below:

For beneficiaries in levels 3 and 4 only the visits to the nephrologist and some related laboratory tests (urinalysis, 24-hour urine collection for protein, creatinine, albumin, bilirubin, calcium, carbon dioxide chlorine, glucose, alkaline phosphatase, inorganic phosphorus, potassium, total proteins, sodium, hepatic enzymes and BUN, kidney sonogram and the peripheral vascular study to document access to hemodialysis) are considered ASES’ risks.

For beneficiaries in level 3 and 4, medications that appear in the PDL under the Nephrology Section will be part of ASES’ risk.

Level 5 beneficiaries will be subscribed to primary renal groups. All of the beneficiary’s services in these primary renal groups are ASES’ risks.

It is important to continuously monitor the patients at risk of this condition, for the early detection of the condition and include the beneficiary in the registry, prior to beginning the dialysis treatment.

The surgery needed to perform the fistula required for hemodialysis and the insertion of catheters are considered part of ASES’ risk, even when the beneficiary is not included in the registry for the condition. Once the fistula is performed, even when the beneficiary has not begun the dialysis treatment, he may be registered under a primary renal group.

 

  

3

  

 

In cases of acute kidney failure that recover their renal function, only the peritoneal dialysis or hemodialysis will be considered ASES’ risk.

Peritoneal dialysis and hemodialysis will be considered ASES’ risk, even when the beneficiary has not been included in the registry for the condition under a primary renal group.

Once the beneficiary is included in the special coverage for chronic renal condition the beneficiary receives a notification by mail, indicating him the changes in his coverage or the change from a primary medical group to a primary renal group and his new ID card. The change to the renal group will be effective on the month the request for change is made. From this moment on, the primary medical group stops receiving the capitation that corresponds to this beneficiary. Service received by the beneficiary, prior to the change to the primary renal group or the beneficiary’s inclusion in the special coverage because of a chronic renal condition, will be the risk of the primary medical group,  except those directly related to the dialysis, Outpatient services received outside the preferred network and not related to the dialysis provided to  these beneficiaries that belong to the primary renal group, must be coordinated by the nephrologist, who will become the primary care physician for these beneficiaries. Requirements to grant renal coverage depend on the GFR (gromerular filtration rate):

           

GFR = 186 x (PCr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if black)

If you need further information regarding this formula, go to the webpage of the National Kidney Foundation (www.kidney.org).

For the beneficiary to be included in the condition registry copy of the laboratory results evidencing creatinine, age and sex of the beneficiary are required. If the beneficiary is an African American woman, this must be specified, for this information is used to calculate the GFR. In those cases that apply, you may include a copy of the HCFA form #2728. The primary care physician, the nephrologist or the renal center may fill out the Special Coverage Registration Form.

SCLERODERMA

All the medical services, including medications, will be ASES’ financial risk once the definitive diagnosis is made and the beneficiary is included in the special coverage registry. To include the beneficiary in the registry of the condition, the Primary Medical Group or specialist must provide evidence of the result of the ANA Test, a report of the skin biopsy, a report on the consultation with the dermatologist or the rheumatologist confirming the condition. The registration may be requested by the beneficiary’s primary care physician or the specialist in charge of the condition.

MULTIPLE SCLEROSIS AND AMYOTROPHIC LATERAL SCLEROSIS

All the medical services, including medications, will be ASES’ financial risk once the definitive diagnosis is made and the beneficiary is included in the special coverage registry of the condition To include the beneficiary in the registry of the condition, they must send evidence of the result of the brain MRI and, if necessary, and MRI of the spinal cord, the result of the lumbar puncture, the type of multiple sclerosis or diagnosis of Amyotrophic Lateral Sclerosis certified by a neurologist and laboratory tests to rule out other diseases under differential diagnosis or with similar symptoms. The registration may be requested by the beneficiary’s primary care physician or the neurologist in charge of the condition.

 

  

4

  

 

As of the effective date of the inclusion of the beneficiary in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation that corresponds to the beneficiary.

CYSTIC FIBROSIS

All the medical services, including medications, provided to beneficiaries with a diagnosis of cystic fibrosis, included in the special coverage registry, are considered ASES’ financial risk.  To register the beneficiary, results of the sweat test, treatment and/or certification of the pulmonologist are required. These beneficiaries can be included in the registry for the condition by the pulmonologist, pediatrician or primary care physician that provides medical services to the beneficiary. The Primary Medical Group will not receive the monthly capitation for these beneficiaries and the pulmonologist will become the primary care physician for the beneficiary with Cystic Fibrosis.

HEMOPHILIA

The medical services related to a diagnosis of hemophilia and the treatment with anti-hemophilic factor for beneficiaries with hemophilia, are considered ASES’ economic risk. To include these beneficiaries in the registry for the condition a certification by the Hemophilia Clinics or by a hematologist evidencing the condition is required, as well as the results of blood coagulation factors levels.

LEPROSY

Services related to the condition, visits to the infectologist, medications for the condition, cultures, follow-up biopsies, as well as hospitalizations and procedures with the ICD-9/ICD-10 of the condition, are ASES’ risk from the date the beneficiary is included in the Special Coverage registry. The request for inclusion in the special coverage may be submitted by the primary care physician or the specialist in charge of the condition. The term of the registration will be based on the duration of treatment.

SYSTEMIC LUPUS ERYTHEMATOSUS

All the medical services, including drugs, will be ASES’ risk once the final diagnosis is made and the beneficiary is included in the Special Coverage Registry. To include the beneficiary on the registry of the condition a rheumatology assessment certifying the condition and the results of ANA-Test, DS-ANA, Anti SM and Anti-Phospholipids Abs laboratory tests are required. The request for enrollment in the Special Coverage can be done by the primary care physician or the specialist in charge of the condition.

As of the effective date of the inclusion of the beneficiary in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation that corresponds to the beneficiary.

 

  

5

  

 

CHILDREN WITH SPECIAL HELATH NEEDS

All covered medical services, including drugs, accepted in the Children with Special Health Needs Registry are ASES’ economic risk. The primary care physician will be responsible for providing the child the preventive care according to the child’s age, prescriptions and precertifications. These beneficiaries do not require a referral to visit specialists. Notwithstanding, in case the specialist, laboratory or facility requires it, the primary care physician will be responsible of providing it and the service will not be deducted from the economic risk of the Primary Medical Group.

 

To include the child in the registry for the condition they must fill out the Children with Special Health Needs Form with the following information:

	
  

	
●

	
Evidence of the medical condition according to the list of special condition diagnosis (See Attachment 2)

	
  

	
●

	
Laboratory tests relevant to the condition

	
  

	
●

	
Pending surgeries to correct the condition

	
  

	
●

	
Current pharmacotherapy

The decision to include the child in the registry will be made considering the age (up to 21 years of age) and the diagnosis.

As of the effective date of the inclusion of the beneficiary in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation that corresponds to the beneficiary.

Conditions that qualify the child for his inclusion in the registry are detailed below:

CONDITIONS TO INCLUDE PATIENTS IN THE REGISTRY OF CHILDREN WITH SPECIAL HEALTH NEEDS

 

	
Principal Diagnosis

	
Specifications

	
ICD-9

	
A.  Metabolic Diseases

	
1.       Specific amino acids disorders

2.       Non- specific amino acids disorders

3.      Carbohydrate transportation and metabolism disorders

  a.       Glycogenesis

  b.       Galactosemia

  c.       Fructose intolerance

  d.       Specific carbohydrate transportation and metabolism

            disorders

  e.       Non-specific carbohydrate transportation and

            metabolism disorders

4.       Lipid metabolism disorders

  a.       Disorders of  lipoproteins

  b.       Lipidoses

5.       Disorders of plasma protein metabolism

6.       Disorders of mineral metabolism

7.       Other non-specific disorders of metabolism

 

	
270.0 - 270.8

270.9

 

271.0 -271.9

 

 

271.0

271.1

271.2

271.8

 

271.9

 

 

272.0 - 272.7

272.5

272.7

 

  

6

  

 

 

	
Principal Diagnosis

	
Specifications

	
ICD-9

	
 

	
  a.       Disorders of porphyrin, purine and pyrimidine

  b.       Amyloidosis

  c.       Mucopolysaccharidosis

 

8.      Circulation enzyme deficiency

	
273.0-273.9

 

275.01-275.9

 

 

277.00 - 277.6, 277.81-

 

277.89, 277.9

277.1 - 277.2

277.30 -277.39

277.5

277.6

	
B. Hereditary and Central nervous system diseases

	
1.    Autism

       a.      Brain Degeneration

2.    Leucodistrophy

       a.      Cerebral Lipidosis

       b.      Acquired Obstructive Hydrocephalia

3.    Other motor and extrapyramidal  disorders

4.    Spinal cerebral diseases

5.    Spinal muscular dystrophy and related   syndromes

6.    Central nervous system demyelinating diseases

7.    Cerebral palsy

8.    Other paralysis syndromes

9.    Epilepsy

10.  Other brain conditions

11.  Heritable peripheral neuropathies

12.  Polyneuritis

13.  Muscular dystrophy and other myopathies, myotonic disorders

	
299.00, 299.80

330

 

330.0

 330.1 - 330.8

331.4

333.1, 333.2, 333.4

334.0 - 334.9

335.0-335.11

341.0 - 341.9

342.00-342.91

343.0 - 343.9

344.00 -344.09

345.00-345.91

348.0, 348.30

356.0 - 356.9

357.0

359.0 - 359.29

	
C. Musculoskeletal disorders

	
1.    Torticollis

 

                    a.    Congenital spasmodic torticollis, Sternocleidomastoid muscle torticollis

 

2.    Pelvis and hip juvenile osteochondritis

3.    Lower limb juvenile osteochondritis, excluding the foot

4.    Other acquired malformation of the ankle and foot

5.    Scoliosis

6.    Spina biphida

7.    Other congenital deformities of the central nervous system

	
723.5

754.1

732.1

732.4

 

736.70 - 736.72

737.0  - 737.39

741.00 -741.03,

741.90 - 741.93

742.0  - 74.59, 742.8 -  742.9

	
D. malformations*

	
1.    Anencephalia and similar malformations

2.    Congenital eye malformations

 

                a.    Anophthalmia

                b.    Microphthalmia, Buphthalmos

                c.    Congenital cataract and lenses malformation

	
740.0-740.2

743.00-743.06,

 

743.10 - 743.12, 

743.20 - 743.22

743.30 - 743.39

 

  

7

  

 

	
Principal Diagnosis

	
Specifications

	
ICD-9

	
 

	
Coloboma and other malformations of the anterior segment of the eye

d.    Congenital malformations of the posterior segment of the eye

e.    Congenital malformation of the eyelid, lachrymal apparatus and orbit

 

3.  Congenital malformations of the ear, face and neck

 

  a.  Malformations that cause hearing impairment

  b.  Choanal atresia and other congenital malformation  of the nose, larynx, trachea and bronchi

  c.  Cleft lip and palate

  d.  Congenital malformations of upper alimentary tract

4.  Congenital malformations of the circulatory system

5.  Congenital malformations of pulmonary and tricuspid valve

6.  Congenital malformations of great arteries

7.  Congenital malformations of genital organs and urinary

     system

8.  Congenital musculoskeletal malformations

9.  Congenital osteodistrophy

10.Congenital skin malformations

11.Other non-specific malformations

12.Chromosomal abnormalities

	
743.41-743.48

743.51 - 743.59

743.61 - 743.9

 

 

744.00 - 744.3

744.41  - 744.5,

744.81 - 744.9 

748.0  - 748.9

749.00  - 749.25

750.0 - 750.9

751.0-751.9

745.0-745.9746.00-746.9

 

747.0-747.9

752.0-752.89

753.0-753.8

754.0 - 754.89

755.00- 755.64,

756.0-756.17,

756.2-756.6,

756.71, 756.79,

756.83

757.0-757.6

759.0-759.89

758.0  - 758.89,

	
E. Perinatal period conditions

 

	
1. Fetal alcohol syndrome

2. Prematurity

3. Injury to the thorax

4. Hypoxia, anoxia, perinatal asphyxia

5. Intraventricular hemorrahage (grade III – IV)

6. Kernicterus

7. Periventricular leucomalacia

	
760.71

765.00-765.09

767.6

768.9

772.13-772.14

774.7

779.7

	
Disorders of sensory organs

 

	
1.   Of the globe and surroundings

2.   Retinopathy prematurity

3.   Conductive hearing loss

4.   Sensorineural hearing loss

5.   Blindness and low vision

6.   Strabismus and other disorders of eye movement

       a.     Esotropia

       b.     Exotropia

       c.     Intermittent heterotropia

 

7.   Alterations of the voice

	
360.00-360-.9

362.22-362.29

389.00  - 389.08

389.10  - 389.9

369.00  - 369.04,

369.20,369.4,

369.60

378

378.00  - 378.08

378.10 - 378.18

378.20  - 378.9

784.41,784.49

 

  

8

  

 

 

	
Principal Diagnosis

	
Specifications

	
ICD-9

	 	 	 
	
G. Development Disorders

	
1.Delay in the normal physiological development

2.Development delay and disorders

	
783.40-783.43

315.31-315.9

	
H. Endocrine Disorders

	
1.Congenital Hypothyroidism

2. Other endocrine disorders

	
243

246.8, 252.0, 252.8,

253.0, 253.3,255.2,

255.8, 259.1, 259.4,

278.01

	
I. Burns and Trauma

	
1.  Burns with disabling scars

2.  Scars and skin fibrosis

	
906.9, 949.0, 952.9

709.2

	
J. Immunologic and hematologic disorders

	
1. Myelodisplasia

2.  Aplastic Anemia

3. Immunological Disorders

	
238.71 -238.74

284.0 – 284.9

279.00-279.09,

279.10-279.19,

279.2-279.49,

282.40-282.49,

282.60-282.69,

283.9

	
K. Collagen Diseases**

	
1. Systemic Lupus Erythematous

2. Juvenile Rheumatoid Arthritis

3. Sclerosis; Scleroderma

4. Other conditions of connective tissue

	
710.0

714.0

710.1

710.2-710.4

 

	
L. Growth Hormone Deficiency

	  	
253.3

	
  

	 

	
*

	
Congenital malformations that require surgical correction will be kept in the registry for three (3) months after the surgery or after receiving the release from the surgeon that performed the surgery.

	
**

	
Each case will be evaluated individually according to the treatment and the severity of the condition.

► Case Management for Children with Special Needs

Triple-S Salud has a Case Management Program for pediatric patients, who for their diagnosis, do not qualify for the special coverage. The requirement for the program is that they have multiple medical conditions that require frequent visits to two or more specialists (4 or more visits per specialist a year) or high risk patients for hospitalizations such as the pediatric population with Diabetes Mellitus Type 1. The nurse in charge of managing this population will be responsible to guarantee beneficiaries access to specialists, diagnosis tests and the necessary medical treatment in communication with the primary care physician. Evaluation will be according to the benefits coverage of the Mi Salud Health Plan and the Preferred Drug List (PDL). The economic risk of the services offered to this population belongs to the Primary Medical Group until the Stop Loss amount is reached.

 

  

9

  

 

OBSTETRICS

All the covered medical services provided to Mi Salud’s female beneficiaries enrolled with Triple-S Salud, and registered in the obstetrics special coverage are ASES’ economic risk. Triple- S Salud has an electronic process to register pregnant beneficiaries. Through this process the obstetrician is able to register the patient through our webpage www.ssspr.com/sesweb.  This allows the physician to provide the beneficiary the registration certification letter on the first prenatal visit, so she can have the laboratory tests done and get the prescription drugs without needing the authorization or referral from the primary care physician.

If the obstetrician does not have access to the Internet, he/she must fill out the Form to Register Obstetrics Cases and send it to the Special Conditions Registry Area. Once the case is registered, a certificate of special coverage will be mailed to the female beneficiary.

If the female beneficiary is not registered, the obstetrician will only be able to receive payment for the obstetrics initial prenatal visit, but not for subsequent prenatal visits. This initial prenatal visit will always be considered ASES’ risk. The Primary Medical Group will not receive the capitation for this beneficiary from the time she is in the obstetric registry.

The following obstetric procedures require precertification through the Triple-S Salud Precertification Call Center (1-866-365-9024):

	
●

	
Non-stress test” in the office

While the beneficiary is in the obstetrics registry, prescription drugs outside the Obstetrics formulary must be precertified by filling out the request form and faxing it to (787) 625-8698.

Sterilizations performed in a separate admission after the vaginal delivery or C-section will be the responsibility of the Primary Medical Group; therefore, they will require the referral from the primary care physician.

Newborns under the mother’s contract will be ASES’ risk until the obstetric registration ends (41 days after the estimated date of delivery). Under this premise, the assistance of the pediatrician during a C-section or high risk delivery and the routine care of the newborn in the hospital (nursery room) will also be ASES’ responsibility.

The capitation payment for the baby will be paid once the mother is no longer in the obstetric registry or the mother completes the baby certification requirements, whichever happens first.

PRE-ORGAN TRANSPLANT

Services related to evaluations and tests prior performing an organ transplant are part of the risk of the Primary Medical Group, except those services that are already ASES’ risk, such as cardiac caths and Nuclear Medicine studies.

 

  

10

  

 

POST ORGAN TRANSPLANTS

Procedures to perform a transplant are not covered by Mi Salud Plan.

However, all the services covered after the organ transplant for beneficiaries included in the Special Coverage Registry are ASES’ risk. Post kidney transplant beneficiaries will be included in a renal primary group.  Heart, liver, lung and bone marrow post- transplant beneficiaries will be included in a special registry for beneficiaries who have had a transplant. To include the beneficiary in the registry for the condition, medical evidence of the transplant and evidence of use of immunosuppressor drugs are required. The registration request may be made by the primary care physician or the specialist in charge of the case. The beneficiary will be taken out of the registry when he/she no longer uses Immunosuppressor drugs.

As of the effective date of the beneficiary’s inclusion in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation they receive for the beneficiary.

TUBERCULOSIS

The services related to the condition, visits to the pulmonologist or infectologist, antibiotics for the condition, cultures, follow-up X-rays, as well as hospitalizations and procedures with the ICD-9/ICD-10 of the condition will be ASES’ risk. Specialty drugs that appear on the list at the end of this letter will also be included under ASES’ risk.

To be included in the registry for the condition, evidence of X-rays, positive cultures for the infection, report of bronchial wash or report of the biopsy of the part affected are required.  The request for inclusion in the condition registry may be made by the primary care physician or by the specialist in charge of the condition.

The term of registration will be based on the duration of treatment.

VIH + / SIDA

All covered medical services, including prescription drugs for beneficiaries with this condition will be ASES economic risk. For the beneficiary to be included in the registry for the condition, they require:

	
  

	
●

	
Evidence of a positive HIV test confirmed by the Western Blot test for HIV beneficiaries

	
  

	

●

	
CD-4 under 200 or evidence of an opportunistic disease for beneficiaries with AIDS

The request for registration may be made by the primary care physician, specialist or personnel of the Immunology Clinics of the Health Department or other centers specialized in treating the condition.

Antiretroviral drugs included in coverage and hospitalizations with the mentioned diagnoses will be assumed under the ASES economic risk, even when the insured is not included in the registry of the condition:

	
  

	

●

	
Esophageal, bronchial, tracheal or pulmonary candidiasis

	
  

	

●

	
Invasive cervical cancer

 

  

11

  

 

	
  

	

●

	
Disseminated or extrapulmonary Coccidioidomycosis

	
  

	

●

	
Extrapulmonary Cryptococcosis

	
  

	

●

	
Chronic Intestinal Cryptosporidiosis (with a duration of more than one month)

	
  

	

●

	
Cytomegalovirus disease in the liver, vessels or nodules

	
  

	

●

	
Cytomegalovirus Retinitis,  with loss of vision

	
  

	

●

	
HIV related encephalopathy

	
  

	

●

	
Herpes Simplex Bronchitis, Pneumonitis o Esophagitis

	
  

	

●

	
Hystoplasmosis, disseminated or extrapulmonary

	
  

	

●

	
Chronic intestinal Isosporasis  (with a duration of more than one month)

	
  

	

●

	
Kaposi’s Sarcoma

	
  

	

●

	
Burkitt’s Lymphoma  (or equivalent term)

	
  

	

●

	
Immunoblastic Lymphoma (or its equivalent term)

	
  

	

●

	
Primary Brain Lymphoma

	
  

	

●

	
Mycobacterium Avium complex or Type M, Kanasii, disseminated or extrapulmonary

	
  

	

●

	
Mycobacterium tuberculosis (anywhere in the lung or extrapulmonary)

	
  

	

●

	
Other unidentified Mycobacterium species , disseminated or extrapulmonary

	
  

	

●

	
Pneumocystis carinii pneumonia

	
  

	

●

	
Recurring Pneumonia

	
  

	

●

	
Progressive Multifocal Leucoencephalopathy

	
  

	

●

	
Brain Toxoplasmosis

 

Beneficiaries with protease inhibitors drug therapy must be referred to the Immunology Clinics of the Health Department for treatment, for these drugs are not included in pharmacy coverage established by ASES for Mi Salud Plan beneficiaries.

A child is considered to have a final positive HIV diagnosis if he/she has evidence of HIV antibodies after 18 months of age or has positive results for two of the tests: P24 Antigen, Viral Charge Test, and Virus Culture.  In pediatric cases, every child born of HIV-positive mother should be considered infected and it is required to be managed according to the protocol established for these purposes. Cases of infants over the age of 18 months, who do not have antibodies, cease to be regarded as an ASES risk.  From the effective date of the inclusion of the beneficiary in the Special Condition Registry, the Primary Medical Group will stop receiving the monthly capitation assigned to the beneficiary.

  

12

  

 

The following table summarizes the economic risk distribution by condition.

      

	
Economic risk distribution by condition

	
Condition

	
Medical Services

	
Medications

	
Aplastic Anemia

	
Services related

	
Services related

	
Rheumatoid Arthritis

	
All

	
All

	
Autism

	
All

	
All

	
Cancer

	
Services related

	
Services related

	
Scleroderma

	
All

	
All

	
Multiple Sclerosis and ALS

	
All

	
All

	
Cystic Fibrosis

	
All

	
All

	
Hemophilia*

	
Services related

	
Services related

	
Leprosy

	
Services related

	
Services related

	
Systemic Lupus Erithematosus

	
All

	
All

	
Children with Special needs

	
All

	
All

	
Obstetrics

	
All

	
All

	
Post organ transplant

	
All

	
All

	
Renal 3 and 4

	
Defined

	
Nephrology PDL

	
Renal 5 (GMP # 49)

	
All

	
All

	
HIV/AIDS

	
All

	
All

	
* Children with Hemophilia are part of the Children with Special Needs Registry

OTHER RISKS

ASES assumes other financial risks according to what was established in Mi Salud benefits coverage. It is not required to request the inclusion of these beneficiaries in the registry, for they are identified through the related billing codes.  .

The definitions of these other risks are detailed below:

ACUTE CEREBROVASCULAR ACCIDENTS (CVA)

Services rendered to a beneficiary with this diagnosis during a hospitalization or visit to an emergency room will be ASES’ risk. Medical follow-up and the rehabilitation of this beneficiary, once released from the hospital, will be the risk of the Primary Medical Group.

THERAPEUTIC APHERESIS

Therapeutic apheresis procedures will be included in the risks assumed by ASES.

AMBULANCE SERVICE

Ambulance services for emergency transportation, either ground or air ambulance, are risks assumed by ASES and do not require a precertification. Ambulance transportation of beneficiaries to medical appointments or his/her home or after being released from the hospital are not covered by Mi Salud Plan. 

 

  

13

  

 

Some cases may be precertified as an exception, for example: beneficiaries that are bedridden, that receive IVF therapy or under mechanical ventilation at his/her home.

 

Non-emergency transportation in other vehicles contracted is not considered a benefit with Mi Salud Plan.

MULTIPLACE HYPERBARIC CHAMBER

Payment for the use of the multiplace hyperbaric chamber and medical services related to it are economic risks assumed by ASES. This service requires precertification. Medical documents justifying the medical necessity for the use of the service may be faxed to (787) 774-4835.  In emergency cases, the request for precertification may be sent on the next business day, after the service is rendered.

CARDIOVASCULAR AND PERIPHEROVACULAR SURGERIES

Invasive procedures such as cardiac catheterizations angioplasties, pacemakers and all cardiovascular and periphero vascular surgeries, as well as hospitalizations associated to these procedures, from the moment the medical need of the surgery is established, are considered ASES’ economic risks. Once the surgeon releases the person from the hospital in which the procedure was performed, the economic risk passes the Primary Medical Group.

In cases in which a beneficiary is hospitalized because of a myocardium infarction and they perform a cardiac catheterization during said hospitalization, only the day of the cardiac catheterization will be considered ASES’ risk. Once the surgeon releases the beneficiary from the hospital in which the procedure was performed, the economic risk passes to the Primary Medical Group.

Ambulatory follow-up by the cardiologist, once the beneficiary is released from the hospital, is not part of the risk assumed by ASES. This follow-up must continue through the primary care physician and the consulting cardiologist.

MAXILLARY SURGERIES

Procedures with CPT codes performed by maxillofacial surgeons such as the reconstruction of dental malocclusion or correction and hospitalizations, anesthesia or analgesia associated to these procedures will an economic risk assumed by ASES and require precertification through Triple-S Salud Dental Claims Department. The request and the required documents must be sent to PO BOX 383628, San Juan, Puerto Rico 0093603628 to the attention of the Department previously indicated.

In cases in which the beneficiaries are not part of the Special Condition Registry, and they required a referral form(s) for the specialist, laboratory or facility, the primary care physician will be responsible of providing the referral and the service will not be deducted from the economic risk of the primary group.

  

14

  

 

DENTAL SERVICES AND DRUGS FROM THE DENTAL FORMULARY PRESCRIBED BY DENTISTS

CDT Manual Codes defined included in the dental coverage defined by ASES, as well as the prescription drugs included in the dental formulary that have been prescribed by a dentist will be ASES’ risks. These prescribed drugs will follow the rule established by the PBM for the dispensing of prescription drugs under acute conditions.

EMERGENCIES AND HOSPITALIZATIONS TO TREAT CONDITIONS RESULTING FROM SELF-INFLICTED INJURIES OR FELONIES BY THE BENEFICIARY

Emergency services and hospitalizations resulting  from emergencies with diagnosis codes E950.0 to E989.0 are part of the economic risk assumed by ASES/ Emergency room services, surgeries, medical services and hospitalization of those cases rejected by ACAA are included under this risk.

In those cases in which the Primary Care Group identifies that services for conditions resulting from self-inflicted injuries and felonies were not coded with the ICD9-CM indicated, the Primary Medical Group must provide Triple-S Salud any document (e.g. summary of hospital release, ACCA Letter of Denial of Services, etc.) that may facilitate the adjudication of these cases to the ASES’ risk

NUCLEAR MEDICINE STUDIES

Nuclear medicine studies (codes 78000 @ 79999) and radiopharmaceutical contrast materials necessary to perform them are an economic risk assumed by ASES. The requirement to precertify some of these studies will continue through Triple-S Salud Precertification Program, which you can reach at 1-866-365-9024.

NEONATAL INTENSIVE CARE UNIT

All babies that have admission criteria to the Neonatal Intensive Care Unit (NICU) will be considered economic risks assumed by ASES. Once the infant is released from NICU, he stops being considered under the ASES’ risk. Ambulatory medical follow-up will continue through his primary care physician and other specialists or sub-specialists that may be consulted and will be part of the economic risk assumed by the primary medical group.

 

PEDIATRIC INTENSIVE CARE UNIT AND ADULT INTENSIVE CARE UNIT

All covered hospital services provided to the beneficiaries in Pediatric Intensive Care Unit and Adult Intensive Care Unit will an economic risk assumed by ASES. Once the beneficiary complies with all the medical criteria to be transferred to another level of care, it will become an economic risk for the primary medical group.

CYTOGENETIC LABORATORY TESTS

Cytogenetic laboratory tests are an economic risk assumed by ASES. The codes that correspond to this type of laboratory tests are 88230 @ 88299.

 

  

15

  

EXTRACORPOREAL LITHOTRIPSY

Both the institutional and the medical service portions of the procedure are an economic risk assumed by ASES. This procedure requires precertification, which must be handled through the Triple-S Salud Precertifications Call Center at 1-866-365-9024.

MA-10

ASES will assume the economic risk of the claims for services rendered to those beneficiaries certified as eligible by the Medicaid Program and who by the date of the service have not completed the enrollment process with Triple-S Salud. A beneficiary certified by Mi Salud is one that has completed the enrollment process and has a primary medical group and a primary care physician assigned. When these processes are completed, the claims will become part of the economic risk of the primary medical group, in accordance with what is being provided in this document.

MAMMOGRAPHY

Screening and diagnosis mammography are part of the risk assumed by ASES

SPECIAL DRUGS*

The following medications are part of the risk assumed by ASES:

	
Medications

	
GPI

	
HCPCS-as applicable

	
Chemotherapy §**

	
21

	
J8501 al J8999 y J9000 al J 9999

	
Antiretrovirals § - HIV*

	
1210

	  
	
Baraclude ¥

	
1235

	  
	
Adcetris IV ¥

	
2135

	  
	
Erivedge ¥

	
2137

	  
	
Halaven ¥

	
2150

	
J9179

	
Afinitor §

	
2153

	
J7527

	
Inlyta ¥

	
2153

	  
	
Nexavar§

	
2153

	  
	
Sprycel§

	
2153

	  
	
Sutent§

	
2153

	  
	
Tarceva¥

	
2153

	  
	
Tasigna§

	
2153

	  
	
Tykerb¥

	
2153

	  
	
Votrient¥

	
2153

	  
	
Xalkori¥

	
2153

	  
	
Zelboraf¥

	
2153

	  
	
Stivarga¥

	
2153

	  
	
Supprelin La implant¥

	
3008

	
J1675

 

  

16

  

 

	
Somavert¥

	
3018

	  
	
AcThar gel¥

	
3030

	  
	
Veletri¥

	
4017

	  
	
Flolan¥

	
4017

	
J1325

	
Ventavis¥

	
4017

	  
	
Tyvaso¥

	
4017

	
J7686

	
Remodulin¥

	
4017

	
J3285

	
Xolair¥

	
4460

	
J2357

	
Prolastin¥

	
4510

	
J0256

	
Xenazine¥

	
6238

	  
	
Gilenya¥

	
6240

	  
	
Kineret¥

	
6626

	  
	
Humira§

	
6627

	
J0135

	
Enbrel§

	
6629

	
J1438

	
Orencia¥

	
6640

	
J0129

	
Actemra¥

	
6650

	
J3262

	
Leukine¥

	
8240

	
J2820

	
Nplate¥

	
8240

	
J2796

	
Hemophilia §

	
8510

	
J7180-J7195

	
Panhematin¥

	
8525

	
J1640

	
Revlimid¥

	
9939

	  
	
Thalomid¥

	
9939

	  
	
Immunosupresors§

	
9940

	
J7500 al J7599

	
Benlysta¥

	
9942

	
J0490

	
Forteo¥

	
30044

	
J3110

	
Reclast¥

	
300420

	
J3488

	
Boniva¥

	
300420

	
J1740

	
Sandostatin

	
302010

	
J2354 Y J2353

	
Kuvan¥

	
309085

	  
	
Promacta¥

	
824050

	  
	
Dificid¥

	
3530025

	  
	
Simponi¥

	
6627004

	  
	
Pentamidine

	
16000045

	
J2545 y J7676

	
Zyvox¥

	
16230040

	
J2020

	
Gammaglobulins§

	
19100020

	
J1459 al J1569; J1572, J1599

	
 Synagis§

	
19502060

	  
	
Eulexin§

	
21402440

	
S0175

	
Fareston¥

	
21402680

	  
	
Nolvadex§

	
21402680

	
S0187

	
Arimidex§

	
21402810

	
S0170

	
Aromasin§

	
21402835

	
S0156

 

  

17

  

 

	
Femara§

	
21402860

	  
	
Faslodex¥

	
21403530

	
J9395

	
Hydrea§

	
21700030

	
S0176

	
Vesanoid¥

	
21708080

	  
	
Leucovorin§

	
21755040

	
J0640

	
Megace§

	
26000023

	
S0179

	
Desmopresine DDAVD§

	
30201010

	
J2597

	
Carnitor§

	
30903045

	
J1955

	
Rocaltrol§

	
30905030

	  
	
Sensipar§

	
30905225

	  
	
Pulmozyme§

	
45304020

	
J7639

	
Remicade¥

	
52505040

	
J1745

	
Phoslo§

	
52800020

	  
	
Renvela§

	
52800070

	  
	
Copaxone§

	
62400030

	
J1595

	
Rebif¥

	
62403060

	
J1826; Q3026

	
Betaseron§

	
62403060

	
J1830

	
Extavia§

	
6240306050

	  
	
Novantrone§

	
21200055

	  
	
Avonex§

	
62403060

	
J1826; Q3025

	
Tysabri¥

	
62405050

	
J2323

	
Arava¥

	
66280050

	  
	
Botox¥

	
74400020

	
J0585; J0587

	
Rilutek¥

	
74503070

	  
	
Calciferol§

	
77202030

	  
	
Aranesp§

	
82401015

	
J0881; J0882

	
Epogen§

	
82401020

	
J0885; J0886

	
 Procrit§

	
82401020

	  
	
Neupogen§

	
82401520

	
J1440; J1441

	
Neulasta§

	
82401570

	  
	
Neumega¥

	
82403060

	
J2355

	
Leukine§

	  	  
	
Cerezyme¥

	
82700050

	
J1786

	
Agrylin¥

	
85156010

	  
	
Exjade¥

	
93100025

	  
	
TOBI§

	
700007000

	
J7682

	
Growth Hormone§

	
301000-301500

	  
	
Soliris¥

	
85800050

	
J1300

	
Trelstar¥

	
2140505020

	
J3315

	
Tracleer¥

	
40160015

	  

 

  

18

  

 

	
Promacta¥

	
82405030

	  
	
Angiomax¥

	
83334020

	
J0583

	
Intergrilin¥

	
85153030

	
J1327

	
*

	
Some prescription drugs require a precertification. The precertification may be handled by fax at (787) 625-8698.

	
 ¥

	
Any prescription drug approved through the exception process and is not part of the Preferred Drug List (PDL) or Plan Drug List (Medular Formulary) will always be ASES’ risk.

	
§

	
Prescription Drug included in the PDL.

NEUROSURGERY

All neurosurgery procedures are classified as an economic risk assumed by ASES. This classification ends when the beneficiary is released from the hospital by the neurosurgeon. Medical follow-up by professionals and specialists after the beneficiary is released from the hospital will be the economic risk of the Primary Medical Group and must be coordinated through the primary care physician. The surgery to treat carpal tunnel syndrome is considered a surgery excluded from the ASES risk.

The coordination of the services for the beneficiary that requires an elective neurosurgery procedure is the responsibility of the primary care physician. This coordination must include the issuance of the referrals necessary for the pre-admission and for the procedure.

PROSTHESIS

The following prostheses are covered and are part of the risk assumed by ASES:

	
  

	
●

	
Pacemakers, defibrillators*

	
  

	
●

	
Heart and neurosurgical  valves or any other artificial instrumentation or device (require precertification)

	
  

	
●

	
Orthopedic tray for instrumentation of fractures (screws, nails, rods, etc.),  back surgeries*, scoliosis* and joint replacement surgeries

	
  

	
●

	
Limb prosthesis *

	
  

	
●

	
Eye prosthesis

	
  

	
●

	
Bone replacement (Cadaver bone grafts*)

* Precertifications must be handled through (787) 774-4835.

Any prosthesis or device approved through the exception process and that is not part of this list will always be ASES’ risk.

ASES will only reimburse the provider, through Triple-S Salud, the cost of the trays and the materials used in the surgery; therefore, the invoice submitted must have attached the evidence of cost, copy of the surgeon’s a report and a detailed list materials used.

The cost for the intraocular lens cataract removal surgery will be considered an economic risk of the Primary Medical Group. This cost is billed by the ambulatory surgery center.

 

  

19

  

 

RADIOSURGERY

All radiosurgeryl procedures such as stereotactic surgery, Cyberknife and Gamma Knife are financial risks assumed by ASES and require pre-certification through the Triple-S Salud Pre-certification Call Center at 1-866-365-9024. The pre-certification can be arranged by the primary physician, neurosurgeon or facility that will perform the procedure.

The following is required for the evaluation of the cases:

	
  

	
●

	
Radiotherapist and/or neurosurgeon consultation report

	
  

	
●

	
MRI results to evidence the size of the lesion to be treated

	
  

	
●

	
Venogram results (if applicable)

	
  

	
●

	
Karnofski Scale (KPS)

MORBID OBESITY

The management of morbid obesity prior to the bariatric surgery Primary Medical Group risk. The bariatric surgery is an ASES risk. Reconstruction services after bariatric surgery, in medically necessary cases, are part of the Primary Medical Group risk.

MENTAL HEALTH

All mental health services will be provided by the MBHO contracted by ASES. Subscriber evaluations to rule out physical conditions will be the risk of the primary medical group. This includes laboratory tests and studies required for the evaluation of children with suspected ADD or hyperactivity, evaluations of patients with suspected dementias, evaluation of patients eligible for detoxification of controlled substances, and emergency room visits of subscribers with physical symptoms (e.g. chest pain) where the final diagnosis is one of mental health or suicide attempt. In these cases, the intervention of the emergency room or hospital is limited to ruling out a physical health condition and is not intended to treat the psychiatric condition. Diagnosis tests such as laboratories, CT scan, MRI, EEG, will be the risk of the MBHO only when referred by a psychiatrist.

Once the diagnosis of Attention Deficit Disorder (ADD) with or without hyperactivity is confirmed, the treatment will be the responsibility of the MBHO contracted by ASES. This treatment includes but is not limited to Neurologist visits and tests related to the treatment of this diagnosis.

 

  

20

  

PREVENTIVE SERVICES (See enclosed table)

 

	
MI SALUD PROGRAM- PREVENTIVE SERVICES – QUICK REFERENCE GUIDE 2011- 2012

	  
	
 

Category

	
CPT 

Code

	
Brief Description

	
ICD-9 DM

	
Indications

	
Frequency

	  	  	  	  	  	  
	
Aortic Abdominal Aneurysm (AAA)

	
G0389

	
Ultrasound for Aortic Abdominal Aneurysm; screening

	
V81.2

	
One per lifetime in males > 

65-75 years at risk

	
 1 x lifetime

	  	  	  	  	  	  
	
Cholesterol Management

	
80061

	
Lipid Panel

	
V81.0

	
Over 18 years of age

	
1 every 5 years until age 

64 and annually in older 

than 65 years

	  	  	  	  	  	  
	
Diabetes 

Screening

	
82947

	
Glucose, quantitative, blood (except reagent strip)

	
V77.1

	
In patients diagnosed with 

pre-diabetes, 1 test per year

	
1 per year

	
82950

	
Glucose, blood; post glucose dose (includes glucose)

	
82951

	
GTT, 3 specimens (includes glucose)

	  	  	  	  	  	  
	
Cervical 

Cancer 

Screening 

(Pathologies)

	
G0123

	
Screening cytopathology; automated thin layer prep; by cytotech. under physician supervision

	
V76.2

	
Sexually active females 

with cervix

	
Annual in high risk and 

every 24 months in 

general not-at-risk 

population

	
G0124

	
Screening cytopathology; automated thin layer prep; requiring physician interpretation

	
G0141

	
Screening cytopathology; automated thin layer prep; w manual rescreening; requiring physician interpretation

	
G0143

	
Screening cytopathology; automated thin layer prep; w manual screening & rescreening; by cytotech. under physician supervision

	
G0144

	
Screening cytopathology; automated thin layer prep; w screening by automated system under physician supervision  

 

  

21

  

 

	  	  	  	  	  	  
	  	
G0145

	
Screening cytopathology; automated thin layer prep; w screening by automated system and manual rescreening under physician supervision

	  	  	  
	  	
G0147

	
Screening cytopathology; performed by automated system; under physician supervision

	  	  	  
	  	
G0148

	
Screening cytopathology; performed by automated system with manual rescreening

	  	  	  
	  	
88142

	
Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision

	  	  	  
	  	
88150

	
Cytopathology, slides, cervical or vaginal; manual screening under physician supervision

	  	  	  
	  	  	  	  	  	  
	
Cervical 

Cancer 

Screening 

(Sample 

collection)

	
G0101

	
Cervical or Vaginal Cancer Screening; Pelvic and Clinical Breast Examination

	
V76.2

	
Sexually active females 

with cervix

	
 

Annual in high risk and 

every 24 months in 

general not-at-risk 

population

 

	  	  	  	  	  	  
	
Breast 

Cancer 

screening 

and 

diagnosis

	
77052

	
Add on Code for Computer-aided Screening mammography

	
V76.11 o V76.12

	
Anual 40 years and older

	
1 per year.

	
77055

	
Mammography, unilateral

 

  

22

  

 

	  	  	  	  	  	 
	  	
77057

	
Mammography, bilateral

	  	  	  
	  	
77057

	
Screening mammography; bilateral (2-view study of each breast)

	  	  	  
	  	
G0202

	
Screening mammography; digital; bilateral

	  	  	  
	  	  	  	  	  	  
	
BRCA

	
81211-81217

	
BRCA 1, BRCA2, Breast Cancer and Ovarian cancer

	
V84.1 Breast 

V84.2 Ovary

	
Women with high risk of 

genetic mutations for breast 

and ovarian cancer

	
1 per lifetime

	
Colorectal 

Cancer 

Screening 

(COL)

	
G0104

	
Colorectal Cancer; flexible sigmoidoscopy

	
V76.51

	
50-75 years

	
Occult Blood (G0328 o 

82270) 1/annual. Flexible 

sigmoidoscopy 1 every 4 

years. Screening 

Colonoscopy1 every 10 

years in general 

population and every 2 

years in high risk. Barium 

Enema as alternative to 

colonoscopy.

	
G0105

	
Colorectal Cancer; colonoscopy; high risk

	
G0106

	
Colorectal Cancer; barium enema

	
G0120

	
Colorectal Cancer; barium enema

	
G0121

	
Colorectal Cancer; colonoscopy; non high risk

	
G0122

	
Colorectal Cancer; barium enema

	
G0328

	
Colorectal Cancer; FOBT

	
82270

	
FOBT, by Guiac

	  	  	  	  	  	  
	
Prostate 

Cancer 

Screening

	
G0103

	
PSA Test; screening

	
V76.44

	
Males over age 50 years

	
1 annually

	  	  	  	  	  	  
	
HIV

Screening

	
G0432

	
HIV-1 and/or HIV-2 screening by EIA

	
V73.89-Primary

V22.0, V22.1, 

V69.8 or V23.9 

Secondary, as 

appropriate

	
Subscribers with high risk of HIV infection and during pregnancy

	
Annual for high risk and 

3 times during pregnancy 

(diagnosis, third trimester 

and delivery)

	
G0433

	
HIV-1 and/or HIV-2 screening by ELISA

	
G0435

	
HIV-1 and/or HIV-2 screening by Rapid Antibody Test

	  	  	  	  	  	  
	
Osteoporosis 

Screening

	
G0130

	
SEXA; 1 or more sites; appendicular skeleton

	
V82.81

	
Women over age 65 years

	
One screening test every 

2 years

	
77078

	
CT bone density; axial skeleton.; (hips, pelvis, spine)

 

  

23

  

 

	  	
77079

	
CT for bone density; appendicular skeleton (radius, wrist, heel)

	  	  	  
	  	
77080

	
DXA Bone; axial skeleton; (hips, pelvis, spine)

	  	  	  
	  	
77081

	
DXA Bone; appendicular skeleton; (radius, wrist, heel)

	  	  	  
	  	
77083

	
Photo densitometry

	  	  	  
	  	
76977

	
Ultrasound bone density measurement and interpretation; peripheral site(s), any method

	  	  	  
	  	  	  	  	  	  
	
Glaucoma 

screening

	
G0117

	
Glaucoma screening by an Optometrist or Ophthalmologist

	
V80.1

	
Individuals over age 65 

years

	
Annual

	  	  	  	  	  	  
	
Sexually 

Transmitted 

Disease 

(STD) 

Screening

	

86592

	

Syphilis test; qualitative (ex, VDRL, RPR, ART)

	
V74.5

	
Sexually active at risk 

population

	
1 per year

	
87270

	
Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis

	
87490

	
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique

	
87491

	
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique

	
87110

	
Culture, chlamydia, any source

	
87590

	
Neisseria gonorrhea, direct probe

	
87591

	
Neisseria gonorrhea, amplified probe

	  	  	  	  	  	  
	
Neonatal 

Metabolic 

Screening

	  	
As per the Health Department protocol it is included within the obstetric

 

	  	
Neonates during delivery 

admission.

	
1 per lifetime

 

  

24

  

 

	  	  	  	  	  	  
	
Neonatal Auditory Screening

	
92586

	
Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited

	
V72.1

	
Neonates during delivery admission.

	
1 of each per lifetime

	
92587

	
Evoked otoacoustic emissions; limited (single stimulus, either transient or distortion products)

	  	  	  	  	  	  
	
Lead Screening

	
83655

	
Lead

	
V15.86

	
Twelve (12) to seventy two (72) months of age

	
1 per lifetime

	  	  	  	  	  	  
	
Annual

Preventive 

Visit

	
99381 al 

99397

	
Comprehensive

preventive medicine 

visit (by age group)

	  	
 

• For the pediatric population it includes elements of the preventive visit described in EPSDT.

• For the adult population it includes detailed history and physical exam, including weight, height, body mass index, blood pressure test, vital signs and identification of risk factors. Screening of vision, hearing, pain and nutritional status. Assessment of high-risk behaviors (violence, tobacco use, sexually transmitted diseases, use of alcohol and of controlled substances). Evaluation of depression. Counseling on use of aspirin for prevention of cardiovascular risk. End-of-life planning. Evaluation of everyday activities, exercise, and safety aspects and fall prevention and education, and counseling as identified in all of the above.

 

	
•   Pediatric Population as established in EPSDT

•  Adult Population - Annual

	
 

General comment: For those tests that have no specific CPT codes for screening, the first test of the year with the appropriate diagnosis is considered as the responsibility of ASES, and subsequent tests as the responsibility of the GMP.   

 

 

  

25

  

VACCINES

The payment of $4.00 that is offered to primary medical groups for the administration of vaccines listed in the vaccination schedule of the Department of Health is a financial risk assumed by ASES. This service may be rendered and billed to Triple-S Salud for any subscriber, regardless of primary medical group to which the subscriber belongs and without need of a physician referral. The administration of a single vaccine will be billed even if it contains several antigens (e.g. DPT).

This payment does not apply to beneficiaries insured under Medicare A and B, or Medicare Advantage because Medicare covers the cost and administration of vaccines. Vaccines that are not part of the immunization schedule of the Department of Health and are medically necessary will be the risk of the Primary Medical Group.

	
CPT

	
Vaccine

	
ICD-9 CM

	
90633

	
Hepatitis A (pediatric)

	
V05.3

	
90634

	
Hepatitis A (pediatric)

	
V05.3

	
90644

	
Meningococcal

	
V06.8

	
90645

	
Haemophilus influenza B (Hib)

	
V03.81

	
90646

	
Haemophilus influenza B (Hib)

	
V03.81

	
90647

	
Haemophilus influenza B (Hib)

	
V03.81

	
90648

	
Haemophilus influenza B (Hib)

	
V03.81

	
90649

	
Human Papilloma Virus (HPV) – Gardasil

	
V04.89

	
90650

	
Human Papilloma Virus (HPV) – Cervarix

	
V04.89

	
90655

	
Influenza virus children

	
V04.81

	
90656

	
Influenza virus

	
V04.81

	
90657

	
Influenza virus children

	
V04.81

	
90658

	
Influenza virus

	
V04.81

	
90660

	
Influenza virus intranasal

	
V04.81

	
90669

	
Pneumococcal vaccine

	
V03.82

	
90670

	
Pneumococcal vaccine

	
V03.82

	
90680

	
Rotavirus vaccine

	
V04.89

	
90681

	
Rotavirus vaccine

	
V04.89

	
90700

	
DTaP

	
V06.1

	
90702

	
Diphtheria and Tetanus

	
V06.5

	
90707

	
Measles, mumps and rubella (MMR)

	
V06.4

	
90713

	
Poliovirus (IPV)

	
V04.0

	
90715

	
Tetanus, diphtheria toxoids and acellular 

pertussis vaccine (Tdap)

	
V06.1

	
90716

	
Varicella virus vaccine

	
V05.4

	
90732

	
Pneumococcal polysaccharide

	
V03.82

	
90733

	
Meningococcal polysaccharide

	
V03.89

	
90734

	
Meningococcal conjugate

	
V03.89

	
90744

	
Hepatitis B vaccine pediatric

	
V05.3

	
90746

	
Hepatitis B vaccine adult

	
V05.3

 

  

26

  

 

ATTACHMENT 17

 

LIST OF SUBCONTRACTORS

 

	
1.

	
Jaye, Inc.

	
2.

	
McKesson Health Solutions

	
3.

	
Mercer Oliver Wyman Actuarial Consulting, Inc.

	
4.

	
Uticorp

	
5.

	
VIPS Healthcare Information Solutions

	
6.

	
Neodeck Holdings

 

  

  

  

 

Attachment 18

 

90 DAYS SUPPLY

 

ASES 90 DAYS SUPPLY

 

METHOTREXATE TAB

Methotrexate Sodium Tab 2.5 MG (Base Equiv)

Methotrexate Sodium Tab 5 MG (Base Equiv)

Methotrexate Sodium Tab 7.5 MG (Base Equiv)

Methotrexate Sodium Tab 10 MG (Base Equiv)

Methotrexate Sodium Tab 15 MG (Base Equiv)

 

ANTI ESTROGENS

Tamoxifen Citrate Tab 10 MG (Base Equivalent)

Tamoxifen Citrate Tab 20 MG (Base Equivalent)

 

AROMATASE INHIBITORS

Anastrozole Tab 1 MG

Exemestane Tab 25 MG

Letrozole Tab 2.5 MG

Letrozole Tab 2.5 MG

 

BISPHOSPHONATES

Alendronate Sodium Tab 5 MG

Alendronate Sodium Tab 10 MG

Alendronate Sodium Tab 35 MG

Alendronate Sodium Tab 70 MG

Etidronate Disodium Tab 400 MG

Risedronate Sodium Tab 5 MG

Risedronate Sodium Tab 30 MG

Risedronate Sodium Tab 35 MG

Risedronate Sodium Tab 150 MG

 

ESTROGENS

Estrogens, Conjugated Tab 0.3 MG

Estrogens, Conjugated Tab 0.625 MG

Estrogens, Conjugated Tab 0.9 MG

Estrogens, Conjugated Tab 1.25 MG

Estradiol Tab 0.5 MG

Estradiol Tab 1 MG

Estradiol Tab 2 MG

Estropipate Tab 0.75 MG

Estropipate Tab 1.5 MG

Estropipate Tab 3 MG

Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-2.5 MG

Conjugated Estrogen-Medroxyprogest Acetate Tab 0.625-5 MG

Estradiol & Norethindrone Acetate Tab 1-0.5 MG

Norethindrone Acetate-Ethinyl Estradiol Tab 1 MG-5 MCG

 

PROGESTINS

Medroxyprogesterone Acetate Tab 2.5 MG

Medroxyprogesterone Acetate Tab 5 MG

Medroxyprogesterone Acetate Tab 10 MG

 

  

  

  

 

ANTIDIABETIC

Glipizide Tab 5 MG

Glipizide Tab 10 MG

Glyburide Tab 1.25 MG

Glyburide Tab 2.5 MG

Glyburide Tab 5 MG

Glyburide Micronized Tab 1.5 MG

Glyburide Micronized Tab 3 MG

Sotalol HCI (AFIB/AFL) Tab 160 MG

Atenolol Tab 25 MG

Atenolol Tab 50 MG

Atenolol Tab 100 MG

Metoprolol Succinate Tab SR 24HR 25 MG

Metoprolol Succinate Tab SR 24HR 50 MG

Metoprolol Succinate Tab SR 24HR 100 MG

Metoprolol Succinate Tab SR 24HR 200 MG

Metoprolol Tartrate Tab 25 MG

Metoprolol Tartrate Tab 50 MG

Metoprolol Tartrate Tab 100 MG

Carvedilol Tab 3.125 MG

Carvedilol Tab 6.25 MG

Carvedilol Tab 12.5 MG

Carvedilol Tab 25 MG

Labetalol HCI Tab 100 MG

Labetalol HCI Tab 200 MG

Labetalol HCI Tab 300 MG

 

CALCIUM BLOCKERS

Amlodipine Besylate Tab 2.5 MG

Amlodipine Besylate Tab 5 MG

Amlodipine Besylate Tab 10 MG

Dilliazem HCI Tab 30 MG

Diltiazem HCI Tab 60 MG

Diltiazem HCI Tab 90 MG

Diltiazem HCI Tab 120 MG

Diltiazem HCI Cap SR 12HR 60 MG

Diltiazem HCI Cap SR 12HR 90 MG

Diltiazem HCI Cap SA 12HR 120 MG

Diltiazem HCI Cap SR 24HR 120 MG

Diltiazem HCI Cap SR 24HR 180 MG

Oiltiazem HCI Cap SA 24HR 240 MG

Dilliazem HCI Extended Release Beads Cap SA 24HR 120 MG

Diltiazem HCI Extended Release Beads Cap SR 24HR 180 MG

Oiltiazem HCI Extended Release Beads Cap SA 24HR 240 MG

Oilliazem HCI Extended Release Beads Cap SA 24HR 300 MG

Oiltiazem HCI Extended Release Beads Cap SR 24HR 360 MG

Diltiazem HCI Coated Beads Cap SR 24HR 120 MG

Di ltiazem HCI Coated Beads Cap SA 24HR 180 MG

Diltiazem HCI Coated Beads Cap SA 24HR 240 MG

Di ltiazem HCI Coated Beads Cap SA 24HA 300 MG

Nifedipine Tab SA 24HR 30 MG

Nifedipine Tab SR 24HR 60 MG

Nifedipine Tab SA 24HR Osmotic 30 MG

Nifedipine Tab SA 24HR Osmotic 60 MG

Nifedipine Tab SA 24HR Osmotic 90 MG

Verapamil HCI Tab 40 MG

Verapamil HCI Tab 80 MG

 

  

  

  

 

Verapamil HCI Tab 120 MG

Verapamil HCI Tab CR 120 MG

Verapamil HCI Tab CR 180 MG

Verapamil HCI Tab CR 240 MG

Terazosin HCI Cap 2 MG

Terazosin HCI Cap 5 MG

Terazosin HCI Cap 10 MG

Hydralazine HCI Tab 10 MG

Hydralazine HCI Tab 25 MG

Hydralazine HCI Tab 50 MG

Hydralazine HCI Tab 100 MG

Minoxidil Tab 2.5 MG

Minoxidil Tab 10 MG

Captopril & Hydrochlorothiazide Tab 25-15 MG

Captopril & Hydrochlorothiazide Tab 25-25 MG

Captopril & Hydrochlorothiazide Tab 50-15 MG

Captopril & Hydrochlorothiazide Tab 50-25 MG

Enalapril Maleate & Hydrochlorothiazide Tab 5-1 2.5 MG

Enalapril Maleate & Hydrochlorothiazide Tab 10-25 MG

Lisinopril & Hydrochlorothiazide Tab 10-12.5 MG

Lisinopril & Hydrochlorothiazide Tab 20-12.5 MG

Lisinopril & Hydrochlorothiazide Tab 20-25 MG

Atenolol & Chlorthalidone Tab 50-25 MG

Atenolol & Chlorthalidone Tab 100-25 MG

Metoprolol & Hydrochlorothiazide Tab 50-25 MG

Metoprolol & Hydrochlorothiazide Tab 100-25 MG

Metoprolol & Hydrochlorothiazide Tab 100-50 MG

Propranolol & Hydrochlorothiazide Tab 40-25 MG

Propranolol & Hydrochlorothiazide Tab 80-25 MG

Losartan Potassium & Hydrochlorothiazide Tab 50-1 2.5 MG

Losartan Potassium & Hydrochlorothiazide Tab 100-1 2.5 MG

Losartan Potassium & Hydrochlorothiazide Tab 100-25 MG

 

DIURETICS

Acetazolamide Tab 125 MG

Acetazolamide Tab 250 MG

Bumetanide Tab 0.5 MG

Bumetanide Tab 1 MG

Bumetanide Tab 2 MG

Furosemide Tab 20 MG

Furosemide Tab 40 MG

Furosemide Tab 80 MG

Furosemide Oral Soln 8 MG/ML

Furosemide Oral Soln 10 MG/ML

Spironolactone Tab 25 MG

Spironolactone Tab 50 MG

Spironolactone Tab 100 MG

Chlorothiazide Tab 250 MG

Chlorothiazide Tab 500 MG

Chlorothiazide Susp 250 MG/5ML

Chlorthalidone Tab 15 MG

Chlorthalidone Tab 25 MG

Chlorthalidone Tab 50 MG

Chlorthalidone Tab 100 MG

Hydrochlorothiazide Tab 12.5 MG

Hydrochlorothiazide Tab 25 MG

 

  

  

  

 

Hydrochlorothiazide Tab 50 MG

Trihexyphenidyl HCI Tab 2 MG

Trihexyphenidyl HCI Tab 5 MG

Trihexyphenidyl HCI Elixir 0.4 MG/ML

Amantadine HCI Cap 1 00 MG

Amantadine HCI Syrup 50 MG/SML

Bromocriptine Mesylate Cap 5 MG

Bromocriptine Mesylate Tab 2.5 MG

Pramipexole Dihydrochloride Tab 0.125 MG

Pramipexole Dihydrochloride Tab 0.25 MG

Pramipexole Dihydrochloride Tab 0.5 MG

Pramipexole Dihydrochloride Tab 0.75 MG

Pramipexole Dihydrochloride Tab 1 MG

Pramipexole Oihydrochloride Tab 1.5 MG

Ropinirole Hydrochloride Tab 0.25 MG

Ropinirole Hydrochloride Tab 0.5 MG

Ropinirole Hydrochloride Tab 1 MG

Ropinirole Hydrochloride Tab 2 MG

Ropinirole Hydrochloride Tab 3 MG

Ropinirole Hydrochloride Tab 4 MG

Ropinirole Hydrochloride Tab 5 MG

Carbidopa & Levodopa Tab 1 0-1 00 MG

Carbidopa & Levodopa Tab 25-100 MG

Carbidopa & Levodopa Tab 25-250 MG

Carbidopa & Levodopa Tab CR 25-100 MG

Carbidopa & Levodopa Tab CR 50-200 MG

Carbidopa-Levodopa-Entacapone Tabs 12.5-50-200 MG

Carbidopa-Levodopa-Entacapone Tabs 18.75-75-200 MG

Carbidopa-Levodopa-Entacapone Tabs 25-100-200 MG

Carbidopa-Levodopa-Entacapone Tabs 31.25-125-200 MG

Carbidopa-Levodopa-Entacapone Tabs 37.5-150-200 MG

Carbidopa-Levodopa-Entacapone Tabs 50-200-200 MG

Selegiline HCI Tab 5 MG

 

  

  

  

 

Auto Enroll / Automatic Subscription

Protocol for Drug Dispatch

(Effective from July 1, 2011)

 

As of July 1, 2011, all new beneficiaries eligible for the Health Plan of the Government of Puerto Rico will be automatically enrolled and covered by Mi Salud.  The enrollee can begin to receive health services from the day that the Office of Medicaid of the Puerto Rico’s Health Department handles the MA-10, named “Notice of Action Taken on Application and / or Re-Evaluation”.

 

The date to determine how long a person is covered is shown in the section “Certification Date” of the MA-10. The enrollee will also receive the Welcome Letter.  The enrollee must submit both documents when applying for a covered health service of Mi Salud to show that his or her name is on the MA-10, that is enrolled, and that can receive services.

 

This Protocol for Drug Dispatch in cases of Automatic Enrollment also aims to achieve the objective that enrollees can access the benefits of drug coverage in Mi Salud for physical, dental, and mental health services.

 

The Protocol establishes the rules to be followed in the following three stages:

 

Table 1:                      PBM has not the Certified Enrollees on file

Table 2:                      PBM receives from ASES the file of Certified Enrollees

Table 3:                      PBM receives from the Insurer the file of Certified Enrollees

 

In each of the tables the following scenarios are considered:

 

Scenario 1: Mi Salud Participating Pharmacy – The enrollee presents a prescription by:

 

(1)           a participant doctor or dentist, or

(2)           a non-participating physician or dentist

 

Scenario 2: A pharmacy not participating in Mi Salud – The enrollee presents a prescription by:

 

(1)           a participant doctor or dentist, or

(2)           a non-participating physician or dentist

 

The Medicaid Program sends ASES the Electronic File of certified enrollees. ASES assigns the coverage for the enrollee, and sends the file to the PBM, the MBHO (APS Healthcare) and Insurers (Humana and Triple-S). The PBM installs the Certified Enrollee’s file in its information system for 10 days. After receiving the Certified Enrollee’s file, the insurer shall immediately issue and send to the enrollee’s identification card of Mi Salud with the Primary Medical Group (PMG) and the primary care physician (PCP) assigned. In summary, the 10 days is the maximum period before the enrollee receives the ID card of the Mi Salud plan.

 

NOTICE: This Protocol does not apply to beneficiaries who:

 

(1)           Are in a Platino Plan and

(2)           Have a MA-10 certificate dated prior July 1, 2011.  In this case, the recipient must go to the Insurer’s in their region (Humana or Triple-S) and procure the Mi Salud’s card to start receiving the covered services.

 

  

  

  

 

	 	
Table 1

	 	
(Effective from July 1, 2011 and reviewed on November 1, 2011)

	 	
PBM does not have the Certified Enrollee file and an enrollee request the dispatch of a prescription by a participant physician or dentist of Mi Salud before or after the date of the MA-10 certification.

	 	
Enrollee

	
Participant Pharmacy

	
PBM

	 	
1.    Go to the pharmacy in their region.

2.    Show to the pharmacy the MA-10 (date in the certification must be after July  1, 2011), the welcome letter and an identification.

3.    Pay the applicable copay:

       a.    Less than 21 do not pay, it’s $0.

       b.    Pregnant women do not pay, it’s $0.

       c.    Adults pay $1/generic and $3/brand.

	
1.    Request the enrollee his MA-10, the welcome letter and the identification.

2.    Ask if the enrollee is a Platino Plan insured.  This protocol does not apply in this case.

3.    Verify if the enrollee is active in the eligibility file of the PBM.

4.    Contact the PBM to activate the enrollee in its information systems.

5.    Process the prescription and dispatch the drugs for physical, mental or dental health, as indicated by the PBM.

6.    Charge the required copay for this special event.

7.    Submit a claim for the dispatched drug, as per the PBM’s instructions.

	
1.    Activate the enrollee in its information system for 10 days, as the enrollee does not have the Mi Salud Plan card.  The enrollee must receive the card in that period.

2.    Authorize the dispatch of the covered prescription, as established by the PDL of Emergency Room in case of physical health, in the Dental PDL for the cases of dental or in the PDL of mental health, as applicable.

3.    Provide instruction to process the prescription and submit the claim of the dispatched drugs.

	 	
Rules for when the PBM does not have the Certified Enrollee’s file:

A.    Non-Participant Pharmacies:  Pharmacy services will not be covered before or after receiving the MA-10 only if authorized by the plan.

B.    Non-Participant physician and dentist: Prescriptions of non-participant physician or dentist before or after the MA-10: (1) Physical Health: The rules regarding the Emergency Room PDL will be applicable, which authorize the dispatch up to 5 days. (2) Mental Health: Will follow the rules regarding drug dispatch. (3) Dental Health: Will follow the rules regarding drug dispatch.

 

  

  

  

 

	 	
Table 2

	 
	 	
(Effective from July 1, 2011 and reviewed on November 1, 2011)

	 
	 	
PBM receive from ASES the Certified Enrollee file and an enrollee request the dispatch of a prescription by a participant physician or dentist of Mi Salud before or after the date of the MA-10 certification.

	 
	 	
Enrollee

	
Participant Pharmacy

	 	
PBM

	 
	 	
1.    Go to the pharmacy in their region.

2.    Show to the pharmacy the MA-10 (date in the certification must be after July 1, 2011), the welcome letter and an identification.

3.    Pay the applicable copay:

a.    Less than 21 with 100, 110, 230, 300, 310, 320 or 330 coverage do not pay, it’s $0.00.

b.    Pregnant women with 100 and 110 coverage pay $0.00.

c.    Adults with coverage:

●    100, 110 and 300 pay $1/generic and $3/brand.

●    310 pay $2/generic and $4/brand.

●    320 pay $3/generic and $5/brand.

●    330 pay $5/generic and $7/brand.

	
1.    Request the enrollee his MA-10, the welcome letter and the identification.

2.    Ask if the enrollee is in a Platino Plan because this process does not apply in this case.

3.    Verify if the enrollee is active in the eligibility file of the PBM.

4.   Contact the PBM to request instructions on how to process the prescription and dispatch the drugs.

5.    Process the prescription and dispatch the drugs for physical, mental or dental health, as indicated by the PBM.

6.    Charge the required copay as indicated in the Copay Table.

7.    Submit a claim for the dispatched drug, as per the PBM’s instructions.

	 	
1.    Activate the enrollee in its information system for 10 days, as the enrollee does not have the Mi Salud Plan card.  The enrollee must receive the card in that period.

2.    Authorize the dispatch of the covered prescription, as established by the norms for physical, mental, or dental health.

3.    Provide instruction to process the prescription and submit the claim of the dispatched drugs.

	 
	 	
Rule for when the PBM receives the Certified Enrollee’s file from ASES:

A.     Non-Participant Pharmacies:  Pharmacy services will not be covered before or after receiving the MA-10 only if authorized by the plan.

B.      Non-Participant physician and dentist: Prescriptions of non-participant physician or dentist before or after the MA-10: (1) Physical Health: The rules regarding the Emergency Room PDL will be applicable, which authorize the dispatch up to 5 days. (2) Mental Health: Will follow the rules regarding drug dispatch. (3) Dental Health: Will follow the rules regarding drug dispatch.

	 

 

  

  

  

 

Ss

	 	
Table 2

	 
	 	
(Effective from July 1, 2011 and reviewed on November 1, 2011)

	 
	 	
PBM receive from Insurer the Certified Enrollee file and an enrollee request the dispatch of a prescription by a participant physician or dentist of Mi Salud before or after the date of the MA-10 certification.

	 
	 	
Enrollee

	
Participant Pharmacy

	 	
PBM

	 
	 	
1.    Go to the pharmacy in their region.

2.    Show the pharmacy identification card for Mi Salud plan.

3.    Obtain the counter-sign of the PCP if the physician is not of the preferred network.

4.     Pay the applicable copay, as indicated in the Copay Table:

a.     Less than 21 with 100, 110, 230, 300, 310, 320 or 330 coverage do not pay, it’s $0.00.

b.    Pregnant women with 100 and 110 coverage do not pay, it’s $0.00.

c.    Adults with coverage:

●     100, 110 and 300 pay $1/generic and $3/brand.

●     310 pay $2/generic and $4/brand.

●     320 pay $3/generic and $5/brand.

●     330 pay $5/generic and $7/brand.

	
1.    Request the enrollee the identification card of Mi Salud.

2.    Ask if the enrollee is in a Platino Plan because this process does not apply in this case.

3.    Verify if the enrollee is active in the eligibility file of the PBM.

4.    Request the counter-sign if the physician is not part of the preferred network.

5.    Contact the PBM to request instructions on how to process the prescription.

6.    Process the prescription and dispatch the drugs as indicated in the applicable PDL: Physical, Dental or Mental.

7.    Charge the copay as indicated in the Copay Table.

8.    Submit a claim for the dispatched drug, as per the PBM’s instructions.

	 	
1.    Activate the enrollee in its information and include the information sent by the Insurer with the data related to Medical Group, primary physician (PCP) and preferred network.  The enrollee must have the Mi Salud card.

2.    Authorize the dispatch of the covered prescription

3.    Use the norms established in the PDL for physical, mental, or dental health.

4.    Authorize the dispatch of the drugs as provided by the applicable PDL.

5.    Provide instruction to process the prescription and submit the claim of the dispatched drugs.

	 
	 	
Rule for when the PBM receives the Certified Enrollee’s file from ASES:

A.     Non-Participant Pharmacies:  Pharmacy services will not be covered before or after receiving the MA-10 only if authorized by the plan.

B.     Non-Participant physician and dentist: Prescriptions of non-participant physician or dentist before or after the MA-10: (1) Physical Health: Will follow the rules regarding drug dispatch. (2) Mental Health: Will follow the rules regarding drug dispatch. (3) Dental Health: Will follow the rules regarding drug dispatch.

	 

 

  

  

  

 

Attachment 20

 

TO ALL OUR SUPPLIERS

 

The Puerto Rico Heath Insurance Administration hereby notifies all our suppliers and contracted services that starting on May 1, 2013, payments will be made by way of electronic payment.

 

To this effect, you must complete and return by postal mail with the next invoice, the enclosed Authorization for Electronic Payment Form, duly completed in all its parts, along with a cancelled check to:

 

PR HEALTH INSURANCE ADMINISTRATION

FINANCE DEPARTMENT

ATTENTION: MR. LUCAS DELGADO

PO BOX 195661

SAN JUAN, PUERTO RICO 00919-5661

 

We have also enclosed the payment format that applies solely to contracted services. It is essential for the payment of your subsequent accounts-payable invoices for services rendered during the month of April 2013.

 

Sincerely,

 

(signed)

Lucas Delgado-Martínez, CPA

Finance Director

 

 

 

 

 

 

  

  

  

 

TO ALL OUR CONTRACTED SERVICES

 

With the purpose of streamlining the pre-intervention process of your service invoices, we request that starting on April 1, your next invoice includes or is accompanied by a short summary of your contract’s total amount, submitted invoices and the remaining balance in your contract. We suggest the following format:

 

	
Initial balance (contract)

	 	 	 	 
	 	Contracted Hours	Hourly Rate	Total	 
	 	##_______	$_______	$_______	 
	 	 	 	 	 
	Invoices Paid	##_______	$_______	$_______	 
	 	 	 	 	 
	Current Invoice	##_______	$_______	$_______	 
	 	 	 	 	 
	
Remaining balance 

in contract

	##_______	$_______	$_______	 

 

  

  

  

 

TO ALL OUR CONTRACTED SERVICES

 

With the purpose of streamlining the pre-intervention process of your service invoices, we request that starting on July 1, this is included as a requirement in every contract and PO. Invoices must be accompanied by a short summary of your contract’s total amount, submitted invoices and the remaining balance in your contract.

 

We suggest the following format:

 

Contract No. _________

 

Balance $ __________

	Detail:       	Invoice xxx	$_________	 
	 	Invoice xxx	$_________	 
	 	Invoice xxx	$_________	 
	 	Current Invoice	$_________	 
	 	 	 
	Balance as of the date of this invoice	$_________	 

 

  

  

  

ATTACHMENT 21

 

TEMPLATE PROVIDER NETWORK LIST – MENTAL HEALT

 

Provider Network List

Primary Provider

 

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	  
	
Region

	
Last Name

	
Last

Name 2

	
First

Name

	
Middle

	
Full Name

	
NPI

	
Provider #

	
License #

	
EIN/ SSN

	
Specialty Name

	
Specialty Code

	
Effective contract date

	
Office Address Line 1

	
Office Address Line 2

	
Municipality

	
Zip Code

	
Office Telephone

	
Office Fax

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	
Buprenorphine

	
Provider

Affiliated Group

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Hospital

 

	
Region

	
Hospital Name

	
Contact Person

	
NPI

	
Institution  #

	
CMS

Certification #

	
Last TIN

	
Contract Date

	
Physical

Address

Line 1

	
Physical

Address

Line 2

	
Municipality

	
Zip Code

	
Main Telephone

	
Main Fax

	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	     	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Detox Center

 

	
Region

	
Hospital Name

	
Contact Person

	
NPI

	
Institution  #

	
CMS

Certification #

	
Last TIN

	
Contract Date

	
Physical Address Line 1

	
Physical

Address

Line 2

	
Municipality

	
Zip Code

	
Main Fax

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Stabilization Unit

 

	
Region

	
Hospital Name

	
Contact Person

	
NPI

	
Institution  #

	
CMS

Certification #

	
Last TIN

	
Physical Address Line 1

	
Physical

Address 

Line 2

	
Municipality

	
Zip Code

	
Main 

Telephone

	
Main Fax

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Ambulance

 

	
Region

	
Hospital Name

	
Contact Person

	
NPI

	
Institution  #

	
CMS

Certification #

	
Last TIN

	
Contract Date

	
Physical Address

Line 1

	
Physical Address

Line 2

	
Municipality

	
Zip Code

	
Main 

Telephone

	
Main Fax

	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Clinical Laboratory

 

	
Region

	
Last Name

	
Last Name 2

	
First Name

	
Middle Name

	
Facility Name

	
Contact Person

	
 NPI 

	
 Provider 

#

	
 License  #

	
 EIN/   SSN 

	
Contract Name

	
Specialty Name

	
Specialty Code

	
Office Address Line 1

	
Office Address Line 2

	
Municipality

	
Zip Code

	
Office Telephone

	
Office Fax

	
Sunday

	
 Monday 

	
 Tuesday 

	
 Wednesday 

	
 Thursday 

	
 Friday 

	
 Saturday 

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Groups

 

	
Region

	
PMG

	
PMG #

	
Last

Name 1

	
Last

Name 2

	
First Name

	
Middle Name

	
Entity Name

	
NPI

	
License Number

	
EIN/ SSN

	
Specialty Name

	
Lives assigned

	
Effective contract Date

	
Office Address

Line 1

	
Office Address

Line 2

	
Municipality

	
Zip Code

	
Office

Telephone

	
Office Fax

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Template Provider Network List – Physical Health

 

Provider Network List

Primary Provider

 

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	  
	
Region

	
Ipa Full Name

	
Ipa Number Id

	
NPI

	
First Name

	
Second Name

	
Directory Full name

	
Legacy Id

	
License #

	
Federal Id

	
Specialty Description

	
Specialty Code

	
Lives Assigned

	
Effective

contract 

date

	
Physical

address 1

	
Physical

address 2

	
Physical

city

	
Phy

zip

	
Phone

	
Faxphone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	
Buprenorphine

	
Provider

Affiliated Group

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

X-Rays

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG

	
PMG #

	
Last

name 1

	
Last

name 2

	
First  name

	
Middle name

	
Full name

	
NPI

	
# Lic

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr 1

	
Phy addr 2

	
Phy city

	
Phy zip

	
Phone

	
Fax phone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Hospital

 

	
Region

	
PMG

	
Hospital Name

	
NPI Number

	
Institution  #

	
CCN

	
EIN

	
Contract Date

	
Physical Address1

	
Physical Address 2

	
Municipality

	
Zip Code

	
Main Telephone

	
Main Fax

	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Laboratory

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG #

	
PMG Name

	
Full Name

	
NPI

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr 1

	
Phy addr 2

	
Phy city

	
Phy zip-Code

	
Phone

	
Fax phone

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Specialty

 

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG

#

	
PMG Name

	
Last

name 1

	
Last

name 2

	
First name

	
Middle name

	
Full Name

	
NPI

	
Duplicates

	
# Lic

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr 1

	
Phy addr 2

	
Phy city

	
Phy zip

	
Phone

	
Fax phone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Other Health Care Professional

	  	  	  	  	  	  	  	  	  	  	  	  	  	
Examples

	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG

#

	
PMG Name

	
Last

name 1

	
Last

name 2

	
First name

	
Middle

name

	
Full name

	
NPI

	
# Lic

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr 1

	
Phy addr 2

	
Phy city

	
Phy zip

	
Phone

	
Fax phone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	
AUDIOLOGY

	
64

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	
NUTRICIONIST

	
71

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	
OCCUPATIONAL THERAPY

	
67

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	
PHYSICAL THERAPY

	
65

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	
SPEECH PATHOLOGY

	
ST

	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Specialized Services Providers

	
Region

	
PMG #

	
PMG Name

	
NPI

	
Full name

	
Specialty Conversion

	
Phy city

	
Phy addr 1

	
Phy addr 2

	
Phy zip

	
Phone

	
Fax phone

	  	  	  	  	  	
AMBULANCE

	  	  	  	  	  	  
	  	  	  	  	  	
AMBULANCE-CRITICAL CARE

	  	  	  	  	  	  
	  	  	  	  	  	
AUDIOLOGY

	  	  	  	  	  	  
	  	  	  	  	  	
BLOOD BANK

	  	  	  	  	  	  
	  	  	  	  	  	
DIALISYS CENTER

	  	  	  	  	  	  
	  	  	  	  	  	
DURABLE MEDICAL EQUIPMENT

	  	  	  	  	  	  
	  	  	  	  	  	
HOME INFUSION

	  	  	  	  	  	  
	  	  	  	  	  	
PROSTHESIS SUPPLIER

	  	  	  	  	  	  
	  	  	  	  	  	
SPECIALTY PHARMACY

	  	  	  	  	  	  
	  	  	  	  	  	
VACCINATION CLINIC

	  	  	  	  	  	  
	  	  	  	  	  	
WOUND CARE

	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Urgent Care and Emergency Centers-Facility

	
Region

	
PMG #

	
PMG Name

	
NPI

	
Full name

	
Specialty Conversion

	
Phy city

	
Phy addr 1

	
Phy addr 2

	
Phy zip

	
Phone

	
Fax phone

	  	  	  	  	  	
AMBULANCE

	  	  	  	  	  	  
	  	  	  	  	  	
AMBULANCE-CRITICAL CARE

	  	  	  	  	  	  
	  	  	  	  	  	
AUDIOLOGY

	  	  	  	  	  	  
	  	  	  	  	  	
BLOOD BANK

	  	  	  	  	  	  
	  	  	  	  	  	
DIALISYS CENTER

	  	  	  	  	  	  
	  	  	  	  	  	
DURABLE MEDICAL EQUIPMENT

	  	  	  	  	  	  
	  	  	  	  	  	
HOME INFUSION

	  	  	  	  	  	  
	  	  	  	  	  	
PROSTHESIS SUPPLIER

	  	  	  	  	  	  
	  	  	  	  	  	
SPECIALTY PHARMACY

	  	  	  	  	  	  
	  	  	  	  	  	
VACCINATION CLINIC

	  	  	  	  	  	  
	  	  	  	  	  	
WOUND CARE

	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Dentist

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG

#

	
PMG Name

	
Last

name 1

	
Last name 2

	
First name

	
Middle name

	
Full name

	
NPI

	
# Lic

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr

1

	
Phy addr

2

	
Phy city

	
Phy zip

	
Phone

	
Fax phone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Provider Network List

Any other Providers

 

	  	  	  	  	  	  	  	  	  	  	  	  	  	
Examples

	  	  	  	  	  	  	  	
Hours

	
Region

	
PMG

#

	
PMG Name

	
Last

name 1

	
Last

name 2

	
First name

	
Middle name

	
Full name

	
NPI

	
# Lic

	
Legacy

	
Fed Id

	
Contract Date

	
Specialty Conversion

	
Specialty Code

	
Phy addr 1

	
Phy addr 2

	
Phy city

	
Phy zip

	
Phone

	
Fax phone

	
Sunday

	
Monday

	
Tuesday

	
Wednesday

	
Thursday

	
Friday

	
Saturday

	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  
	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  	  

 

  

  

  

 

Attachment 22

 

[to come from ASES]

 

  

  

  

 

Attachment 23

 

	  	
Fee Schedule locator by type of Provider

	
Provider Type

	
Provider File

	
SES WEB

	
Portal

	
Clinical Laboratory

	  	  	
X

	
Clinical Laboratory (Preferred Network)

	  	  	
X

	
Dental

	  	  	
X

	
Blood Bank

	
X

	  	  
	
Physician

	  	
X

	
X

	
Hospital

	
X

	  	  
	
Emergency Room (Free Standing)

	
X

	  	  
	
Ambulatory Surgery (Free Standing)

	
X

	  	  
	
Wound Care

	
X

	  	  
	
Home Infusion (High Cost Drugs)

	
X

	  	  
	
Specialty Pharmacy

	
X

	  	  
	
DME

	
X

	  	  
	
Ambulance

	
X

	  	  
	
Non Emergency Tranportation

	
X

	  	  
	
Vaccination Clinic

	
X

	  	  
	
Urgent Care Center

	
X

	  	  
	
Dialysis Center

	
X

	  	  
	
Allied Professional*

	  	  	
X

	
Prosthesis Supplier

	
X

	  	  
	
PMG

	
X

	  	  

 

X Differentiated fees by specialty are published on SES Web, otherwise fees are posted on Triple-S portal.

 

*Allied fees are posted on Triple-S portal under Physician non-surgical link.

 

  

  

  

 

Attachment 24

 

[to come from ASES]

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00220-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00220-of-00352.parquet"}]]