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10-K - FORM 10-K - IASIS Healthcare LLCd275632d10k.htm
EX-31.2 - EX-31.2 - IASIS Healthcare LLCd275632dex312.htm
EX-31.1 - EX-31.1 - IASIS Healthcare LLCd275632dex311.htm
EX-21 - EX-21 - IASIS Healthcare LLCd275632dex21.htm
EX-10.28 - EX-10.28 - IASIS Healthcare LLCd275632dex1028.htm
EX-10.26 - EX-10.26 - IASIS Healthcare LLCd275632dex1026.htm
EX-10.24 - EX-10.24 - IASIS Healthcare LLCd275632dex1024.htm
EX-10.21 - EX-10.21 - IASIS Healthcare LLCd275632dex1021.htm
EX-10.20 - EX-10.20 - IASIS Healthcare LLCd275632dex1020.htm
EX-10.19 - EX-10.19 - IASIS Healthcare LLCd275632dex1019.htm
EX-10.18 - EX-10.18 - IASIS Healthcare LLCd275632dex1018.htm
EX-10.17 - EX-10.17 - IASIS Healthcare LLCd275632dex1017.htm
EX-10.13 - EX-10.13 - IASIS Healthcare LLCd275632dex1013.htm
EX-10.12 - EX-10.12 - IASIS Healthcare LLCd275632dex1012.htm

Exhibit 10.14

 

LOGO   

 

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE

 

SECTION A: CONTRACT AMENDMENT

 

1.      AMENDMENT #      

  

2.      CONTRACT #:      

  

3.      EFFECTIVE DATE OF AMENDMENT:

  

4.      PROGRAM

14    YH14-0001-07    October 1, 2016    DHCM - ACUTE

 

5. CONTRACTOR NAME AND ADDRESS:

Health Choice Arizona

410 N. 44th Street, Suite 900

Phoenix, AZ 85008

 

5. PURPOSE: To extend the Contract for the period October 1, 2016 through September 30, 2017 and to amend Section B, Capitation Rates and Contractor Specific Requirements, Section C, Definitions, Section D, Acute Care Program Requirements, Section E, Contract Terms and Conditions, and Section F, Attachments.

 

6. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:

 

    Section B, Capitation Rates and Contractor Specific Requirements

 

    Section C, Definitions

 

    Section D, Acute Care Program Requirements

 

    Section E, Contract Terms and Conditions

 

    Section F, Attachments

Therefore, this Contract is hereby REMOVED IN ITS ENTIRETY, including but not limited to all terms, conditions, requirements, and pricing and is amended, restated and REPLACED with the documents attached hereto as of the Effective Date of this Amendment.

Refer to the individual Contract sections for specific changes.

 

7. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

 

9.     SIGNATURE OF AUTHORIZED REPRESENTATIVE:   10. SIGNATURE OF AHCCCS CONTRACTING OFFICER:
LOGO   LOGO
TYPED NAME:  

 

MIKE UCHRIN

  TYPED NAME:  

 

MEGGAN HARLEY

TITLE:  

 

CHIEF EXECUTIVE OFFICER

  TITLE:  

 

ACTING CHIEF PROCUREMENT OFFICER

DATE:  

 

9/1/16

  DATE:  

 

8/8/2016


   Contract No. YH14-0001

 

 

 

TABLE OF CONTENTS

 

SECTION A: CONTRACT AMENDMENT

     1   

SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS

     5   

SECTION C: DEFINITIONS

     6   

    PART 1. DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS

     6   

    PART 2. DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS

     21   

SECTION D: ACUTE CARE PROGRAM REQUIREMENTS

     29   

    1.

  PURPOSE, APPLICABILITY, AND INTRODUCTION      29   

    2.

  ELIGIBILITY CATEGORIES      30   

    3.

  ENROLLMENT AND DISENROLLMENT      31   

    4.

  ANNUAL AND OPEN ENROLLMENT CHOICE      34   

    5.

  RESERVED      34   

    6.

  AUTO-ASSIGNMENT ALGORITHM      34   

    7.

  AHCCCS MEMBER IDENTIFICATION CARDS      35   

    8.

  ACCOMODATING AHCCCS MEMBERS      35   

    9.

  TRANSITION ACTIVITIES      36   

    10.

  SCOPE OF SERVICES      38   

    11.

  SPECIAL HEALTH CARE NEEDS      49   

    12.

  BEHAVIORAL HEALTH SERVICES      50   

    13.

  AHCCCS GUIDELINES, POLICIES AND MANUALS      56   

    14.

  MEDICAID SCHOOL BASED CLAIMING      56   

    15.

  PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM      56   

    16.

  STAFF REQUIREMENTS AND SUPPORT SERVICES      57   

    17.

  WRITTEN POLICIES AND PROCEDURES      62   

    18.

  MEMBER INFORMATION      63   

    19.

  SURVEYS      65   

    20.

  CULTURAL COMPETENCY      65   

    21.

  MEDICAL RECORDS      65   

    22.

  ADVANCE DIRECTIVES      66   

    23.

  QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT      67   

    24.

  MEDICAL MANAGEMENT      75   

    25.

  TELEPHONE PERFORMANCE STANDARDS      79   

    26.

  GRIEVANCE AND APPEAL SYSTEM      79   

    27.

  NETWORK DEVELOPMENT      80   

    28.

  PROVIDER AFFILIATION TRANSMISSION      82   

    29.

  NETWORK MANAGEMENT      82   

    30.

  PRIMARY CARE PROVIDER STANDARDS      83   

    31.

  MATERNITY CARE PROVIDER STANDARDS      84   

    32.

  REFERRAL MANAGEMENT PROCEDURES AND STANDARDS      85   

    33.

  APPOINTMENT STANDARDS      85   

    34.

  FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS      87   

    35.

  PROVIDER MANUAL      88   

    36.

  PROVIDER REGISTRATION      88   

    37.

  SUBCONTRACTS      88   

    38.

  CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM      90   

    39.

  SPECIALTY CONTRACTS      94   

    40.

  HOSPITAL SUBCONTRACTING AND REIMBURSEMENT      95   

    41.

  RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT      95   

    42.

  INCENTIVES/PAY FOR PERFORMANCE      96   

    43.

  MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN      96   

 

  2   Acute Care Contract
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   Contract No. YH14-0001

 

 

 

    44.

  MATERIAL CHANGE TO BUSINESS OPERATIONS      97   

    45.

  MINIMUM CAPITALIZATION      97   

    46.

  PERFORMANCE BOND OR BOND SUBSTITUTE      97   

    47.

  AMOUNT OF PERFORMANCE BOND      98   

    48.

  ACCUMULATED FUND DEFICIT      98   

    49.

  ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS      98   

    50.

  FINANCIAL VIABILITY STANDARDS      98   

    51.

  SEPARATE INCORPORATION      100   

    52.

  MERGER, ACQUISITION, REORGANIZATION, JOINT VENTURE AND CHANGE IN OWNERSHIP      100   

    53.

  COMPENSATION      100   

    54.

  PAYMENTS TO CONTRACTORS      103   

    55.

  CAPITATION ADJUSTMENTS      104   

    56.

  MEMBER BILLING AND LIABILITY FOR PAYMENT      105   

    57.

  REINSURANCE      105   

    58.

  COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY      109   

    59.

  COPAYMENTS      112   

    60.

  MEDICARE SERVICES AND COST SHARING      112   

    61.

  MARKETING      113   

    62.

  CORPORATE COMPLIANCE      113   

    63.

  RECORDS RETENTION      117   

    64.

  SYSTEMS AND DATA EXCHANGE REQUIREMENTS      118   

    65.

  ENCOUNTER DATA REPORTING      120   

    66.

  ENROLLMENT AND CAPITATION TRANSACTION UPDATES      122   

    67.

  PERIODIC REPORTING REQUIREMENTS      123   

    68.

  REQUESTS FOR INFORMATION      123   

    69.

  DISSEMINATION OF INFORMATION      123   

    70.

  OPERATIONAL AND FINANCIAL READINESS REVIEWS      124   

    71.

  MONITORING AND OPERATIONAL REVIEWS      124   

    72.

  SANCTIONS      125   

    73.

  BUSINESS CONTINUITY AND RECOVERY PLAN      126   

    74.

  MEDICARE REQUIREMENTS      127   

    75.

  PENDING ISSUES      128   

    76.

  VALUE-BASED PURCHASING      129   

SECTION E: CONTRACT TERMS AND CONDITIONS

     132   

    1.

  ADVERTISING AND PROMOTION OF CONTRACT      132   

    2.

  APPLICABLE LAW      132   

    3.

  ARBITRATION      132   

    4.

  ASSIGNMENT AND DELEGATION      132   

    5.

  ASSIGNMENT OF CONTRACT AND BANKRUPTCY      132   

    6.

  AUDITS AND INSPECTIONS      132   

    7.

  AUTHORITY      132   

    8.

  CHANGES      132   

    9.

  CHOICE OF FORUM      133   

    10.

  COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS      133   

    11.

  CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION      133   

    12.

  CONFLICT OF INTEREST      133   

    13.

  CONTINUATION OF PERFORMANCE THROUGH TERMINATION      134   

    14.

  CONTRACT      134   

    15.

  CONTRACT INTERPRETATION AND AMENDMENT      134   

    16.

  COOPERATION WITH OTHER CONTRACTORS      134   

    17.

  COVENANT AGAINST CONTINGENT FEES      134   

    18.

  DATA CERTIFICATION      134   

    19.

  DISPUTES      135   

    20.

  E-VERIFY REQUIREMENTS      135   

 

  3   Acute Care Contract
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   Contract No. YH14-0001

 

 

 

    21.

  EFFECTIVE DATE      135   

    22.

  EMPLOYEES OF THE CONTRACTOR      135   

    23.

  FEDERAL IMMIGRATION AND NATIONALITY ACT      135   

    24.

  GRATUITIES      135   

    25.

  INCORPORATION BY REFERENCE      135   

    26.

  INDEMNIFICATION      135   

    27.

  INDEMNIFICATION - PATENT AND COPYRIGHT      136   

    28.

  INSURANCE      136   

    ATTACHMENT E-1

     137   

    29.

  IRS W9 FORM      141   

    30.

  LIMITATIONS ON BILLING AND COLLECTION PRACTICES      141   

    31.

  LOBBYING      141   

    32.

  NO GUARANTEED QUANTITIES      141   

    33.

  NON-DISCRIMINATION      141   

    34.

  NON-EXCLUSIVE REMEDIES      141   

    35.

  OFF-SHORE PERFORMANCE OF WORK PROHIBITED      141   

    36.

  ORDER OF PRECEDENCE      141   

    37.

  OWNERSHIP OF INFORMATION AND DATA      142   

    38.

  RESERVED      142   

    39.

  RELATIONSHIP OF PARTIES      142   

    40.

  RIGHT OF OFFSET      142   

    41.

  RIGHT TO ASSURANCE      142   

    41.

  RESERVED      142   

    42.

  SEVERABILITY      143   

    43.

  SUSPENSION OR DEBARMENT      143   

    44.

  TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR      143   

    45.

  TERM OF CONTRACT AND OPTION TO RENEW      144   

    46.

  TERMINATION      144   

    47.

  TERMINATION - AVAILABILITY OF FUNDS      145   

    48.

  TERMINATION FOR CONFLICT OF INTEREST      145   

    49.

  TERMINATION FOR CONVENIENCE      145   

    50.

  THIRD PARTY ANTITRUST VIOLATIONS      145   

    51.

  TYPE OF CONTRACT      145   

    52.

  WARRANTY OF SERVICES      145   

SECTION F: ATTACHMENTS

     147   

    ATTACHMENT F1. ENROLLEE GRIEVANCE AND APPEAL SYSTEM STANDARDS

     147   

    ATTACHMENT F2. PROVIDER CLAIM DISPUTE STANDARDS

     153   

    ATTACHMENT F3. CONTRACTOR CHART OF DELIVERABLES

     155   

SECTION G: RESERVED

     183   

SECTION H: RESERVED

     184   

SECTION I: RESERVED

     185   

ENDNOTES

     186   

 

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    10/01/2016


SECTION B:   
CAPITATION RATES AND CONTRACTOR SPECIFIC REQS    Contract No. YH14-0001

 

 

 

SECTION B: CAPITATION RATES AND CONTRACTOR SPECIFIC REQUIREMENTS

The Contractor shall provide services as described in this contract. In consideration for these services, the Contractor will be paid Contractor-specific rates per member per month for the period October 1, 2016 through September 30, 2017unless otherwise modified by contract amendment.

Capitation Rates:

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

CAPITATION RATE SUMMARY - ACUTE RATES

Health Choice Arizona

10/01/16 - 12/31/16

 

Title XIX Rates:

  TANF
<1, M/F
    TANF
1-13, M/F
    TANF
14-44, F
    TANF
14-44, M
    TANF
45+, M/F
    SSI
w/ Med
    SSI
w/o Med
    Delivery
Supplement
    Adults <=
106% of FPL
    Adults >
106% of FPL
 

4      Apache/Coconino/Mohave/Navajo

  $ 416.65      $ 104.98      $ 253.76      $ 161.08      $ 392.31      $ 140.80      $ 973.29      $ 5,770.44      $ 438.27      $ 402.37   

8      Gila/Pinal

  $ 459.60      $ 111.09      $ 249.76      $ 148.49      $ 428.90      $ 168.73      $ 841.27      $ 5,364.20      $ 458.64      $ 396.27   

10    Pima

  $ 429.30      $ 102.93      $ 238.48      $ 138.88      $ 391.92      $ 125.86      $ 807.37      $ 6,092.10      $ 401.10      $ 360.88   

12    Maricopa

  $ 458.55      $ 108.85      $ 241.38      $ 138.29      $ 423.81      $ 133.02      $ 861.76      $ 6,334.59      $ 461.54      $ 400.73   

 

KidsCare Rates:

   KidsCare
<1 M/F
     KidsCare
1-13, M/F
     KidsCare
14-44, F
     KidsCare
14-44, M
 

4      Apache/Coconino/Mohave/Navajo

   $ 416.65       $ 104.98       $ 253.76       $ 161.08   

8      Gila/Pinal

   $ 459.60       $ 111.09       $ 249.76       $ 148.49   

10    Pima

   $ 429.30       $ 102.93       $ 238.48       $ 138.88   

12    Maricopa

   $ 458.55       $ 108.85       $ 241.38       $ 138.29   

 

PPC Rates:

   TANF
<1, M/F
     TANF
1-13, M/F
     TANF
14-44, F
     TANF
14-44, M
     TANF
45+, M/F
     SSI
w/ Med
     SSI
w/o Med
     Adults <=
106% of FPL
     Adults >
106% of FPL
 

4      Apache/Coconino/Mohave/Navajo

   $ 975.23       $ 54.23       $ 222.61       $ 170.71       $ 407.67       $ 61.07       $ 546.04       $ 830.06       $ 395.83   

8      Gila/Pinal

   $ 707.36       $ 55.61       $ 177.22       $ 131.67       $ 321.28       $ 57.23       $ 480.54       $ 706.53       $ 331.89   

10    Pima

   $ 1,092.25       $ 43.74       $ 190.44       $ 126.66       $ 252.87       $ 56.48       $ 480.12       $ 558.55       $ 281.33   

12    Maricopa

   $ 1,022.50       $ 55.11       $ 196.04       $ 145.84       $ 356.78       $ 70.82       $ 616.35       $ 674.59       $ 341.73   

 

Other Rates:

   Option 1
Transplant
     Option 2
Transplant
 

4      Apache/Coconino/Mohave/Navajo

   $ 16.50       $ 16.50   

8      Gila/Pinal

   $ 16.50       $ 16.50   

10    Pima

   $ 16.50       $ 16.50   

12    Maricopa

   $ 16.50       $ 16.50   

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

CAPITATION RATE SUMMARY - ACUTE RATES

Health Choice Arizona

01/01/17 - 09/30/17

 

Title XIX Rates:

  TANF
<1, M/F
    TANF
1-13, M/F
    TANF
14-44, F
    TANF
14-44, M
    TANF
45+, M/F
    SSI
w/ Med
    SSI
w/o Med
    Delivery
Supplement
    Adults <=
106% of FPL
    Adults >
106% of FPL
 

4      Apache/Coconino/Mohave/Navajo

  $ 421.58      $ 105.24      $ 254.29      $ 161.58      $ 392.31      $ 140.79      $ 973.70      $ 5,770.44      $ 438.27      $ 402.37   

8      Gila/Pinal

  $ 464.84      $ 111.26      $ 249.88      $ 149.12      $ 428.90      $ 168.73      $ 841.61      $ 5,364.20      $ 458.64      $ 396.27   

10    Pima

  $ 430.93      $ 103.21      $ 238.67      $ 139.21      $ 391.92      $ 125.89      $ 808.21      $ 6,092.10      $ 401.09      $ 360.88   

12    Maricopa

  $ 462.17      $ 109.32      $ 241.54      $ 139.13      $ 423.82      $ 133.03      $ 864.19      $ 6,334.59      $ 461.54      $ 400.73   

 

KidsCare Rates:

   KidsCare
<1 M/F
     KidsCare
1-13, M/F
     KidsCare
14-44, F
     KidsCare
14-44, M
 

4      Apache/Coconino/Mohave/Navajo

   $ 421.58       $ 105.24       $ 254.29       $ 161.58   

8      Gila/Pinal

   $ 464.84       $ 111.26       $ 249.88       $ 149.12   

10    Pima

   $ 430.93       $ 103.21       $ 238.67       $ 139.21   

12    Maricopa

   $ 462.17       $ 109.32       $ 241.54       $ 139.13   

 

PPC Rates:

   TANF
<1, M/F
     TANF
1-13, M/F
     TANF
14-44, F
     TANF
14-44, M
     TANF
45+, M/F
     SSI
w/ Med
     SSI
w/o Med
     Adults <=
106% of FPL
     Adults >
106% of FPL
 

4      Apache/Coconino/Mohave/Navajo

   $ 975.23       $ 54.23       $ 222.61       $ 170.71       $ 407.67       $ 61.07       $ 546.04       $ 830.06       $ 395.83   

8      Gila/Pinal

   $ 707.36       $ 55.61       $ 177.22       $ 131.67       $ 321.28       $ 57.23       $ 480.54       $ 706.53       $ 331.89   

10    Pima

   $ 1,092.25       $ 43.74       $ 190.44       $ 126.66       $ 252.87       $ 56.48       $ 480.12       $ 558.55       $ 281.33   

12    Maricopa

   $ 1,022.50       $ 55.11       $ 196.04       $ 145.84       $ 356.78       $ 70.82       $ 616.35       $ 674.59       $ 341.73   

 

Other Rates:

   Option 1
Transplant
     Option 2
Transplant
 

4      Apache/Coconino/Mohave/Navajo

   $ 16.50       $ 16.50   

8      Gila/Pinal

   $ 16.50       $ 16.50   

10    Pima

   $ 16.50       $ 16.50   

12    Maricopa

   $ 16.50       $ 16.50   

Contractor Specific Requirements:

Geographic Service Areas: The Contractor serves eligible members in the following Geographic Service Areas (GSAs) and counties:

 

GSA

  

County

04    Apache, Coconino, Mohave, Navajo
08    Gila, Pinal
10    Pima (Only)
12    Maricopa

Zip Code Alignment: Zip codes 85542, 85192, and 85550 were moved from the GSA which includes Gila County and assigned to the GSA which includes Graham County. As part of the Greater AZ Integrated RBHA implementation effective October 1, 2015, this move occurred to align tribal members from a single tribe into a single RBHA. This change was implemented for this contract as well in order to keep zip code assignment consistent between AHCCCS lines of business.

High Need/High Cost Program: The Contractor shall collaborate with the Regional Behavioral Health Authority (RBHA) to select members for the High Need/High Cost Program and plan interventions for care coordination in order to promote appropriate utilization of services and improve member outcomes. The Contractor is required to include the number of members indicated below, by RBHA Geographic Service Area, and as further outlined in Section D, Paragraph 24, Medical Management of the contract:

 

RBHA Geographic Service Area

  

# of High Need/High Cost Members

Maricopa    30
*Northern    40
**Southern    30

 

* Northern region includes: Apache, Coconino, Mohave, Navajo, Gila (excluding zip codes 85542, 85192, and 85550), and Yavapai
** Southern region includes: Yuma, La Paz, Santa Cruz, Pima, Cochise, Graham (including zip codes 85542, 85192, 85550), Greenlee, and Pinal

 

  5   Acute Care Contract
    10/01/2016


SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

SECTION C: DEFINITIONS

PART 1. DEFINITIONS PERTAINING TO ALL AHCCCS CONTRACTS

The definitions specified in Part 1 below refer to terms found in all AHCCCS contracts. The definitions specified in Part 2 below refer to terms that exist in one or more contracts but do not appear in all contracts.

 

638 TRIBAL FACILITY    A facility that is owned and/or operated by a Federally recognized American Indian/Alaskan Native Tribe and that is authorized to provide services pursuant to Public Law 93-638, as amended. Also referred to as: tribally owned and/or operated 638 facility, tribally owned and/or operated facility, 638 tribal facility, and tribally-operated 638 health program.
ACUTE CARE CONTRACTOR    A contracted managed care organization (also known as a health plan) that provides acute care physical health services to AHCCCS members in the acute care program who are Title XIX or Title XXI eligible. The Acute Care Contractor is also responsible for providing behavioral health services for its enrolled members who are treated by a Primary Care Provider (PCP) for anxiety, depression, and Attention Deficit Hyperactivity Disorder (ADHD). Acute Care Contractors are also responsible for providing behavioral health services for dual eligible adult members with General Mental Health and/or Substance Abuse (GMH/SA) needs.
ACUTE CARE SERVICES    Medically necessary services that are covered for AHCCCS members and which are provided through contractual agreements with managed Care Contractors or on a Fee-For-Service (FFS) basis through AHCCCS.
ADJUDICATED CLAIM    A claim that has been received and processed by the Contractor which resulted in a payment or denial of payment.
ADMINISTRATIVE SERVICES SUBCONTRACTS    An agreement that delegates any of the requirements of the contract with AHCCCS, including, but not limited to the following:
   a.    Claims processing, including pharmacy claims,
   b.    Credentialing, including those for only primary source verification (i.e. Credential Verification Organization),
   c.    Management Service Agreements,
   d.    Service Level Agreements with any Division or Subsidiary of a corporate parent owner,
   e.    DDD acute care subcontractors.
   Providers are not Administrative Services Subcontractors.
ADULT    A person 18 years of age or older, unless the term is given a different definition by statute, rule, or policies adopted by AHCCCS.
AGENT    Any person who has been delegated the authority to obligate or act on behalf of a provider [42 CFR 455.101].

 

  6   Acute Care Contract
    10/01/2016


SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

AHCCCS CONTRACTOR OPERATIONS MANUAL (ACOM)    The ACOM provides information related to AHCCCS Contractor operations and is available on the AHCCCS website at www.azahcccs.gov.
AHCCCS ELIGIBILITY DETERMINATION    The process of determining, through an application and required verification, whether an applicant meets the criteria for Title XIX/XXI funded services.
AHCCCS MEDICAL POLICY MANUAL (AMPM)    The AMPM provides information regarding covered health care services and is available on the AHCCCS website at www.azahcccs.gov.
AHCCCS MEMBER    See “MEMBER.”
AHCCCS RULES    See “ARIZONA ADMINISTRATIVE CODE.”
AMBULATORY CARE    Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and/or other health care providers.
AMERICAN INDIAN HEALTH PROGRAM (AIHP)    An acute care Fee-For-Service program administered by AHCCCS for eligible American Indians which reimburses for services provided by and through the Indian Health Service (IHS), tribal health programs operated under 638 or any other AHCCCS registered provider. AIHP was formerly known as AHCCCS IHS.
AMERICANS with DISABILITIES ACT (ADA)    The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities transportation, and telecommunications. Refer to the Americans with Disabilities Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C. 5.
APPEAL RESOLUTION    The written determination by the Contractor concerning an appeal.
ARIZONA ADMINISTRATIVE CODE (A.A.C.)    State regulations established pursuant to relevant statutes. Referred to in Contract as “Rules.” AHCCCS Rules are State regulations which have been promulgated by the AHCCCS Administration and published by the Arizona Secretary of State.
ARIZONA DEPARTMENT OF HEALTH SERVICES (ADHS)    The state agency that has the powers and duties set forth in A.R.S. §36- 104 and A.R.S. Title 36, Chapters 5 and 34.
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS)    Arizona’s Medicaid Program, approved by the Centers for Medicare and Medicaid Services as a Section 1115 Waiver Demonstration Program and described in A.R.S. Title 36, Chapter 29.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

ARIZONA LONG TERM CARE SYSTEM (ALTCS)    An AHCCCS program which delivers long-term, acute, behavioral health and case management services as authorized by A.R.S. §36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with developmental disabilities, through contractual agreements and other arrangements.
ARIZONA REVISED STATUTES (A.R.S.)    Laws of the State of Arizona.
BALANCED BUDGET ACT (BBA)    See “MEDICAID MANAGED CARE REGULATIONS.”
BEHAVIORAL HEALTH (BH) BEHAVIORAL HEALTH DISORDER    A mental health and substance use/abuse collectively. Any behavioral, mental health, and/or substance use diagnoses found in the most current version of the Diagnostic and Statistical Manual of International Classification of Disorders (DSM) excluding those diagnoses such as mental retardation, learning disorders and dementia, which are not typically responsive to mental health or substance abuse treatment.
BEHAVIORAL HEALTH PROFESSIONAL    As specified in A.A.C. R9-10-101, an individual licensed under A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual to:
   a.    Independently engage in the practice of behavioral health as defined in A.R.S. §32-3251; or
   b.    Except for a licensed substance abuse technician, engage in the practice of behavioral health as defined in A.R.S. §32-3251 under direct supervision as defined in A.A.C. R4-6-101.;
   c.    A psychiatrist as defined in A.R.S. §36-501;
   d.    A psychologist as defined in A.R.S. §32-2061;
   e.    A physician;
   f.    A registered nurse practitioner licensed as an adult psychiatric and mental health nurse; or
   g.    A behavior analyst as defined in A.R.S. §32-2091; or
   h.    A registered nurse.
BEHAVIORAL HEALTH SERVICES    Physician or practitioner services, nursing services, health-related services, or ancillary services provided to an individual to address the individual’s behavioral health issue. See also “COVERED SERVICES.”
BOARD CERTIFIED    An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification and when applicable, requirements for maintenance of certification.
BORDER COMMUNITIES    Cities, towns or municipalities located in Arizona and within a designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding neighboring countries, due to service availability or distance.

 

  8   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

CAPITATION    Payment to a Contractor by AHCCCS of a fixed monthly payment per person in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S. §36-2904 and §36-2907.
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)    An organization within the United States Department of Health and Human Services, which administers the Medicare and Medicaid programs and the State Children’s Health Insurance Program.
CHILD    A person under the age of 18, unless the term is given a different definition by statute, rule or policies adopted by AHCCCS.
CHILD AND FAMILY TEAM (CFT)    A defined group of individuals that includes, at a minimum, the child and his or her family, a behavioral health representative, and any individuals important in the child’s life that are identified and invited to participate by the child and family. This may include teachers, extended family members, friends, family support partners, healthcare providers, coaches and community resource providers, representatives from churches, synagogues or mosques, agents from other service systems like (DCS) Department of Child Safety or the Division of Developmental Disabilities (DDD). The size, scope and intensity of involvement of the team members are determined by the objectives established for the child, the needs of the family in providing for the child, and by who is needed to develop an effective service plan, and can therefore expand and contract as necessary to be successful on behalf of the child.
CHILDREN with SPECIAL HEALTH CARE NEEDS (CSHCN)    Children under age 19 who are blind, children with disabilities, and related populations (eligible for SSI under Title XVI). Children eligible under section 1902(e)(3) of the Social Security Act (Katie Beckett); in foster care or other out-of-home placement; receiving foster care or adoption assistance; or receiving services through a family-centered, community-based coordinated care system that receives grant funds under section 501(a)(1)(D) of Title V (CRS).
CLAIM DISPUTE    A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance.
CLEAN CLAIM    A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by A.R.S. §36-2904.
CLIENT INFORMATION SYSTEM (CIS)    The centralized processing system for files from each TRBHA/RBHA to AHCCCS as well as an informational repository for a variety of BH related reporting. The CIS system includes Member Enrollment and Eligibility, Encounter processing data, Demographics and SMI determination processes.
CODE OF FEDERAL REGULATIONS (CFR)    The general and permanent rules published in the Federal Register by the departments and agencies of the Federal Government.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

CONTRACT SERVICES    See “COVERED SERVICES.”
CONTRACTOR    An organization or entity that has a prepaid capitated contract with AHCCCS pursuant to A.R.S. §36-2904, §36-2940, or §36-2944to provide goods and services to members either directly or through subcontracts with providers, in conformance with contractual requirements, AHCCCS Statute and Rules, and Federal law and regulations.
CONVICTED    A judgment of conviction has been entered by a Federal, State or local court, regardless of whether an appeal from that judgment is pending.
COPAYMENT    A monetary amount that the member pays directly to a provider at the time covered services are rendered, as defined in 9 A.A.C. 22, Article 7.
CORRECTIVE ACTION PLAN (CAP)    A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/ tasks to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish CAP goals and objectives, and staff responsible to carry out the CAP within established timelines. CAPs are generally used to improve performance of the Contractor and/or its providers, to enhance Quality Management/Process Improvement activities and the outcomes of the activities, or to resolve a deficiency.
COST AVOIDANCE    The process of identifying and utilizing all confirmed sources of first or third-party benefits before payment is made by the Contractor.
COVERED SERVICES    The health and medical services to be delivered by the Contractor as described in Section D, Program Requirements or the Scope of Work Section.
CREDENTIALING    The process of obtaining, verifying and evaluating information regarding applicable licensure, accreditation, certification, educational and practice requirements to determine whether a provider has the required credentials to deliver specific covered services to members.
DAY    A day means a calendar day unless otherwise specified.
DAY – BUSINESS/WORKING    A business day means a Monday, Tuesday, Wednesday, Thursday, or Friday unless a legal holiday falls on Monday, Tuesday, Wednesday, Thursday, or Friday.
DELEGATED AGREEMENT    A type of subcontract agreement with a qualified organization or person to perform one or more functions required to be performed by the Contractor pursuant to this contract.
DIVISION OF BEHAVIORAL HEALTH SERVICES (DBHS)    The state agency that formerly had the duties set forth by the legislature to provide BH services within Arizona.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

DEPARTMENT OF ECONOMIC SECURITY/DIVISION OF DEVELOPMENTAL DISABILITIES (DES/DDD)    The Division of a State agency, as defined in A.R.S. Title 36, Chapter 5.1, which is responsible for serving eligible Arizona residents with a developmental/intellectual disability. AHCCCS contracts with DES/DDD to serve Medicaid eligible individuals with a developmental/intellectual disability.
DISENROLLMENT    The discontinuance of a member’s eligibility to receive covered services through a Contractor.
DIVISION OF HEALTH CARE MANAGEMENT (DHCM)    The division responsible for Contractor oversight regarding AHCCCS Contractor operations, quality, maternal and child health, behavioral health, medical management, case management, rate setting, encounters, and financial/operational oversight.
DUAL ELIGIBLE    A member who is eligible for both Medicare and Medicaid.
DURABLE MEDICAL EQUIPMENT (DME)    Equipment that provides therapeutic benefits; is designed primarily for a medical purpose; is ordered by a physician/provider; is able to withstand repeated use; and is appropriate for use in the home.
EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT)    A comprehensive child health program of prevention, treatment, correction, and improvement of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources as well as to assist Medicaid recipients in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS members less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in Federal Law 42 U.S.C. 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.
EMERGENCY MEDICAL CONDITION    A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b)serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part [42 CFR 438.114(a)].
EMERGENCY MEDICAL SERVICE    Covered inpatient and outpatient services provided after the sudden onset of an emergency medical condition as defined above. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize the emergency medical condition [42 CFR 438.114(a)].

 

  11   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

ENCOUNTER    A record of a health care-related service rendered by a provider or providers registered with AHCCCS to a member who is enrolled with a Contractor on the date of service.
ENROLLEE    A Medicaid recipient who is currently enrolled with a Contractor [42 CFR 438.10(a)].
ENROLLMENT    The process by which an eligible person becomes a member of a Contractor’s plan.
EQUITY PARTNERS    The sponsoring organizations or parent companies of the managed care organization that share in the returns generated by the organization, both profits and liabilities.
EVIDENCE-BASED PRACTICE    An intervention that is recognized as effective in treating a specific health-related condition based on scientific research; the skill and judgment of care health professionals; and the unique needs, concerns and preferences of the person receiving services.
EXHIBITS    All items attached as part of the solicitation.
FEDERAL FINANCIAL PARTICIPATION (FFP)    FFP refers to the contribution that the Federal government makes to the Title XIX and Title XXI program portions of AHCCCS, as defined in 42 CFR 400.203.
FEE-FOR-SERVICE (FFS)    A method of payment to an AHCCCS registered provider on an amount-per-service basis for services reimbursed directly by AHCCCS for members not enrolled with a managed care Contractor.
FEE-FOR-SERVICE MEMBER    A Title XIX or Title XXI eligible individual who is not enrolled with an AHCCCS Contractor.
FRAUD    An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable State or Federal law, as defined in 42 CFR 455.2.
GENERAL MENTAL HEALTH/SUBSTANCE ABUSE (GMH/SA)    A classification of adult persons age 18 and older who have general behavioral health issues, have not been determined to have a serious mental illness, but are eligible to receive covered behavioral health services.
GEOGRAPHIC SERVICE AREA (GSA)    An area designated by AHCCCS within which a Contractor of record provides, directly or through subcontract, covered health care service to a member enrolled with that Contractor of record, as defined in 9 A.A.C. 22, Article 1.
GRIEVANCE AND APPEAL SYSTEM    A system that includes a process for enrollee grievances, SMI grievances, enrollee appeals, provider claim disputes, and access to the state fair hearing system.

 

  12   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

HEALTH CARE PROFESSIONAL    A physician, podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist, therapist assistant, speech language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), licensed social worker, registered respiratory therapist, licensed marriage and family therapist and licensed professional counselor.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)    The Health Insurance Portability and Accountability Act; also known as the Kennedy-Kassebaum Act, signed August 21, 1996 as amended and as reflected in the implementing regulations at 45 CFR Parts 160, 162, and 164.
HEALTH PLAN    See “CONTRACTOR.”
INCURRED BUT NOT REPORTED LIABILITY (IBNR)    Incurred but not reported liability for services rendered for which claims have not been received.
INDIVIDUAL RECOVERY PLAN (FORMERLY KNOWN AS THE INDIVIDUAL SERVICE PLAN)    See “SERVICE PLAN”
INDIAN HEALTH SERVICES (IHS)    The operating division within the U.S. Department of Health and Human Services, responsible for providing medical and public health services to members of federally recognized Tribes and Alaska Natives as outlined in 25 U.S.C. 1661.
INFORMATION SYSTEMS    The component of the Offeror’s organization which supports the Information Systems, whether the systems themselves are internal to the organization (full spectrum of systems staffing), or externally contracted (internal oversight and support).
INTERGOVERNMENTAL AGREEMENT (IGA)    When authorized by legislative or other governing bodies, two or more public agencies or public procurement units by direct contract or agreement may contract for services or jointly exercise any powers common to the contracting parties and may enter into agreements with one another for joint or cooperative action or may form a separate legal entity, including a nonprofit corporation to contract for or perform some or all of the services specified in the contract or agreement or exercise those powers jointly held by the contracting parties. A.R.S. Title 11, Chapter 7, Article 3 (A.R.S. §11-952.A).
LIABLE PARTY    An individual, entity, or program that is or may be liable to pay all or part of the medical cost of injury, disease or disability of an AHCCCS applicant or member as defined in A.A.C. R9-22-1001.

 

  13   Acute Care Contract
    10/01/2016


SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

LIEN    A legal claim, filed with the County Recorder’s office in which a member resides and in the county an injury was sustained for the purpose of ensuring that AHCCCS receives reimbursement for medical services paid. The lien is attached to any settlement the member may receive as a result of an injury.
MAJOR UPGRADE    Any systems upgrade or changes that may result in a disruption to the following: loading of contracts, providers or members, issuing prior authorizations or the adjudication of claims.
MANAGED CARE    Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality, medical management and the coordination of care.
MANAGEMENT SERVICES AGREEMENT    A type of subcontract with an entity in which the owner of the Contractor delegates all or substantially all management and administrative services necessary for the operation of the Contractor.
MATERIAL CHANGE TO BUSINESS OPERATIONS    Any change in overall operations that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as required in contract including, but not limited to, any change that would impact or is likely to impact more than 5% of total membership and/or provider network in a specific GSA.
MANAGING EMPLOYEE    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 [42 CFR 455.101].
MATERIAL OMISSION    A fact, data or other information excluded from a report, contract, etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, contract, etc.
MEDICAID    A Federal/State program authorized by Title XIX of the Social Security Act, as amended.
MEDICAID MANAGED CARE REGULATIONS    The Federal law mandating, in part, that States ensure the accessibility and delivery of quality health care by their managed care Contractors. These regulations were promulgated pursuant to the Balanced Budget Act (BBA) of 1997.
MEDICARE    A Federal program authorized by Title XVIII of the Social Security Act, as amended.
MEDICAL MANAGEMENT (MM)    An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the continuum of care (from prevention to end of life care).

 

  14   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

MEDICAL RECORDS    A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints, the provider’s physical findings, behavioral health findings, the results of diagnostic tests and procedures, medications and therapeutic procedures, referrals and treatment plans.
MEDICAL SERVICES    Medical care and treatment provided by a Primary Care Provider (PCP), attending physician or dentist or by a nurse or other health related professional and technical personnel at the direction/order of a licensed physician or dentist.
MEDICALLY NECESSARY    As defined in 9 A.A.C. 22 Article 101. Medically necessary means a covered service provided by a physician or other licensed practitioner of the health arts within the scope of practice under State law to prevent disease, disability or other adverse conditions or their progression, or prolong life.
MEDICALLY NECESSARY SERVICES    Those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life.
MEMBER    An eligible person who is enrolled in AHCCCS, as defined in A.R.S. §36-2931, §36-2901, §36-2901.01 and A.R.S. §36-2981.
MEMBER INFORMATION MATERIALS    Any materials given to the Contractor’s membership. This includes, but is not limited to: member handbooks, member newsletters, surveys, on hold messages and health related brochures/reminders and videos, form letter templates, and website content. It also includes the use of other mass communication technology such as e-mail and voice recorded information messages delivered to a member’s phone.
NATIONAL PROVIDER IDENTIFIER (NPI)    A unique identification number for covered health care providers, assigned by the CMS contracted national enumerator.
NON-CONTRACTING PROVIDER    A person or entity that provides services as prescribed in A.R.S. §36- 2901 who does not have a subcontract with an AHCCCS Contractor.
OFFEROR    An organization or other entity that submits a proposal to AHCCCS in response to a Request For Proposal as defined in 9 A.A.C. 22, Article 1.
PARENT    A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction.
PERFORMANCE IMPROVEMENT PROJECT (PIP)    A planned process of data gathering, evaluation and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery. Formerly referred to as Quality Improvement Projects (QIP).

 

  15   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

PERFORMANCE STANDARDS    A set of standardized measures designed to assist AHCCCS in evaluating, comparing and improving the performance of its Contractors.
POSTSTABILIZATION CARE SERVICES    Medically necessary services, related to an emergency medical condition provided after the member’s condition is sufficiently stabilized in order to maintain, improve or resolve the member’s condition so that the member could alternatively be safely discharged or transferred to another location [42 CFR 438.114(a)].
POTENTIAL ENROLLEE    A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR 438.10(a)].
PREPAID MEDICAL MANAGEMENT INFORMATION SYSTEM (PMMIS)    An integrated information infrastructure that supports AHCCCS operations, administrative activities and reporting requirements.
PREMIUM TAX    The premium tax is equal to the tax imposed pursuant to A.R.S. §36- 2905 and §36-2944.01 for all payments made to Contractors for the contract year.
PRIMARY CARE PROVIDER (PCP)    An individual who meets the requirements of A.R.S. §36-2901, and who is responsible for the management of the member’s health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15. The PCP must be an individual, not a group or association of persons, such as a clinic.
PRIMARY PREVENTION    The focus on methods to reduce, control, eliminate and prevent the incidence or onset of physical or mental health disease through the application of interventions before there is any evidence of disease or injury.
PRIOR AUTHORIZATION    Prior authorization is a process used to determine in advance of provision whether or not a prescribed procedure, service, or medication will be covered. The process is intended to act as a safety and cost savings measure.
PRIOR PERIOD    See “PRIOR PERIOD COVERAGE.”

 

  16   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

PRIOR PERIOD COVERAGE (PPC)    The period of time prior to the member’s enrollment, during which a member is eligible for covered services. The timeframe is from the effective date of eligibility (usually the first day of the month of application) until the date the member is enrolled with the Contractor. Refer to 9 A.A.C. 22 Article 1. If a member made eligible via the Hospital Presumptive Eligibility (HPE) program is subsequently determined eligible for AHCCCS via the full application process, prior period coverage for the member will be covered by AHCCCS Fee-For- Service and the member will be enrolled with the Contractor only on a prospective basis.
PRIOR QUARTER COVERAGE    The period of time prior to an individual’s month of application for AHCCCS coverage, during which a member may be eligible for covered services. Prior Quarter Coverage is limited to the three month time period prior to the month of application. An applicant may be eligible during any of the three months prior to application if the applicant:
   1.    Received one or more covered services described in 9 A.A.C. 22, Article 2 and Article 12, and 9 A.A.C. 28, Article 2 during the month; and
   2.    Would have qualified for Medicaid at the time services were received if the person had applied regardless of whether the person is alive when the application is made. Refer to A.A.C. R9-22-303
   AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter.
PROGRAM CONTRACTOR    See “CONTRACTOR”
PROVIDER    Any person or entity that contracts with AHCCCS or a Contractor for the provision of covered services to members according to the provisions A.R.S. §36-2901 or any subcontractor of a provider delivering services pursuant to A.R.S. §36-2901.
PROVIDER GROUP    Two or more health care professionals who practice their profession at a common location (whether or not they share facilities, supporting staff, or equipment).
PRUDENT LAYPERSON (for purposes of determining whether an emergency medical condition exists)    A person without medical training who relies on the experience, knowledge and judgment of a reasonable person to make a decision regarding whether or not the absence of immediate medical attention will result in: 1) placing the health of the individual in serious jeopardy, 2) serious impairment to bodily functions, or 3) serious dysfunction of a bodily part or organ.

 

  17   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

QUALIFIED MEDICARE BENEFICIARY DUAL ELIGIBLE (QMB DUAL)    A person determined eligible under A.A.C. R9-29-101 et seq. for Qualified Medicare Beneficiary (QMB) and eligible for acute care services provided for in A.A.C. R9-22-201 et seq. or ALTCS services provided for in A.A.C. R9-28-201 et seq. A QMB dual person receiving both Medicare and Medicaid services and cost sharing assistance.
REFERRAL    A verbal, written, telephonic, electronic or in-person request for health services.
REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA)    A Managed Care Organization that has a contract with the administration, the primary purpose of which is to coordinate the delivery of comprehensive mental health services to all eligible persons assigned by the administration to the managed care organization. Additionally the Managed Care Organization shall coordinate the delivery of comprehensive physical health services to all eligible persons with a serious mental illness enrolled by the administration to the managed care organization.
REINSURANCE    A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of certain contract service costs incurred for a member beyond a predetermined monetary threshold.
RELATED PARTY    A party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by a Contractor. “Related parties” include, but are not limited to, agents, managing employees, persons with an ownership or controlling interest in the Offeror and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and other entities controlled or managed by any such entities or persons.
REQUEST FOR PROPOSAL (RFP)    A RFP includes all documents, whether attached or incorporated by references that are used by the Administration for soliciting a proposal under 9 A.A.C. 22 Article 6.
ROOM AND BOARD (or ROOM)    The amount paid for food and/or shelter. Medicaid funds can be expended for room and board when a person lives in an institutional setting (e.g. NF, ICF). Medicaid funds cannot be expended for room and board when a member resides in an alternative residential setting (e.g. Assisted Living Home, Behavioral Health Residential Facilities) or an apartment like setting that may provide meals.
SCOPE OF SERVICES    See “COVERED SERVICES.”
SERVICE LEVEL AGREEMENT    A type of subcontract with a corporate owner or any of its Divisions or Subsidiaries that requires specific levels of service for administrative functions or services for the Contractor specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this contract.

 

  18   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

SERVICE PLAN    A complete written description of all covered health services and other informal supports which includes individualized goals, family support services, care coordination activities and strategies to assist the member in achieving an improved quality of life.
SPECIAL HEALTH CARE NEEDS    Serious or chronic physical, developmental and/or behavioral health conditions. Members with special health care needs require medically necessary services of a type or amount beyond that generally required by members.
SPECIALTY PHYSICIAN    A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.
STATE    The State of Arizona.
STATEWIDE    Of sufficient scope and breadth to address the health care service needs of members throughout the State of Arizona.
STATE FISCAL YEAR    The budget year-State fiscal year: July 1 through June 30.
STATE PLAN    The written agreements between the State and CMS, which describes how the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children’s Health Insurance Program.
SUBCONTRACT    An agreement entered into by the Contractor with any of the following: a provider of health care services who agrees to furnish covered services to member; or with any other organization or person who agrees to perform any administrative function or service for the Contractor specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this contract, as defined in 9 A.A.C. 22 Article 1.
SUBCONTRACTOR    1.    A provider of health care who agrees to furnish covered services to members.
   2.    A person, agency or organization with which the Contractor has contracted or delegated some of its management/administrative functions or responsibilities.
   3.    A person, 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 AHCCCS agreement.
SUBSIDIARY    An entity owned or controlled by the Contractor.
SUBSTANCE USE DISORDERS    A range of conditions that vary in severity over time, from problematic, short-term use/abuse of substances to severe and chronic disorders requiring long-term and sustained treatment and recovery management.

 

  19   Acute Care Contract
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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

SUPPLEMENTAL SECURITY INCOME (SSI) AND SSI RELATED GROUPS    Eligible individuals receiving income through Federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or have a disability and have household income levels at or below 100% of the FPL.
THIRD PARTY LIABILITY (TPL)    See “LIABLE PARTY.”
TITLE XIX    Known as Medicaid, Title XIX of the Social Security Act provides for Federal grants to the states for medical assistance programs. Title XIX enables states to furnish medical assistance to those who have insufficient income and resources to meet the costs of necessary medical services, rehabilitation and other services, to help those families and individuals become or remain independent and able to care for themselves. Title XIX members include but are not limited to those eligible under Section 1931 of the Social Security Act, Supplemental Security Income (SSI), SSI-related groups, Medicare cost sharing groups, Breast and Cervical Cancer Treatment Program and Freedom to Work Program. Which include those populations 42 U.S.C. 1396a(a)(10)(A).
TITLE XIX MEMBER    Title XIX members include those eligible under 1931 provisions of the Social Security Act (previously AFDC), Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI) or SSI-related groups, Medicare Cost Sharing groups, Adult Group at or below 106% Federal Poverty Level (Adults </= 106%), Adult Group above 106% Federal Poverty Level (Adults > 106%), Breast and Cervical Cancer Treatment program, Title IV-E Foster Care and Adoption Subsidy, Young Adult Transitional Insurance, and Freedom to Work.
TREATMENT    A procedure or method to cure, improve, or palliate an individual’s medical condition or behavioral health issue. Refer to A.A.C. R9-10-101.
TRIBAL REGIONAL BEHAVIORAL HEALTH AUTHORITY (TRBHA)    A tribal entity that has an intergovernmental agreement with the administration, the primary purpose of which is to coordinate the delivery of comprehensive mental health services to all eligible persons assigned by the administration to the tribal entity. Tribal governments, through an agreement with the State, may operate a Tribal Regional Behavioral Health Authority for the provision of behavioral health services to American Indian members. Refer to A.R.S. §36-3401, §36-3407.
YEAR    See “CONTRACT YEAR.”
[END OF PART 1 DEFINITIONS]   

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

SECTION C: DEFINITIONS

PART 2. DEFINITIONS PERTAINING TO ONE OR MORE AHCCCS CONTRACTS

 

1931 (ALSO REFERRED TO AS TANF RELATED)    Eligible individuals and families under Section 1931 of the Social Security Act, with household income levels at or below 100% of the Federal Poverty Level (FPL). See also “TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF).”
ABUSE (OF MEMBER)    Intentional infliction of physical, emotional or mental harm, caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault as defined by A.R.S. §46-451 and A.R.S. §13-3623.
ABUSE (BY PROVIDER)    Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the AHCCCS 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 AHCCCS program as defined by 42 CFR 455.2.
ACUTE CARE ONLY (ACO)    ACO refers to the enrollment status of a member who is otherwise financially and medically eligible for ALTCS but who either 1) refuses HCBS offered by the case manager; 2) has made an uncompensated transfer that makes him or her ineligible; 3) resides in a setting in which Long Term Care Services cannot be provided; or 4) has equity value in a home that exceeds $552,000. These ALTCS enrolled members are eligible to receive acute medical services but not eligible to receive LTC institutional, alternative residential or HCBS.
ADMINISTRATIVE OFFICE OF THE COURTS (AOC)    The Arizona Constitution authorizes an administrative director and staff to assist the Chief Justice with administrative duties. Under the direction of the Chief Justice, the administrative director and the staff of the Administrative Office of the Courts (AOC) provide the necessary support for the supervision and administration of all State courts.
ADULT GROUP ABOVE 106% FEDERAL POVERTY LEVEL (ADULTS > 106%)    Adults aged 19-64, without Medicare, with income above 106% through 133% of the Federal Poverty Level (FPL).
ADULT GROUP AT OR BELOW 106% FEDERAL POVERTY LEVEL (ADULTS </= 106%)    Adults aged 19-64, without Medicare, with income at or below 106% of the Federal Poverty Level (FPL).
AGENT    Any person who has been delegated the authority to obligate or act on behalf of another person or entity.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

AID FOR FAMILIES WITH DEPENDENT CHILDREN (AFDC)    See “TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF).”
ANNIVERSARY DATE    The anniversary date is 12 months from the date the member enrolled with the Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date the member was given an opportunity to change.
ANNUAL ENROLLMENT CHOICE (AEC)    The opportunity for a person to change Contractors every 12 months.
ARIZONA DEPARTMENT OF CHILD SAFETY (DCS)    The department established pursuant to A.R.S. §8-451 to protect children and to perform the following:
   1.    Investigate reports of abuse and neglect.
   2.    Assess, promote and support the safety of a child in a safe and stable family or other appropriate placement in response to allegations of abuse or neglect.
   3.    Work cooperatively with law enforcement regarding reports that include criminal conduct allegations.
   4.    Without compromising child safety, coordinate services to achieve and maintain permanency on behalf of the child, strengthen the family and provide prevention, intervention and treatment services pursuant to this chapter.
ARIZONA DEPARTMENT OF JUVENILE CORRECTION (ADJC)    The State agency responsible for all juveniles adjudicated as delinquent and committed to its jurisdiction by the county juvenile courts.
BED HOLD    A 24 hour per day unit of service that is authorized by an ALTCS member’s case manager or the behavioral health case manager or a subcontractor for an acute care member, which may be billed despite the member’s absence from the facility for the purposes of short term hospitalization leave and therapeutic leave. Refer to the Arizona Medicaid State Plan, 42 C.F.R. §§447.40 and 483.12, and 9 A.A.C. 28 for more information on the bed hold service and AMPM Chapter 100.
BEHAVIORAL HEALTH PARAPROFESSIONAL    As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for a health care institution according to the health care institution’s policies and procedures that:
   a.    If the behavioral health services were provided in a setting other than a licensed health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33; and
   b.    Are provided under supervision by a behavioral health professional.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

BEHAVIORAL HEALTH RESIDENTIAL FACILITY    A health care institution that provides continuous treatment to an individual experiencing a behavioral health issue that causes the individual to:
   a.    Have a limited or reduced ability to meet the individual’s basic physical needs;
   b.    Suffer harm that significantly impairs the individual’s judgment, reason, behavior, or capacity to recognize reality;
   c.    Be a danger to self;
   d.    Be a danger to others;
   e.    Be persistently or acutely disabled as defined in A.R.S. § 36-501; or
   f.    Be gravely disabled.
BEHAVIORAL HEALTH TECHNICIAN    As specified in A.A.C. R9-10-101, an individual who is not a behavioral health professional who provides behavioral health services at or for a health care institution according to the health care institution’s policies and procedures that:
   a.    If the behavioral health services were provided in a setting other than a licensed health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33; and
   b.    Are provided with clinical oversight by a behavioral health professional.
BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)    Eligible individuals under the Title XIX expansion program for women with income up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.
CARE MANAGEMENT PROGRAM (CMP)    Activities to identify the top tier of high need/high cost Title XIX members receiving services within an AHCCCS contracted health plan; including the design of clinical interventions or alternative treatments to reduce risk, cost, and help members achieve better health care outcomes. Care management is an administrative function performed by the health plan. Distinct from case management, Care Managers should not perform the day-to-day duties of service delivery.
CARE MANAGEMENT    A group of activities performed by the Contractor to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost, and help achieve better health care outcomes. Distinct from case management, care management does not include the day-to-day duties of service delivery.
CASE MANAGEMENT    A collaborative process which assess, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.
CASH MANAGEMENT IMPROVEMENT ACT (CMIA)    Cash Management Improvement Act of 1990 [31 CFR Part 205]. Provides guidelines for the drawdown and transfer of Federal funds.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

CHILDREN’S REHABILITATIVE SERVICES (CRS)   

A program that provides medical treatment, rehabilitation, and related support services to Title XIX and Title XXI members who have completed the CRS application and have met the eligibility criteria to receive CRS-related services as specified in 9 A.A.C. 22.

CLIENT ASSESSMENT AND TRACKING SYSTEM (CATS)    A component of AHCCCS’ data management information system that supports ALTCS and that is designed to provide key information to, and receive key information from ALTCS Contractors.
COMPREHENSIVE MEDICAL AND DENTAL PROGRAM (CMDP)    A Contractor that is responsible for the provision of covered, medically necessary AHCCCS services for foster children in Arizona. Refer to A.R.S. §8-512.
COMPETITIVE BID PROCESS    A state procurement system used to select Contractors to provide covered services on a geographic basis.
COUNTY OF FISCAL RESPONSIBILITY    The county of fiscal responsibility is the Arizona county that is responsible for paying the state’s funding match for the member’s ALTCS Service Package. The county of physical presence (the county in which the member physically resides) and the county of fiscal responsibility may be the same county or different counties.
CRS-ELIGIBLE    An individual AHCCCS member who has completed the CRS application process, as delineated in the CRS Policy and Procedure Manual, and has met all applicable criteria to be eligible to receive CRS-related services as specified in 9 A.A.C. 22.
CRS RECIPIENT    An individual who has completed the CRS application process, and has met all applicable criteria to be eligible to receive CRS related covered Services.
DEVELOPMENTAL DISABILITY (DD)    As defined in A.R.S. §36-551, a strongly demonstrated potential that a child under six years of age has a developmental disability or will become a child with a developmental disability, as determined by a test performed pursuant to section 36-694 or by other appropriate tests, or a severe, chronic disability that:
   a.    Is attributable to cognitive disability, cerebral palsy, epilepsy or autism.
   b.    Is manifested before age eighteen.
   c.    Is likely to continue indefinitely.
   d.    Results in substantial functional limitations in three or more of the following areas of major life activity:
      (i) Self-care.
      (ii) Receptive and expressive language.
      (iii) Learning.
      (iv) Mobility.
      (v) Self-direction.
      (vi) Capacity for independent living.
      (vii) Economic self-sufficiency.
   e.    Reflects the need for a combination and sequence of individually planned or coordinated special, interdisciplinary or generic care, treatment or other services that are of lifelong or extended duration.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

EPISODE OF CARE    The period between the beginning of treatment and the ending of covered services for an individual. The beginning and end of an episode of care is marked with a demographic file submission. Over time, an individual may have multiple episodes of care.
FAMILY-CENTERED    Care that recognizes and respects the pivotal role of the family in the lives of members. It supports families in their natural care-giving roles, promotes normal patterns of living, and ensures family collaboration and choice in the provision of services to the member.
FAMILY OR FAMILY MEMBER    A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction, or other member representative responsible for making health care decisions on behalf of the member. Family members may also include siblings, grandparents, aunts and uncles.
FEDERAL EMERGENCY SERVICES (FES)    A program delineated in A.A.C. R9-22-217, to treat an emergency condition for a member who is determined eligible under A.R.S. §36- 2903.03(D).
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)    A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting criteria under Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act.
FEDERALLY QUALIFIED HEALTH CENTER LOOK-ALIKE    A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting the definition of “health center” under Section 330 of the Public Health Service Act, but does not receive grant funding under Section 330.
FIELD CLINIC    A “clinic” consisting of single specialty health care providers who travel to health care delivery settings closer to members and their families than the Multi-Specialty Interdisciplinary Clinics (MSICs) to provide a specific set of services including evaluation, monitoring, and treatment for CRS-related conditions on a periodic basis.
FREEDOM OF CHOICE (FC)    The opportunity given to each member who does not specify a Contractor preference at the time of enrollment to choose between the Contractors available within the Geographic Service Area (GSA) in which the member is enrolled.
HOME    A residential dwelling that is owned, rented, leased, or occupied at no cost to the member, including a house, a mobile home, an apartment or other similar shelter. A home is not a facility, a setting or an institution, or a portion and any of these, licensed or certified by a regulatory agency of the state as a defined in A.A.C. R9-28-101.
HOME AND COMMUNITY BASED SERVICES (HCBS)    Home and community-based services, as defined in A.R.S. §36-2931 and §36-2939.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

INTEGRATED MEDICAL RECORD    A single document in which all of the medical information listed in Chapter 900 of the AMPM is recorded to facilitate the coordination and quality of care delivered by multiple providers serving a single patient in multiple locations and at varying times.
INTERDISCIPLINARY CARE    A meeting of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the member based on the most current information available.
INTERMEDIATE CARE FACILITY FOR PERSONS WITH INTELLECTUAL DISABILITIES (ICF)    A placement setting for persons with intellectual disabilities.
JUVENILE PROBATION OFFICE (JPO)    An officer within the Arizona Department of Juvenile Corrections assigned to a juvenile upon release from a secure facility. Having close supervision and observation over juvenile’s who are ordered to participate in the intensive probation program including visual contact at least four times per week and weekly contact with the school, employer, community restitution agency or treatment program. (A.R.S. §8-353)
KIDSCARE    Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare program offers comprehensive medical, preventive, treatment services, and behavioral health care services statewide to eligible children under the age of 19, in households with income between 133% and 200% of the Federal Poverty Level (FPL).
MEDICAL PRACTITIONER    A physician, physician assistant or registered nurse practitioner.
MEDICARE MANAGED CARE PLAN    A managed care entity that has a Medicare contract with CMS to provide services to Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or Medicare Prescription Drug Plan.
MULTI-SPECIALTY INTERDISCIPLINARY CLINIC (MSIC)    An established facility where specialists from multiple specialties meet with members and their families for the purpose of providing interdisciplinary services to treat members.
PERSON WITH A DEVELOPMENTAL/ INTELLECTUAL DISABILITY    An individual who meets the Arizona definition as outlined in A.R.S. §36- 551 and is determined eligible for services through the DES Division of Developmental Disabilities (DDD). Services for AHCCCS-enrolled acute and long term care members with developmental/intellectual disabilities are managed through the DES Division of Developmental Disabilities.
PRE-ADMISSION SCREENING (PAS)    A process of determining an individual’s risk of institutionalization at a NF or ICF level of care as specified in 9 A.A.C. 28 Article 1.
RATE CODE    Eligibility classification for capitation payment purposes.
RISK GROUP    Grouping of rate codes that are paid at the same capitation rate.

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

ROSTER BILLING    Any claim that does not meet the standardized claim requirements of 9 A.A.C. 22, Article 7 is considered roster billing.
RURAL HEALTH CLINIC (RHC)    A clinic located in an area designated by the Bureau of Census as rural, and by the Secretary of the DHHS as medically underserved or having an insufficient number of physicians, which meets the requirements under 42 CFR 491.
SERIOUS MENTAL ILLNESS (SMI)    A condition as defined in A.R.S. §36-550 and determined in a person 18 years of age or older.
SIXTH OMNIBUS BUDGET AND RECONCILIATION ACT (SOBRA)    Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of 1988, 42 U.S.C. 1396(a)(10)(A)(ii)(IX), November 5, 1990, with individually budgeted incomes at or below 150% of the FPL, and children in families with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child.
SMI ELIGIBILITY DETERMINATION    The process, after assessment and submission of required documentation to determine, whether a member meets the criteria for Serious Mental Illness.
STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP)    State Children’s Health Insurance Program under Title XXI of the Social Security Act (Also known as CHIP). The Arizona version of CHIP is referred to as “KidsCare.” See also “KIDSCARE.”
STATE ONLY TRANSPLANT MEMBERS    Individuals who are eligible under one of the Title XIX eligibility categories and found eligible for a transplant, but subsequently lose Title XIX eligibility due to excess income become eligible for one of two extended eligibility options as specified in A.R.S. §36-2907.10 and A.R.S. §36-2907.11.
SUBSTANCE ABUSE    As specified in A.A.C. R9-10-101, an individual’s misuse of alcohol or other drug or chemical that:
   a.    Alters the individual’s behavior or mental functioning;
   b.    Has the potential to cause the individual to be psychologically or physiologically dependent on alcohol or other drug or chemical; and
   c.    Impairs, reduces, or destroys the individual’s social or economic functioning.
TELEMEDICINE    The practice of health care delivery, diagnosis, consultation and treatment and the transfer of medical data through interactive audio, video or data communications that occur in the physical presence of the patient, including audio or video communications sent to a health care provider for diagnostic or treatment consultation. Refer to A.R.S. §36-3601.
TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)    A Federal cash assistance program under Title IV of the Social Security Act established by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193). It replaced Aid To Families With Dependent Children (AFDC).

 

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SECTION C: DEFINITIONS    Contract No. YH14-0001

 

 

 

TITLE XXI    Title XXI of the Social Security Act provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low income children in an effective and efficient manner that is coordinated with other sources of child health benefits coverage.
TITLE XXI MEMBER    Member eligible for acute care services under Title XXI of the Social Security Act, referred to in Federal legislation as the “Children’s Health Insurance Program” (CHIP ). The Arizona version of CHIP is referred to as “KidsCare.”
TREATMENT PLAN    A written plan of services and therapeutic interventions based on a complete assessment of a member’s developmental and health status, strengths and needs that are designed and periodically updated by the multi-specialty, interdisciplinary team.
VIRTUAL CLINICS    Integrated services provided in community settings through the use of innovative strategies for care coordination such as Telemedicine, integrated medical records and virtual interdisciplinary treatment team meetings.

[END OF PART 2 DEFINITIONS]

[END OF SECTION C]

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

SECTION D: ACUTE CARE PROGRAM REQUIREMENTS

 

1. PURPOSE, APPLICABILITY, AND INTRODUCTION

PURPOSE AND APPLICABILITY

The purpose of the contract between AHCCCS and the Contractor is to implement and operate the Arizona Acute Care Program pursuant to A.R.S. §36-2901 et seq.

In the event that a provision of Federal or State law, regulation, or policy is repealed or modified during the term of this contract, effective on the date the repeal or modification by its own terms takes effect:

 

1. The provisions of this contract shall be deemed to have been amended to incorporate the repeal or modification; and

 

2. The Contractor shall comply with the requirements of the contract as amended, unless AHCCCS and the Contractor otherwise stipulate in writing.

INTRODUCTION

AHCCCS Mission and Vision

AHCCCS’ mission and vision are to reach across Arizona to provide comprehensive quality healthcare to those in need while shaping tomorrow’s managed health care from today’s experience, quality and innovation. AHCCCS is dedicated to continuously improving the efficiency and effectiveness of the Acute Care Program while supporting member choice in the delivery of the highest quality care to its customers.

AHCCCS expects the Contractor to implement program innovation and best practices on an ongoing basis. Furthermore, it is important for the Contractor to continuously develop mechanisms to reduce administrative cost and improve program efficiency. Over the term of the contract, AHCCCS will work collaboratively with the Contractor to evaluate ways to reduce program complexity, improve care coordination and chronic disease management, reduce administrative burdens, leverage joint purchasing power, and reduce unnecessary administrative and medical costs.

AHCCCS has remained a leader in Medicaid Managed Care through the diligent pursuit of excellence and cost effective managed care by its collaboration with Contractors.

The Contractor must continue to add value to the program. A Contractor adds value when it:

 

  Recognizes that Medicaid members are entitled to care and assistance navigating the service delivery system and demonstrates special effort throughout its operations to assure members receive necessary services.

 

  Recognizes that Medicaid members with special health care needs or chronic health conditions require care coordination, and provides that coordination.

 

  Recognizes that health care providers are an essential partner in the delivery of health care services, and operates the Health Plan in a manner that is efficient and effective for health care providers as well as the Contractor.

 

  Recognizes that performance improvement is both clinical and operational in nature and self-monitors and self-corrects as necessary to improve contract compliance or operational excellence.

 

  Recognizes that the program is publicly funded, is subject to public scrutiny, and operates in a manner consistent with the public trust.

The Acute Care Program

In 1982 Arizona introduced its innovative Medicaid program by establishing the Arizona Health Care Cost Containment System (AHCCCS), a demonstration program based on principles of managed care. In doing so, AHCCCS became the first statewide Medicaid managed care system in the nation. As of October 1, 2012, AHCCCS, through its Managed Care Organizations (MCOs) serves 1,062,361 members under the Acute Care Program.

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

AHCCCS contracts for acute care services in seven geographic service areas that include the 15 Arizona counties. Contractors are responsible for coordinating, managing and providing acute care services to members and coordinating carved out behavioral health services delivered by the Regional Behavioral Health Authorities through the Arizona Department of Health Services.

Additional information may be obtained by visiting the AHCCCS website: www.azahcccs.gov.

 

2. ELIGIBILITY CATEGORIES

AHCCCS is Arizona’s Title XIX Medicaid program operating under an 1115 Waiver and Title XXI program operating under Title XXI State Plan authority. Arizona has the authority to require mandatory enrollment in managed care. All Acute Care Program members eligible for AHCCCS benefits, with exceptions as identified below, are enrolled with Acute Care Contractors that are paid on a capitated basis. AHCCCS pays for health care expenses on a Fee-For-Service (FFS) basis for Title XIX- and Title XXI- eligible members who receive services through the American Indian Health Program; for Title XIX eligible members who are entitled to emergency services under the Federal Emergency Services (FES) program; and for Medicare cost sharing beneficiaries under the QMB-Only program.

The Contractor is not responsible for determining eligibility.

The following describes the eligibility groups enrolled in the managed care program and covered under this contract [42 CFR 434.6(a)(2)]:

Title XIX

1931 (Also referred to as TANF-related): Eligible individuals and families under the 1931 provision of the Social Security Act, with income at or below 100% of the FPL.

SSI Cash: Eligible individuals receiving Supplemental Security Income through Federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or who have a disability and have income at or below 100% of the Federal Benefit Rate (FBR).

SSI Medical Assistance Only (SSI MAO) and Related Groups: Eligible individuals who are aged, blind or who have a disability and have household income levels at or below 100% of the FPL.

Freedom to Work (Ticket to Work): Eligible individuals under the Title XIX program that extends eligibility to individuals 16 through 64 years old who meet SSI disability criteria, and whose earned income after allowable deductions is at or below 250% of the FPL, and who are not eligible for any other Medicaid program. These members must pay a premium to AHCCCS, depending on income.

SOBRA: Under the Sixth Omnibus Budget Reconciliation Act of 1986, eligible pregnant women, with income at or below 150% of the FPL, and children with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child.

Breast and Cervical Cancer Treatment Program (BCCTP): Eligible individuals under the Title XIX expansion program for women with incomes at or below 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs. Eligible members cannot have other creditable health insurance coverage, including Medicare.

Title IV-E Foster Care and Adoption Subsidy: Children who are in State foster care or are receiving Federally funded adoption subsidy payments.

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

Young Adult Transitional Insurance (YATI): Transitional medical care for individuals age 18 through age 25 who were enrolled in the foster care program under jurisdiction of the Department of Child Safety in Arizona on their 18th birthday.

Adult Group at or below 106% FPL: Adults aged 19-64, without Medicare, with income at or below 106% of the Federal Poverty Level (Adults </= 106%).

Adult Group above 106% FPL: Adults aged 19-64, without Medicare, with income above 106% through 133% of the Federal Poverty Level (Adults > 106%).

Title XXI

KidsCare: Federal and State Children’s Health Insurance Program (Title XXI – CHIP) administered by AHCCCS. The KidsCare program offers comprehensive medical, preventive, treatment services, and behavioral health care services statewide to eligible children under the age of 19, in households with income between 133% and 200% of the Federal Poverty Level (FPL).

State-Only

State-Only Transplants: Title XIX individuals, for whom medical necessity for a transplant has been established and who subsequently lose Title XIX eligibility may become eligible for and select one of two extended eligibility options as specified in A.R.S. §36-2907.10 and A.R.S. §36-2907.11. The extended eligibility is authorized only for those individuals who have met all of the following conditions:

 

  1. The individual has been determined ineligible for Title XIX due to excess income;

 

  2. The individual had been placed on a donor waiting list before eligibility expired; and

 

  3. The individual has entered into a contractual arrangement with the transplant facility to pay the amount of income which is in excess of the eligibility income standards (referred to as transplant share of cost).

The following options for extended eligibility are available to these members:

Option 1: Extended eligibility is for one 12-month period immediately following the loss of AHCCCS eligibility. The member is eligible for all AHCCCS covered services as long as they continue to be medically eligible for a transplant. If determined medically ineligible for a transplant at any time during the period, eligibility will terminate at the end of the calendar month in which the determination is made.

Option 2: The member loses AHCCCS eligibility but maintains transplant candidacy status as long as medical eligibility for a transplant is maintained. At the time that the transplant is scheduled to be performed the transplant candidate will reapply and will be re-enrolled with his/her previous Contractor to receive all covered transplant services. Option 2-eligible individuals are not eligible for any non-transplant related health care services from AHCCCS.

 

3. ENROLLMENT AND DISENROLLMENT

AHCCCS Acute Care members are enrolled with the Contractor in accordance with the rules set forth in 9 A.A.C. 22 Article 17, and 9 A.A.C. 31 Articles 3 and 17. AHCCCS has the exclusive authority to enroll and disenroll members. AHCCCS does not use passive enrollment procedures [42 CFR 438.6(d)(2)]. AHCCCS operates as a mandatory managed care program and choice of enrollment or auto-assignment is used pursuant to the terms of the Arizona Medicaid Section 1115 Demonstration Waiver Special Terms and Conditions.i The Contractor shall not disenroll any member for any reason unless directed to do so by AHCCCS [42 CFR 438.56(d)(5)(iii)]. The Contractor may request AHCCCS to change the member’s enrollment in accordance

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

with ACOM Policy 401. The Contractor may not request disenrollment because of an adverse change in the enrollee’s health status, nor because of the enrollee’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. An AHCCCS member may request disenrollment from the Contractor for cause at any time. Refer to ACOM Policy 401.

AHCCCS will disenroll the member from the Contractor when:

 

    The member becomes ineligible for the AHCCCS program;

 

    In limited situations when the member moves out of the Contractor’s service areas;

 

    The member changes Contractors during the member’s open enrollment and annual enrollment choice period;

 

    The Contractor does not, because of moral or religious objections, cover the service the member seeks unless the Contractor offered a solution that was accepted by AHCCCS in accordance with the requirements in Section D, Paragraph 10, Scope of Services;

 

    The member is approved for a Contractor change through ACOM Policy 401 [42 CFR 438.56]; or

 

    The member is eligible to transition to another AHCCCS program.

Members may submit plan change requests to the Contractor or AHCCCS. A denial of any plan change request must include the Contractor’s reason for not approving the change and options for resolution. The notice must advise the member of the AHCCCS and Contractors grievance policies. The notice must also advise the member of his/her right to request a hearing, including how to request a hearing and the timeframe for making the request.

Member Choice of Contractor: AHCCCS members eligible for services covered under this contract have a choice of available Contractors, except those populations described below.

 

a. Previously enrolled members who have been disenrolled for less than 90 days will be automatically enrolled with the same Contractor, if still available.

 

b. Members residing in a Geographic Service Area where only one Contractor is available will be automatically enrolled with that Contractor and will be given a choice of PCPs.

AHCCCS members eligible under this contract who become eligible for another AHCCCS program will be enrolled as follows:

 

a. Members eligible for Children’s Rehabilitative Services will be enrolled with the CRS Contractor, unless they refuse to participate in the CRS application process, refuse to receive CRS covered services through the CRS Program, or opt out of CRS Program. This includes members who are eligible for CRS who are determined to have a Serious Mental Illness (SMI).

 

b. Adult members determined to have a Serious Mental Illness will be enrolled in a RBHA.

 

c. Children in State custody will be enrolled in CMDP.

Members who do not choose a Contractor prior to AHCCCS being notified of their eligibility are automatically assigned to a Contractor based on re-enrollment rules, family continuity, or the auto-assignment algorithm. If a member is auto-assigned, AHCCCS sends a Choice Notice to the member and allows the member 30 days to choose a different Contractor. See Section D, Paragraph 6, Auto-Assignment Algorithm, for further explanation.

The effective date of enrollment for a new Title XIX member with the Contractor is the day AHCCCS takes the enrollment action. The Contractor is responsible for payment of medically necessary covered services retroactive to the member’s beginning date of eligibility, as reflected in PMMIS.

The effective date of enrollment for a Title XXI member will be the first day of the month following notification to the Contractor. In the event that eligibility is determined on or after the 25th day of the month, eligibility will begin on the first day of the second month following the determination.

 

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Prior Quarter Coverage: Pursuant to Federal Regulation 42 CFR 435.915, AHCCCS is required to implement Prior Quarter Coverage eligibility which expands the time period during which AHCCCS pays for covered services for eligible individuals to include services provided during any of the three months prior to the month the individual applied for AHCCCS, if the individual met AHCCCS eligibility requirements during that month. AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter. Upon verification or notification of Prior Quarter Coverage eligibility, providers will be required to bill AHCCCS for services provided during a prior quarter eligibility period.

Prior Period Coverage: AHCCCS provides Prior Period Coverage for the period of time prior to the Title XIX member’s enrollment during which the member is eligible for covered services. Prior Period Coverage refers to the time frame from the effective date of eligibility (usually the first day of the month of application) until the date the member is enrolled with the Contractor. The Contractor receives notification from AHCCCS of the member’s enrollment. The Contractor is responsible for payment of all claims for medically necessary covered services, excluding most behavioral health services, provided to members during prior period coverage. This may include services provided prior to the contract year and in a Geographic Service Area where the Contractor was not contracted at the time of service delivery. AHCCCS Fee-For-Service will be responsible for the payment of claims for prior period coverage for members who are found eligible for AHCCCS initially through Hospital Presumptive Eligibility and later are enrolled with the Contractor. Therefore, for those members, the Contractor is not responsible for Prior Period Coverage.

Hospital Presumptive Eligibility: As required under the Affordable Care Act, AHCCCS has established standards for the State’s Hospital Presumptive Eligibility (HPE) program in accordance with federal requirements. Qualified hospitals that elect to participate in the HPE Program will implement a process consistent with AHCCCS standards which determines applicants presumptively eligible for AHCCCS Medicaid covered services. Persons determined presumptively eligible who have not submitted a full application to AHCCCS will qualify for Medicaid services from the date the hospital determines the individual to be presumptively eligible through the last day of the month following the month in which the determination of presumptive eligibility was made by the qualified hospital. For persons who apply for presumptive eligibility and who also submit a full application to AHCCCS, coverage of Medicaid services will begin on the date that the hospital determines the individual to be presumptively eligible and will continue through the date that AHCCCS issues a determination on that application. All persons determined presumptively eligible for AHCCCS will be enrolled with AHCCCS Fee-For-Service for the duration of the HPE eligibility period. If a member made eligible via HPE is subsequently determined eligible for AHCCCS via the full application process, Prior Period Coverage for the member will also be covered by AHCCCS Fee-For-Service, and the member will be enrolled with the Contractor only on a prospective basis.

Newborns: Newborns born to AHCCCS eligible mothers enrolled at the time of the child’s birth will be enrolled with the mother’s Contractor (except as noted in the following paragraph), when newborn notification is received by AHCCCS. The Contractor is responsible for notifying AHCCCS of a child’s birth to an enrolled member. Capitation for the newborn will be retroactive to the date of birth if notification is received no later than one day from the date of birth. In all other circumstances, capitation for the newborn will begin on the date notification is received by AHCCCS. The effective date of AHCCCS eligibility for the newborn will be the newborn’s date of birth, and the Contractor is responsible for all covered services to the newborn, whether or not AHCCCS has received notification of the child’s birth. AHCCCS is available to receive notification 24 hours a day, seven days a week via the AHCCCS website. Each eligible mother of a newborn is sent a Choice notice advising her of her right to choose a different Contractor for her child; the date of the change will be the date of processing the request from the mother. If the mother does not request a change within 30 days, the child will remain with the mother’s Contractor.

Babies born to mothers enrolled in the Federal Emergency Services (FES) program, a RBHA, CRS, or CMDP are auto-assigned to an Acute Care Contractor. Mothers of these newborns are sent a Choice Notice advising them of their right to choose a different Contractor for their child, which allows them 30 days to make a choice. In the event the mother chooses a different Contractor, AHCCCS will recoup all capitation paid to the

 

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originally assigned Contractor and the baby will be enrolled retroactive to the date of birth with the second Contractor. The second Contractor will receive prior period capitation from the date of birth to the day before assignment and prospective capitation from the date of assignment forward. The second Contractor will be responsible for all covered services to the newborn from date of birth.

Enrollment Guarantees: Upon initial capitated enrollment as a Title XIX-eligible member, the member is guaranteed a minimum of five full months of continuous enrollment. Upon initial capitated enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of 12 full months of continuous enrollment. The enrollment guarantee is a one-time benefit. If a member changes from one Contractor to another within the enrollment guarantee period, the remainder of the guarantee period applies to the new Contractor. AHCCCS rules at 9 A.A.C 22 Article 17, and 9 A.A.C. 31 Article 3, describe other reasons for which the enrollment guarantee may not apply.

American Indians: If a choice is not made prior to AHCCCS being notified of their eligibility, American Indian Title XIX members living on-reservation will be assigned to the AHCCCS American Indian Health Program (AIHP) as FFS members. American Indian Title XIX members living off-reservation who do not make a Contractor choice will be assigned to an available Contractor using the AHCCCS protocol for family continuity and the auto-assignment algorithm. The designation of a zip code as a ‘reservation zip code’, not the physical location of the residence, is the factor that determines whether a member is considered on or off-reservation for these purposes. Further, if the member resides in a zip code that contains land on both sides of a reservation boundary and the zip code is assigned as off-reservation; the physical location of the residence does not change the off-reservation designation for the member. American Indian members can change enrollment between American Indian Health Program (AIHP) or a Contractor at any time. However, a member can change from one Contractor to another only once a year. American Indian members, title XIX and XXI, on- or off-reservation, eligible to receive services, may choose to receive services at any time from an American Indian Health Facility (I/T/U) - Indian Health Service (IHS) Facility, a Tribally-Operated 638 Health Program, Urban Indian Health Program) [ARRA Section 5006(d), and SMD letter 10-001].ii The Contractor shall not impose enrollment fees, premiums, or similar charges on American Indians served by an American Indian Health Facility (I/T/U) - Indian Health Service (IHS) Facility, a Tribally-Operated 638 Health Program, Urban Indian Health Program) (ARRA Section 5006(d), SMD letter 10-001).iii

 

4. ANNUAL AND OPEN ENROLLMENT CHOICE

AHCCCS conducts an Annual Enrollment Choice (AEC) for members in Geographic Service Areas (GSAs) with multiple Contractors on their annual anniversary date [42 CFR 438.56(c)(2)(ii)]. During AEC, members may change Contractors subject to the availability of other Contractors within their GSA. AHCCCS provides enrollment and other information required by Medicaid Managed Care Regulations 60 days prior to the member’s AEC date. The member may choose a new Contractor by contacting AHCCCS to complete the enrollment process. If the member does not participate in the AEC, no change of Contractor will be made (except for approved changes under ACOM Policy 401) during the new anniversary year. This holds true if a Contractor’s contract is renewed and the member continues to live in a Contractor’s service area. The Contractor shall comply with ACOM Policy 402, and the AMPM.

AHCCCS may hold an open enrollment in any GSA or combination of GSAs as deemed necessary.

 

5. RESERVED

 

6. AUTO-ASSIGNMENT ALGORITHM

Members who do not exercise their right to choose and do not have family continuity are assigned to a Contractor through an auto-assignment algorithm. The algorithm is a mathematical formula used to distribute members to the various Contractors in a manner that is predictable and consistent with AHCCCS goals.

 

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Assignment by the algorithm applies to the following members who do not exercise their right to choose a Contractor within the prescribed time limits:

 

1. New members and members re-enrolling outside the 90-day re-enrollment window.

 

2. Members enrolled with a Contractor that is not available after the member moves to a new Geographic Service Area (GSA).

 

3. Infants born to a mother who is enrolled with the Maricopa County RBHA and diagnosed as Seriously Mentally Ill (SMI) and who has no family continuity with an AHCCCS Acute Care Contractor in Maricopa County.

 

4. Members who were enrolled with the Maricopa County RBHA and diagnosed as SMI but who have been determined to no longer qualify as SMI and who do not have family continuity with an AHCCCS Acute Care Contractor in Maricopa County.

 

5. Members who are disenrolled from the CRS Contractor and who do not have family continuity with an AHCCCS Acute Care Contractor.

Once auto-assigned, AHCCCS sends a Choice notice to the member, allowing the member 30 days to choose a different Contractor from the auto-assigned Contractor.

AHCCCS may change the algorithm at any time during the term of the contract in response to Contractor-specific issues (e.g. imposition of an enrollment cap) or in the best interest of the AHCCCS Program and/or the State.

Maximum Enrollment: A Contractor in Maricopa or Pima County will no longer be eligible for auto assignment of members once the Contractor’s membership reaches 45% of the County’s total enrollment. Member choices will not be impacted by the auto assignment algorithm freeze.

For further details on the AHCCCS Auto-Assignment Algorithm, refer to ACOM Policy 314.

 

7. AHCCCS MEMBER IDENTIFICATION CARDS

The Contractor is responsible for the production, distribution and costs of AHCCCS member identification cards and the AHCCCS Notice of Privacy Practices in accordance with ACOM Policy 433. See also Attachment F3, Contractor Chart of Deliverables.

 

8. ACCOMODATING AHCCCS MEMBERS

The Contractor shall ensure that members are provided covered services without regard to race, color, national origin, sex, sexual orientation, gender identity, age or disability and will not use any policy or practice that has the effect of discriminating on the basis of race, color, or national origin, sex, sexual orientation, gender identity, age or disability [42 CFR 438.3(d)] [45 CFR Part 92].

 

a. Examples of prohibited practices include, but are not limited to, the following:Denying or not providing a member any covered service or access to an available facility;

 

b. Providing to a member any medically necessary covered service which is different, or is provided in a different manner or at a different time from that provided to other members, other public or private patients or the public at large, except where medically necessary;

 

c. Subjecting a member to segregation or separate treatment in any manner related to the receipt of any covered service; restricting a member in any way in his or her enjoyment of any advantage or privilege enjoyed by others receiving any covered service; and

 

d. Assigning times or places for the provision of services on the basis of the race, color, creed, religion, age, gender, national origin, ancestry, marital status, sexual preference, income status, AHCCCS membership, or physical or mental illnesses of the participants to be served.

The Contractor shall assure members the rights as delineated in 42 CFR 438.100.

 

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The Contractor must ensure members and individuals with disabilities are accommodated to actively participate in the provision of services and have physical access to facilities, procedures and exams. For example, the Contractor must provide appropriate auxiliary aids and services to persons with impaired sensory, manual, or speaking skills. The Contractor must provide accommodations to members and individuals with disabilities at no cost to afford such persons an equal opportunity to benefit from the covered services. [45 CFR 92.202 – 92.205]

If the Contractor knowingly executes a subcontract with a provider with the intent of allowing or permitting the subcontractor to implement barriers to care (i.e. the terms of the subcontract act to discourage the full utilization of services by some members) the Contractor will be in default of its Contract.

If the Contractor identifies a problem involving discrimination or accommodations for individuals with disabilities by one of its providers, it shall promptly intervene and require a corrective action plan from the provider. Failure to take prompt corrective measures may place the Contractor in default of its Contract.

 

9. TRANSITION ACTIVITIES

Member Transition: The Contractor shall comply with the AMPM and the ACOM standards for member transitions between Contractors or Geographical Service Areas (GSAs), Children’s Rehabilitative Services (CRS), the Comprehensive Medical and Dental Program (CMDP), or to the Arizona Long Term Care System (ALTCS) Contractor, and upon termination or expiration of a contract. The Contractor shall develop and implement policies and procedures which include but are not limited to:

 

a. Members with significant medical conditions such as, a high-risk pregnancy or pregnancy within the last trimester, the need for organ or tissue transplantation, chronic illness resulting in hospitalization or nursing facility placement, etc.;

 

b. Members who are receiving ongoing services such as dialysis, home health, chemotherapy and/or radiation therapy, or who are hospitalized at the time of transition;

 

c. Members who have conditions requiring ongoing monitoring or screening such as elevated blood lead levels and members who were in the Neonatal Intensive Care Unit (NICU) after birth;

 

d. Members who frequently contact AHCCCS, State and local officials, the Governor’s Office and/or the media;

 

e. Members who have received prior authorization for services such as scheduled surgeries, post-surgical follow-up visits, out-of-area specialty services, or nursing home admission;

 

f. Continuing prescriptions, Durable Medical Equipment (DME) and medically necessary transportation ordered for the transitioning member by the relinquishing Contractor; and

 

g. Medical records of the transitioning member (the cost, if any, of reproducing and forwarding medical records shall be the responsibility of the relinquishing AHCCCS Contractor).

The Contractor shall designate a person with appropriate training and experience to act as the Transition Coordinator. The individual appointed to this position must be a health care professional or an individual who possesses the appropriate education and experience and is supported by a health care professional to effectively coordinate and oversee all transition issues, responsibilities, and activities. This staff person shall interact closely with the transition staff of the receiving Contractor to ensure a safe, timely, and orderly transition. See ACOM Policy 402 for more information regarding the role and responsibilities of the Transition Coordinator.

A new Contractor who receives members from another Contractor as a result of a contract award shall ensure a smooth transition for members by continuing previously approved prior authorizations for 30 days after the member transition unless mutually agreed to by the member or member’s representative.

When relinquishing members, the Contractor is responsible for timely notification to the receiving Contractor regarding pertinent information related to any special needs of transitioning members. When receiving a transitioning member with special needs, the Contractor is responsible for coordinating care with the

 

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relinquishing Contractor in order that services are not interrupted, and for providing the new member with Contractor and service information, emergency numbers and instructions about how to obtain services. See ACOM Policy 402 and AMPM Chapter 500.

For individuals determined to have a Serious Mental Illness (SMI) who are transitioning from a health plan to a RBHA, there shall be a 14 day transition period in order to ensure effective coordination of care. The Contractor shall comply with the AMPM and the ACOM standards for member transitions between Contractors as outlined above. The Contractor is responsible for the provision of services outlined in this contract during the 14 day transition period.

Contract Termination: In the event that the contract or any portion thereof is terminated for any reason, or expires, the Contractor shall assist AHCCCS in the transition of its members to other Contractors. In addition, AHCCCS reserves the right to extend the term of the contract on a month-to-month basis to assist in any transition of members. AHCCCS may discontinue enrollment of new members with the Contractor three months prior to the contract termination date. The Contractor shall make provisions for continuing all management and administrative services until the transition of all members is completed and all other requirements of this contract are satisfied. The Contractor shall submit a detailed plan to AHCCCS for approval regarding the transition of members in the event of contract expiration or termination. The name and title of the Contractor’s transition coordinator shall be included in the transition plan. The Contractor shall be responsible for providing all reports set forth in this contract and necessary for the transition process, and shall be responsible for the following [42 CFR 438.610(c)(3); 42 CFR 434.6(a)(6)]:

 

a. Notifying subcontractors and members;

 

b. Paying all outstanding obligations for medical care rendered to members until AHCCCS is satisfied that the Contractor has paid all such obligations. The Contractor shall provide a monthly claims aging report including IBNR amounts (due the 15th day of the month, for the prior month);

 

c. Providing Quarterly and Audited Financial Statements up to the date specified by AHCCCS. The financial statement requirement will not be absolved without an official release from AHCCCS;

 

d. Continuing encounter reporting until all services rendered prior to contract termination have reached adjudicated status and data validation of the information has been completed, as communicated by a letter of release from AHCCCS;

 

e. Cooperating with reinsurance audit activities on prior contract years until release has been granted by AHCCCS;

 

f. Cooperating with AHCCCS to complete and finalize any open reconciliations, until release has been granted by AHCCCS. AHCCCS will work to complete any pending reconciliations as timely as can be completed, allowing for appropriate lag time for claims run-out and/or changes to be entered into the system;

 

g. Submitting quarterly Quality Management and Medical Management reports as required by Section D, Paragraphs 23, Quality Management, and 24, Medical Management, as appropriate to provide AHCCCS with information on services rendered up to the date of contract termination. This will include Quality Of Care (QOC) concern reporting based on the date of service;

 

h. Participating in and closing out Performance Measures and Performance Improvement Projects as requested by AHCCCS;

 

i. Maintaining a Performance Bond in accordance with Section D, Paragraph 46, Performance Bond or Bond Substitute. A formal request to release the performance bond, as well as a balance sheet, must be submitted when appropriate;

 

j. Indemnifying AHCCCS for any claim by any third party against the State or AHCCCS arising from the Contractor’s performance of this contract and for which the Contractor would otherwise be liable under this contract;

 

k. Returning to AHCCCS, any funds advanced to the Contractor for coverage of members for periods after the date of termination. Funds must be returned to AHCCCS within 30 days of termination of the contract;

 

l. Providing a monthly accounting of Member Grievances and Claim Disputes and their disposition; and

 

m. Preserving and making available records within the timeframes required by state and federal law, including but not limited to, 45 CFR 164.530(j)(2) and 42 CFR 438.3(u)].

 

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The above list is not exhaustive and additional information may be requested to ensure that all operational and reporting requirements have been met. Any dispute by the Contractor, with respect to termination or suspension of this contract by AHCCCS, shall be exclusively governed by the provisions of Section E, Contract Terms and Conditions, Paragraph 19, Disputes.

ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

For the October 1, 2015 integration of general mental health and substance abuse services to an Acute Care Contractor for adult dual members, previously approved prior authorizations shall be continued by the Acute Care Contractor for a period of 90 days unless mutually agreed to by the member or member’s representative.

 

10. SCOPE OF SERVICES

The Contractor shall provide covered services to AHCCCS members in accordance with all applicable Federal and State laws, regulations and policies, including those listed by reference in attachments and this contract. The services are described in detail in AHCCCS rules A.A.C. R9-22 Article 2, the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor Operations Manual (ACOM), all of which are incorporated herein by reference, and may be found on the AHCCCS website [42 CFR 400(a)(1)]. To be covered, services must be medically necessary and cost effective. The covered services are briefly described below. Except for annual well woman exams, behavioral health and children’s dental services, and consistent with the terms of the demonstration, covered services must be provided by or coordinated with a primary care provider.

The Contractor must ensure the coordination of services it provides with services the member receives from other entities, including behavioral health services the member receives through an ADHS/RBHA provider. The Contractor shall ensure that, in the process of coordinating care, each member’s privacy is protected in accordance with the privacy requirements including, but not limited to, 45 CFR Parts 160 and 164, Subparts A and E, and Arizona statute, to the extent that they are applicable [42 CFR 438.208 (b)(2) and (b)(4) and 438.224].

The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) with respect to any amount expended for which funds may not be used under the Assisted Suicide Funding Restriction Act of 1997. (1903(i) final sentence and 1903(i)(16) of the Social Security Act).iv

Services must be rendered by providers that are appropriately licensed or certified, operating within their scope of practice, and registered as an AHCCCS provider. The Contractor shall provide the same standard of care for all members, regardless of the member’s eligibility category. The Contractor shall ensure that the services are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished [42 CFR 434.6(a)(4)]. The Contractor shall not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of diagnosis, type of illness, or condition of the member [42 CFR 438.210(a)(3)(ii)]. The Contractor may place appropriate limits on a service on the basis of criteria such as medical necessity; or for utilization control, provided the services furnished can reasonably be expected to achieve their purpose [42 CFR 438.210(a)(3); 42 CFR 438.210(a)(4)].

Moral or Religious Objections

The Contractor must notify AHCCCS if, on the basis of moral or religious grounds, it elects to not provide or reimburse for a covered service. The Contractor may propose a solution to allow members’ access to the services. AHCCCS does not intend to offer the services on a Fee-For-Service basis to the Contractor’s enrollees. If AHCCCS does not approve the Contractor’s proposed solution, AHCCCS will disenroll members who are seeking these services from the Contractor and assign them to another Contractor [42 CFR 438.56]. That proposal must:

 

  Be submitted to AHCCCS in writing prior to entering into a contract with AHCCCS or at least 60 days prior to the intended effective date of the change in the scope of services based on moral or religious grounds;

 

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  Place no financial or administrative burden on AHCCCS;

 

  Place no significant burden on members’ access to the services;

 

  Be accepted by AHCCCS in writing; and

 

  Acknowledge an adjustment to capitation, depending on the nature of the proposed solution.

If AHCCCS approves the Contractor’s proposed solution for its members to access the services, the Contractor must notify members how to access these services when directed by AHCCCS. The notification and policy must be consistent with the provisions of 42 CFR 438.10, must be provided to newly assigned members within 12 days of enrollment, and must be provided to all current members at least 30 days prior to the effective date of the approved policy [42 CFR 438.102(a)(2)].

Authorization of Services

The Contractor shall have in place and follow written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor shall have mechanisms in place to ensure consistent application of review criteria for authorization decisions. 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 member’s condition or disease [42 CFR 438.210(b)].

Notice of Action

The Contractor shall notify the requesting provider and give the member written notice of any decision by the Contractor to deny, reduce, suspend or terminate a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested [42 CFR 438.400(b)]. The notice shall meet the requirements of 42 CFR 438.404, AHCCCS rules and ACOM Policy 414. The notice to the provider must also be in writing as specified in Attachment F1, Enrollee Grievance and Appeal System Standards of this contract [42 CFR 438.210(c)]. The Contractor must comply with all decision timelines outlined in ACOM Policy 414.

The Contractor shall ensure that its providers, acting within the lawful scope of their practice are not prohibited or otherwise restricted from advising or advocating, on behalf of a member who is his or her patient, for [42 CFR 438.102]:

 

a. The member’s health status, medical care or treatment options, including any alternative treatment that may be self-administered [42 CFR 438.100(b)(2)];

 

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

 

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

 

d. The member’s right to participate in decisions regarding his or her behavioral health care, including the right to refuse treatment, and to express preferences about future treatment decisions [42 CFR 438.100(b)(2)(iv)].

Covered Services

Refer to the AHCCCS Medical Policy Manual (AMPM) for a comprehensive list of Covered Services.

Ambulatory Surgery: The Contractor shall provide surgical services for either emergency or scheduled surgeries when provided in an ambulatory or outpatient setting, such as a freestanding surgical center or a hospital-based outpatient surgical setting.

American Indian Health Program (AIHP): The AHCCCS, Division of Fee-For-Service Management (DFSM) will reimburse claims for acute care services that are medically necessary, and are provided to Title XIX members enrolled with the Contractor by an IHS or 638 tribal facility, eligible for 100% Federal

 

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reimbursement, when the member is eligible to receive services through an IHS or 638 tribal facility. Encounters for Title XIX services billed by an IHS or tribal facilities will not be accepted by AHCCCS or considered in capitation rate development.

The Contractor is responsible for reimbursement to IHS or tribal facilities for services provided to Title XXI American Indian members enrolled with the Contractor. Payment rates must be at least equal to the AHCCCS Fee-For-Service rates. The Contractor may choose to subcontract with an IHS or 638 tribal facility as part of its provider network for the delivery of Title XXI covered services. Expenses incurred by the Contractor for Title XXI services billed by an IHS or 638 tribal facility shall be encountered and considered in capitation rate development.

Anti-hemophilic Agents and Related Services: The Contractor shall provide services for the treatment of hemophilia and von Willebrand’s disease. See Section D, Paragraph 57, Reinsurance.

Audiology: The Contractor shall provide medically necessary audiology services to evaluate hearing loss for all members, on both an inpatient and outpatient basis. Hearing aids are covered only for members under the age of 21 receiving EPSDT services.

Behavioral Health: The Contractor shall provide behavioral health services as described in Section D, Paragraph 12, Behavioral Health Services.

Children’s Rehabilitative Services: The Children’s Rehabilitative Services (CRS) program is administered by AHCCCS utilizing a CRS Contractor for children with special health care needs who meet CRS eligibility criteria. The CRS Contractor provides various combinations of acute, behavioral health and specialty CRS services for these children. The Contractor shall refer children to AHCCCS Division of Member Services (DMS) who are potentially eligible for services related to CRS-covered conditions, as specified in A.A.C. R9-22 Article 13, and A.R.S. Title 36. See ACOM Policy 426 for the processes used to accept and process referrals to the CRS Program. In addition, the Contractor shall notify the member when a referral to CRS has been made. The Contractor is responsible for care of members until those members are determined eligible for CRS by AHCCCS, Division of Member Services. In addition, the Contractor is responsible for CRS covered services for CRS-eligible members unless and until the Contractor has received confirmation from AHCCCS that the member has transitioned to the CRS Contractor. For more detailed information regarding eligibility criteria, referral practices, and Contractor-CRS coordination issues, refer to the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor’s Operation Manual (ACOM) located on the AHCCCS website.

Chiropractic Services: The Contractor shall provide chiropractic services to members under age 21 when prescribed by the member’s PCP and approved by the Contractor in order to ameliorate the member’s medical condition. For Qualified Medicare Beneficiaries, regardless of age, Medicare approved chiropractic services shall be covered subject to limitations specified in 42 CFR 410.21.

Dialysis: The Contractor shall provide medically necessary dialysis, supplies, diagnostic testing and medication for all members when provided by Medicare-certified hospitals or Medicare-certified end stage renal disease (ESRD) providers. Services may be provided on an outpatient basis or on an inpatient basis if the hospital admission is not solely to provide chronic dialysis services.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT): The Contractor shall provide comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21. The Contractor shall ensure that these members receive required health screenings, including developmental and behavioral health screenings, in compliance with the AHCCCS EPSDT Periodicity Schedule, and the AHCCCS Dental Periodicity Schedule (Exhibit 430-1 and 430-1A in the AMPM), including appropriate oral health screening intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician’s assistant or nurse practitioner.

 

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The Contractor shall ensure the initiation and coordination of a referral as indicated on the EPSDT forms received, to the T/RBHA system for members in need of behavioral health services. The Contractor shall have processes in place to follow up with the T/RBHA to monitor whether members have received these EPSDT services. The Contractor will ensure the coordination of referrals and follow-up collaboration, as necessary, for members identified by the T/RBHA as needing acute care services.

Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention: The Contractor shall provide health care services through screening, diagnostic and medically necessary treatment for members 21 years of age and older. These services include, but are not limited to, screening and treatment for hypertension; elevated cholesterol; colon cancer; sexually transmitted diseases; tuberculosis; HIV/AIDS; breast cancer, cervical cancer; and prostate cancer. Nutritional assessment and treatment are covered when medically necessary to meet the needs of members who may have a chronic debilitating disease. Physical examinations, diagnostic work-ups and medically necessary immunizations are also covered as specified in A.A.C. R9-22-205.

Emergency Services: The Contractor shall provide emergency services per the following:

 

a. Emergency services facilities adequately staffed by qualified medical professionals to provide pre-hospital, emergency care on a 24-hour-a-day, seven-day-a-week basis, for an emergency medical condition as defined by A.A.C. R9-22 Article 1. Emergency medical services are covered without prior authorization. The Contractor is encouraged to contract with emergency service facilities for the provision of emergency services. The Contractor shall be responsible for educating members and providers regarding appropriate utilization of emergency room services including behavioral health emergencies. The Contractor shall monitor emergency service utilization (by both provider and member) and shall have guidelines for implementing corrective action for inappropriate utilization. For utilization review, the test for appropriateness of the request for emergency services shall be whether a prudent layperson, similarly situated, would have requested such services. For the purposes of this contract, a prudent layperson is a person who possesses an average knowledge of health and medicine.

 

b. All medical services necessary to rule out an emergency condition; and

 

c. Emergency transportation.

Per the Medicaid Managed Care regulations, 42 CFR 438.114, 422.113, 422.133 the following conditions apply with respect to coverage and payment of emergency services:

The Contractor must cover and pay for emergency services regardless of whether the provider that furnishes the service has a contract with the Contractor.

The Contractor may not deny payment for treatment obtained under either of the following circumstances:

 

a. A member had an emergency medical condition, including cases in which the absence of medical attention would not have resulted in the outcomes identified in the definition of emergency medical condition under 42 CFR 438.114.

 

b. A representative of the Contractor (an employee or subcontracting provider) instructs the member to seek emergency medical services.

Additionally, the Contractor may not:

 

a. Limit what constitutes an emergency medical condition as defined in 42 CFR 438.114, on the basis of lists of diagnoses or symptoms.

 

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b. Refuse to cover emergency services based on the failure of the emergency room provider, hospital, or fiscal agent to notify the Contractor of the member’s screening and treatment within 10 calendar days of presentation for emergency services. Claims submission by the hospital within 10 calendar days of the member’s presentation for the emergency services constitutes notice to the Contractor. This notification stipulation is only related to the provision of emergency services.

 

c. Require notification of Emergency Department treat and release visits as a condition of payment unless the plan has prior approval from AHCCCS.

A member who has an emergency medical condition may not be held liable for payment of subsequent screening and treatment needed to diagnose the specific condition or stabilize the patient.

The attending emergency physician, or the provider actually treating the member, is responsible for determining when the member is sufficiently stabilized for transfer or discharge, and such determination is binding on the Contractor responsible for coverage and payment. The Contractor shall comply with Medicaid Managed Care guidelines regarding the coordination of poststabilization care.

For additional information and requirements regarding emergency services, refer to AHCCCS rules A.A.C. R9-22-201 et seq. and 42 CFR 438.114.

Family Planning: The Contractor shall provide family planning services in accordance with the AMPM, and consistent with the terms of the demonstration, for all members who choose to delay or prevent pregnancy. These include medical, surgical, pharmacological and laboratory services, as well as contraceptive devices. Information and counseling, which allow members to make informed decisions regarding family planning methods, are also included. If the Contractor does not provide family planning services due to moral and religious objections, it must contract for these services through another health care delivery system or have an approved alternative in place, or AHCCCS will disenroll members who are seeking these services from the Contractor and assign them to another Contractor.

Foot and Ankle Services:

Children: The Contractor shall provide foot and ankle services for members under the age of 21 to include bunionectomies, casting for the purpose of constructing or accommodating orthotics, medically necessary orthopedic shoes that are an integral part of a brace, and medically necessary routine foot care for patients with a severe systemic disease that prohibits care by a non-professional person.

Adults: The Contractor shall provide foot and ankle care services to include wound care, treatment of pressure ulcers, fracture care, reconstructive surgeries, and limited bunionectomy services. Medically necessary routine foot care services are only available for members with a severe systemic disease that prohibits care by a non-professional person as described in the AMPM.

Pursuant to A.R.S. §36-2907, podiatry services performed by a podiatrist licensed pursuant to A.R.S. Title 32, Chapter 7 are covered for members when ordered by a primary care physician or primary care practitioner.

Home and Community Based Services: Assisted living facility, alternative residential setting, or Home and Community Based Services (HCBS) as defined in A.A.C. R9-22 Article 2, and A.A.C. R9-28 Article 2 that meet the provider standards described in A.A.C. R9-28 Article 5, and subject to the limitations set forth in the AMPM. These services are covered in lieu of a nursing facility.

Home Health: This service shall be provided under the direction of a physician to prevent hospitalization or institutionalization and may include nursing, therapies, supplies and home health aide services. It shall be provided on a part-time or intermittent basis.

 

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Hospice: These services are covered for members who are certified by a physician as being terminally ill and having six months or less to live. See the AMPM for details on covered hospice services.

Hospital: Inpatient services include semi-private accommodations for routine care, intensive and coronary care, surgical care, obstetrics and newborn nurseries, and behavioral health emergency/crisis services. If the member’s medical condition requires isolation, private inpatient accommodations are covered. Nursing services, dietary services and ancillary services such as laboratory, radiology, pharmaceuticals, medical supplies, blood and blood derivatives, etc. are also covered. Outpatient hospital services include any of the above services which may be appropriately provided on an outpatient or ambulatory basis (i.e., laboratory, radiology, therapies, ambulatory surgery, etc.). Observation services may be provided on an outpatient basis, if determined reasonable and necessary to decide whether the member should be admitted for inpatient care. Observation services include the use of a bed and periodic monitoring by hospital nursing staff and/or other staff to evaluate, stabilize or treat medical conditions of a significant degree of instability and/or disability. Refer to the AMPM for limitations on hospital stays.

Immunizations: The Contractor shall provide medically necessary immunizations for adults 21 years of age and older. Refer to the AMPM for current immunization requirements. The Contractor is required to meet specific immunization rates for members under the age of 21, which are described in Section D, Paragraph 23, Quality Management and Performance Improvement.

Incontinence Briefs: In general, incontinence briefs (diapers) are not covered for members unless medically necessary to treat a medical condition. However, for AHCCCS members over three years of age and under 21 years of age incontinence briefs, including pull-ups and incontinence pads, are also covered to prevent skin breakdown and to enable participation in social community, therapeutic, and educational activities under limited circumstances. In addition, effective December 15, 2014 for members in the ALTCS Program who are 21 years of age and older, incontinence briefs, including pull-ups and incontinence pads are also covered in order to prevent skin breakdown as outlined in AMPM Policy 310-P. See A.A.C. R9-22-212 and AMPM Chapters 300 and 400.

Laboratory: Laboratory services for diagnostic, screening and monitoring purposes are covered when ordered by the member’s PCP, other attending physician or dentist, and provided by a free-standing laboratory or hospital laboratory, clinic, physician office or other health care facility laboratory with Clinical Laboratory Improvement Act (CLIA) licensure or a Certificate of Waiver.

Upon written request, the Contractor may obtain laboratory test data on members from a laboratory or hospital-based laboratory subject to the requirements specified in A.R.S. §36-2903(Q) and (R). The data shall be used exclusively for quality improvement activities and health care outcome studies required and/or approved by AHCCCS.

Maternity: The Contractor shall provide pregnancy identification, prenatal care, treatment of pregnancy related conditions, labor and delivery services, and postpartum care for members. Services may be provided by physicians, physician assistants, nurse practitioners, certified nurse midwives, or licensed midwives. Members may select or be assigned to a PCP specializing in obstetrics while they are pregnant. Members anticipated to have a low-risk delivery, may elect to receive labor and delivery services in their home from their maternity provider, if this setting is included in the allowable settings for the Contractor, and the Contractor has providers in its network that offer home labor and delivery services. Members anticipated to have a low-risk prenatal course and delivery may elect to receive maternity services of prenatal care, labor and delivery and postpartum care provided by certified nurse midwives or licensed midwives, if they are in the Contractor’s provider network. Members receiving maternity services from a certified nurse midwife or a licensed midwife must also be assigned to a PCP for other health care and medical services. A certified nurse midwife may provide those primary care services that they are willing to provide and that the member elects to receive from the certified nurse midwife. Members receiving care from a certified nurse midwife may also elect to receive some or all her primary care from the assigned PCP. Licensed midwives may not provide any

 

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additional medical services as primary care is not within their scope of practice. Members who transition to a new Contractor or become enrolled during their third trimester must be allowed to complete maternity care with their current AHCCCS registered provider, regardless of contractual status, to ensure continuity of care.

The Contractor shall allow women and their newborns to receive up to 48 hours of inpatient hospital care after a routine vaginal delivery and up to 96 hours of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the mother, may discharge the mother or newborn prior to the minimum length of stay. A normal newborn may be granted an extended stay in the hospital of birth when the mother’s continued stay in the hospital is beyond the 48 or 96 hour stay.

The Contractor shall inform all assigned AHCCCS pregnant women of voluntary prenatal HIV/AIDS testing and the availability of medical counseling, if the test is positive. The Contractor shall provide information in the Member Handbook and annually in the member newsletter, to encourage pregnant women to be tested and instructions about where to be tested. Semi-annually, the Contractor shall report to AHCCCS, Division of Health Care Management (DHCM) the number of pregnant women who have been identified as HIV/AIDS-positive for each quarter during the contract year. This report is due as specified in Attachment F3, Contractor Chart of Deliverables.

Medical Foods: Medical foods are covered within limitations defined in the AMPM for members diagnosed with a metabolic condition included under the ADHS Newborn Screening Program and as specified in the AMPM. The medical foods, including metabolic formula and modified low protein foods, must be prescribed or ordered under the supervision of a physician.

Medical Supplies, Durable Medical Equipment (DME), and Prosthetic Devices: These services are covered when prescribed by the member’s PCP, attending physician or practitioner, or by a dentist as described in the AMPM. Prosthetic devices must be medically necessary and meet criteria as described in the AMPM. For persons age 21 or older, AHCCCS will not pay for microprocessor controlled lower limbs and microprocessor controlled joints for lower limbs. Medical equipment may be rented or purchased only if other sources are not available which provide the items at no cost. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit.

Nursing Facility: The Contractor shall provide services in nursing facilities, including religious non-medical health care institutions, for members who require short-term convalescent care not to exceed 90 days per contract year. In lieu of a nursing facility, the member may be placed in an assisted living facility, an alternative residential setting, or receive Home and Community Based Services (HCBS) as defined in A.A.C. R9-22 Article 2 and A.A.C. R9-28 Article 2 that meet the provider standards described in A.A.C. R9-28 Article 5, and subject to the limitations set forth in the AMPM.

Nursing facility services must be provided in a dually-certified Medicare/Medicaid nursing facility, which includes in the per-diem rate: nursing services; basic patient care equipment and sickroom supplies; dietary services; administrative physician visits; non-customized DME; necessary maintenance and rehabilitation therapies; over-the-counter medications; social, recreational and spiritual activities; and administrative, operational medical direction services. See Section D, Paragraph 41, Responsibility for Nursing Facility Reimbursement, for further details.

The Contractor shall notify the Assistant Director of the Division of Member Services, by Email, when a member has been residing in a nursing facility, alternative residential facility or receiving home and community based services for 45 days. This will allow AHCCCS time to follow-up on the status of the ALTCS application and to consider potential Fee-For-Service coverage, if the stay goes beyond the 90 day per contract year maximum. The notice should be sent via e-mail to HealthPlan45DayNotice@azahcccs.gov.

 

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Notifications must include:

 

a. Member Name

 

b. AHCCCS ID

 

c. Date of Birth

 

d. Name of Facility

 

e. Admission Date to the Facility

 

f. Date the member will reach the 90 days

 

g. Name of Contractor of enrollment

Nutrition: Nutritional assessments are conducted as a part of the EPSDT screenings for members under age 21, and to assist members 21 years of age and older whose health status may improve with over- and under-nutritional intervention. Assessment of nutritional status on a periodic basis may be provided as determined necessary, and as a part of the health risk assessment and screening services provided by the member’s PCP. Assessments may also be provided by a registered dietitian when ordered by the member’s PCP. AHCCCS covers nutritional therapy on an enteral, parenteral or oral basis, when determined medically necessary, according to the criteria specified in the AMPM, to provide either complete daily dietary requirements or to supplement a member’s daily nutritional and caloric intake.

Oral Health: The Contractor shall provide all members under the age of 21 years with all medically necessary dental services including emergency dental services, dental screening, preventive services, therapeutic services and dental appliances in accordance with the AHCCCS Dental Periodicity Schedule. The Contractor shall monitor compliance with the AHCCCS Dental Periodicity Schedule for dental screening services. The Contractor must develop processes to assign members to a dental home by one year of age and communicate that assignment to the member. The Contractor must regularly notify the oral health professional which members have been assigned to the provider’s dental home for routine preventative care as outlined in AMPM Chapter 400. The Contractor is required to meet specific utilization rates for members as described in Section D, Paragraph 23, Quality Management and Performance Improvement. The Contractor shall ensure that members are notified in writing when dental screenings are due, if the member has not been scheduled for a visit. If a dental screening is not received by the member, a second written notice must be sent. Members under the age of 21 may request dental services without referral and may choose a dental provider from the Contractor’s provider network.

Pursuant to A.A.C. R9-22-207, for members who are 21 years of age and older, the Contractor shall cover medical and surgical services furnished by a dentist only to the extent such services may be performed under State law either by a physician or by a dentist. These services would be considered physician services if furnished by a physician. Limited dental services are covered for pre-transplant candidates and for members with cancer of the jaw, neck or head. See AMPM for specific details.

Orthotics: Orthotics are covered for AHCCCS members under the age of 21 as outlined in AMPM Policy 430. Orthotics are covered for AHCCCS members 21 years of age and older if all of the following apply:

 

1. The use of the orthotic is medically necessary as the preferred treatment option and consistent with Medicare guidelines;

 

2. The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition; and

 

3. The orthotic is ordered by a physician or primary care practitioner.

Medical equipment may be rented or purchased only if other sources, which provide the items at no cost, are not available. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered for all members over and under the age of 21 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit. The component will be replaced if at the time authorization is sought documentation is provided to establish that the component is not operating effectively.

 

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Physician: The Contractor shall provide physician services to include medical assessment, treatments and surgical services provided by licensed allopathic or osteopathic physicians.

Poststabilization Care Services: Pursuant to A.A.C. R9-22-210 and 42 CFR 438.114, 422.113(c) and 422.133, the following conditions apply with respect to coverage and payment of emergency and of poststabilization care services, except where otherwise noted in the contract:

The Contractor must cover and pay for poststabilization care services without authorization, regardless of whether the provider that furnishes the service has a contract with the Contractor, for the following situations:

 

a. Poststabilization care services that were pre-approved by the Contractor;

 

b. Poststabilization care services were not pre-approved by the Contractor because the Contractor did not respond to the treating provider’s request for pre-approval within one hour after being requested to approve such care or could not be contacted for pre-approval;

 

c. The Contractor representative and the treating physician cannot reach agreement concerning the member’s care and a Contractor physician is not available for consultation. In this situation, the Contractor must give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with care of the patient until a Contractor physician is reached or one of the criteria in 42 CFR 422.113(c)(3) is met.

Pursuant to 42 CFR 422.113(c)(3), the Contractor’s financial responsibility for poststabilization care services that have not been pre-approved ends when:

 

a. A Contractor physician with privileges at the treating hospital assumes responsibility for the member’s care;

 

b. A Contractor physician assumes responsibility for the member’s care through transfer;

 

c. A Contractor representative and the treating physician reach an agreement concerning the member’s care; or

 

d. The member is discharged.

Pregnancy Terminations: AHCCCS covers pregnancy termination if the pregnant member suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the member in danger of death unless the pregnancy is terminated, or the pregnancy is a result of rape or incest.

The attending physician must acknowledge that a pregnancy termination has been determined medically necessary by submitting the Certificate of Necessity for Pregnancy Termination. This certificate must be submitted to the Contractor’s Medical Director and meet the requirements specified in the AMPM. The Certificate must certify that, in the physician’s professional judgment, the criteria have been met.

Prescription Medications: Medications ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the direction of a licensed pharmacist are covered subject to limitations related to prescription supply amounts, Contractor formularies and prior authorization requirements. An appropriate over-the-counter medication may be prescribed as defined in the AMPM when it is determined to be a lower-cost alternative to a prescription medication. The Contractor shall comply with AMPM Policy 310-V.

Pharmaceutical Rebates: The Contractor, including the Contractor’s Pharmacy Benefit Manager (PBM), is prohibited from negotiating any rebates with drug manufacturers for preferred or other pharmaceutical products when AHCCCS has a supplemental rebate contract for the product(s). A listing of products covered under supplemental rebate agreements will be available on the AHCCCS website under the Pharmacy Information section.

 

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If the Contractor or its PBM has an existing rebate agreement with a manufacturer, all outpatient drug claims, including provider-administered drugs for which AHCCCS is obtaining supplemental rebates, must be exempt from such rebate agreements. For pharmacy related encounter data information Section D, Paragraph 65, Encounter Data Reporting.

Medicare Part D: The Medicare Modernization Act of 2003 (MMA) created a prescription drug benefit called Medicare Part D for individuals who are eligible for Medicare Part A and/or enrolled in Medicare Part B. AHCCCS does not cover prescription drugs that are covered under Part D for dual eligible members. AHCCCS will not cover prescription drugs for this population whether or not they are enrolled in Medicare Part D. AHCCCS covers federally reimbursable drugs ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed by or under the direction of a licensed pharmacist, in accordance with Arizona State Board of Pharmacy Rules and Regulations, subject to limitations related to prescription supply amounts, and the Contractor’s prior authorization requirements if they are excluded from Medicare Part D coverage. Medications that are covered by Part D, but are not on a specific Part D Health Plan’s formulary are not considered excluded drugs and are not covered by AHCCCS. This applies to members who are enrolled in Medicare Part D or are eligible for Medicare Part D. See AMPM Chapter 300, Section 310-V.

340B Drug Pricing Program: All federally reimbursable drugs identified in the 340B Drug Pricing Program are required to be billed at the lesser of: 1) the actual acquisition cost of the drug or 2) the 340B ceiling price. The Contractor shall ensure that these drugs be reimbursed at the lesser of the two amounts above plus a professional (dispensing) fee. See Laws 2016, Second Regular Session, Chapter 122, A.R.S. §36-2930.03, and A.A.C. R9-22-710 (C) for further details. The 340B drug pricing program includes:

 

Eligible Organizations and Covered Entities

  

Effective Date

Drugs dispensed by FQHC/RHC and FQHC Look-Alike 340B pharmacies    Already implemented
Drugs dispensed by other 340B covered entities    Effective the later of January 1, 2017 or upon CMS approval
Drugs administered by 340B entity providers (including drugs administered by physicians)    To Be Determined during CYE 17
Drugs dispensed by licensed hospitals and outpatient facilities that are owned or operated by a licensed hospital    Excluded from 340B reimbursement mandate at this time
Drugs administered by providers in licensed hospital and outpatient facilities that are owned or operated by a licensed hospital.    Excluded from 340B reimbursement mandate at this time

The Contractor is required to comply with any changes to reimbursement methodology for 340B entities.

Primary Care Provider: Primary Care Provider (PCP) services are covered when provided by a physician, physician assistant or nurse practitioner selected by, or assigned to, the member. The PCP provides primary health care and serves as a coordinator in referring the member for specialty medical services [42 CFR 438.208(b)]. The PCP is responsible for maintaining the member’s primary medical record, which contains documentation of all health risk assessments and health care services of which they are aware whether or not they were provided by the PCP.

 

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Radiology and Medical Imaging: These services are covered when ordered by the member’s PCP, attending physician or dentist and are provided for diagnosis, prevention, treatment or assessment of a medical condition.

Rehabilitation Therapy: The Contractor shall provide occupational, physical and speech therapies. Therapies must be prescribed by the member’s PCP or attending physician for an acute condition and the member must have the potential for improvement due to the rehabilitation.

Occupational and Speech therapy is covered for all members receiving inpatient hospital (or nursing facility services). Occupational Therapy and Speech therapy services provided on an outpatient basis are only covered for members under the age of 21. Physical Therapy is covered for all members in both inpatient and outpatient settings. Outpatient physical therapy for members 21 years of age or older are subject to visit limits per contract year as described in the AMPM.

Respiratory Therapy: Respiratory therapy is covered when prescribed by the member’s PCP or attending physician, and is necessary to restore, maintain or improve respiratory functioning.

Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs: These services are covered within limitations defined in the AMPM for members diagnosed with specified medical conditions. Services include: pre-transplant inpatient or outpatient evaluation; donor search; organ/tissue harvesting or procurement; preparation and transplantation services; and convalescent care. In addition, if a member receives a transplant covered by a source other than AHCCCS, medically necessary non-experimental services are provided, within limitations, after the discharge from the acute care hospitalization for the transplantation. AHCCCS maintains specialty contracts with transplantation facility providers for the Contractor’s use or the Contractor may select its own transplantation provider. Refer to Section D, Paragraph 57, Reinsurance.

Transportation: These services include emergency and non-emergency medically necessary transportation. Emergency transportation, including transportation initiated by an emergency response system such as 911, may be provided by ground, air or water ambulance to manage an AHCCCS member’s emergency medical condition at an emergency scene and transport the member to the nearest appropriate medical facility. Non-emergency transportation shall be provided for members who are unable to provide or secure their own transportation for medically necessary services using the appropriate mode based on the needs of the member. The Contractor shall ensure that members have coordinated, reliable, medically necessary transportation to ensure members arrive on-time for regularly scheduled appointments and are picked up upon completion of the entire scheduled treatment.

Treat and Refer: Interaction with an individual who has accessed 911 or a similar public emergency dispatch number, but whose illness or injury does not require ambulance transport to an emergency department based on the clinical information available at that time. The interaction must include: (1) documentation of an appropriate clinical and/or social evaluation, (2) a treatment/referral plan for accessing social, behavioral, and/or healthcare services that address the patient’s immediate needs, and (3) evidence of efforts to follow-up with the patient to ascertain adherence with the treatment plan, and (4) documentation of efforts to assess customer satisfaction with the treat and refer visit. Treat and Refer standing orders shall be consistent with medical necessity and consider patient preference when the clinical condition allows.

Triage/Screening and Evaluation: These are covered services when provided by an acute care hospital, an IHS or 638 tribal facility and after-hours settings to determine whether or not an emergency exists, assess the severity of the member’s medical condition and determine services necessary to alleviate or stabilize the emergent condition. Triage/screening services must be reasonable, cost effective and meet the criteria for severity of illness and intensity of service.

Vision Services/Ophthalmology/Optometry: The Contractor shall provide all medically necessary emergency eye care, vision examinations, prescriptive lenses, frames, and treatments for conditions of the eye for all members under the age of 21. For members who are 21 years of age and older, the Contractor shall provide

 

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emergency care for eye conditions which meet the definition of an emergency medical condition. Vision examinations and the provision of prescriptive lenses are covered for adults when medically necessary following cataract removal. Medically necessary vision examinations and prescriptive lenses and frames are covered if required following cataract removal. Refer to AMPM Chapter 300.

Members shall have full freedom to choose, within the Contractor’s network, a practitioner in the field of eye care, acting within the scope of their practice, to provide the examination, care or treatment for which the member is eligible. A “practitioner in the field of eye care” is defined to be either an ophthalmologist or an optometrist.

Well Exams: Well visits, such as, but not limited to, well woman exams, breast exams, and prostate exams are covered for members 21 years of age and older. For members under 21 years of age, AHCCCS continues to cover medically necessary services under the EPSDT Program.

ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Support Services (State Only): Support services including, but not limited to, prevention education, ongoing support to maintain employment, and supported housing, are provided by the Regional Behavioral Health Authorities (RBHAs) as outlined in the AHCCCS Covered Behavioral Health Services Guide, to facilitate the delivery of or enhance the benefit received from other behavioral health services. The Contractor shall assist members with how to access support services and shall coordinate care for the member as appropriate.

 

11. SPECIAL HEALTH CARE NEEDS

AHCCCS has specified in its Quality Assessment and Performance Improvement Strategy certain populations with special health care needs as defined by the State [42 CFR 438.208(c)(1)].v

Members with special health care needs are those members who have serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that required by members generally. A member will be considered as having special health care needs if the medical condition simultaneously meets the following criteria:vi

 

a. Lasts or is expected to last one year or longer, and

 

b. Requires ongoing care not generally provided by a primary care provider.

AHCCCS has determined that the following populations meet this definition:vii

 

a. Members who are recipients of services provided through the Children’s Rehabilitative Services (CRS) program

 

b. Members who are recipients of services provided through the contracted Regional Behavioral Health Authorities (RBHAs), and

 

c. Members diagnosed with HIV/AIDS

 

d. Arizona Long Term Care System:

 

    Members enrolled in the ALTCS program who are elderly and/or have a physically disability, and

 

    Members enrolled in the ALTCS program who have a developmental disability.

AHCCCS monitors quality and appropriateness of care/services for routine and special health care needs members through annual Operational and Financial Reviews of Contractors and the review of required Contractor deliverables set forth in contract, program specific performance measures, and performance improvement projects.viii

 

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The Contractor shall have in place a mechanism to identify all members with special health care needs [42 CFR 438.240(b)(4)]. The Contractor shall implement mechanisms to assess each member identified as having special health care needs, in order to identify any ongoing special conditions of the member which require a course of treatment, regular care monitoring, or transition to another AHCCCS program. The assessment mechanisms shall use appropriate health care professionals [42 CFR 438.208(c)(2)]. The Contractor shall share with other entities providing services to the member the results of its identification and assessment of that member’s needs so that those activities need not be duplicated [42 CFR 438.208(b)(3)].

For members with special health care needs determined to need a specialized course of treatment or regular care monitoring, the Contractor must have procedures in place to allow members to directly access a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified needs [42 CFR 438.208(c)(4)]. For members transitioning, see Section D, Paragraph 9, Transition Activities.

The Contractor shall have a methodology to identify providers willing to provide medical home services and make reasonable efforts to offer access to these providers.

The American Academy of Pediatrics (AAP) describes care from a medical home as:

 

    Accessible

 

    Continuous

 

    Coordinated

 

    Family-centered

 

    Comprehensive

 

    Compassionate

 

    Culturally effective

The Contractor shall ensure that populations with ongoing medical needs, including but not limited to dialysis, radiation and chemotherapy, have coordinated, reliable, medically necessary transportation to ensure members arrive on-time for regularly scheduled appointments and are picked up upon completion of the entire scheduled treatment. See Section D, Paragraph 33, Appointment Standards.

 

12. BEHAVIORAL HEALTH SERVICES

With the exception of adult dual members receiving general mental health and substance abuse services as referenced below, AHCCCS members enrolled with an Acute Care Contractor receive behavioral health services through a Regional Behavioral Health Authority (RBHA) or for American Indians, through a Tribal/Regional Behavioral Health Authority (T/RBHA) or IHS or 638 tribal facility. Behavioral health services include but are not limited to screening, treatment and assistance in coordinating care between the acute and behavioral health providers.

For all enrolled members, the Contractor is responsible for the following:

SMI Eligibility: For TXIX eligible adults enrolled with the Contractor who are later determined to have a Serious Mental Illness (SMI), the member shall be transitioned to a RBHA as outlined in Paragraph 3, Enrollment and Disenrollment. The RBHA will provide the full continuum of care including all physical and behavioral health care as well as supportive services, such as peer and family support, patient education, engagement and follow up.

Member Education: The Contractor shall be responsible for including information in the Member Handbook and other materials to inform members how to access covered behavioral health services. Materials shall include, but not be limited to, information about behavioral health conditions that may be treated by a Primary Care Provider (PCP) which includes anxiety, depression and ADHD. Refer to the AMPM Chapter 300 for covered behavioral health services.

 

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Referrals: Members may self–refer to the T/RBHA system for screening, evaluation or treatment or be referred by schools, State agencies, providers, or other parties.

EPSDT: As specified in Section D, Paragraph 10, Scope of Services, EPSDT, the Contractor must provide behavioral health screenings for members under 21 years of age in compliance with the AHCCCS EPSDT Periodicity Schedule. The Contractor shall ensure the initiation and coordination of behavioral health referrals when determined necessary.

Emergency Services: When members present in an emergency room setting, the Contractor is responsible for payment of all emergency room services and transportation for all members regardless of the principal diagnosis on the emergency room and/or transportation claim. In addition to those emergency services listed above, the Contractor is responsible for payment of the associated professional services when the principal diagnosis on the claim is physical health, as delineated in ACOM Policy 432.

Coordination of Care: For members assigned to a T/RBHA, the Contractor shall meet with the T/RBHAs to improve and address coordination of care issues. The Contractor shall ensure that information and training is available to PCPs regarding behavioral health coordination of care processes. The Contractor shall establish policies and procedures for coordination of care and shall describe them in its provider manual. Policies for referral must include, at a minimum, criteria, processes, responsible parties and minimum requirements no less stringent than those specified in this contract for the forwarding of member medical information.

The Contractor shall ensure that its quality management program incorporates monitoring of the PCP’s management of behavioral health disorders, coordination of care with, and transfer of care to T/RBHA providers as required under this contract.

Medical Records: The Contractor is responsible for ensuring that a medical record is established by the PCP when behavioral health information is received from the T/RBHA or the behavioral health provider about a member assigned to the PCP even if the PCP has not yet seen the assigned member. In lieu of establishing a medical record, the information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established.

Sharing of Data: On a recurring basis (no less than quarterly based on adjudication date), AHCCCS shall provide the Contractor an electronic file of claims and encounter data for members enrolled with the Contractor who have received services, during the member’s enrollment period, from another contractor or through AHCCCS FFS for purposes of member care coordination. Data sharing will comply with Federal privacy regulations.

Sharing of Records: The Contractor shall, within 10 business days of receiving the request, require the PCP to coordinate care and respond to T/RBHA and/or behavioral health provider information requests pertaining to members receiving services through the behavioral health system. The response should include, but is not limited to, current diagnoses, medications, laboratory results, most recent PCP visit, and information about recent hospital and emergency room visits. The Contractor will ensure coordination of referrals and follow-up collaboration, as necessary, for members identified by the behavioral health provider as needing acute care services. For guidance in addressing the needs of members with multi system involvement and complex behavioral health and co-occurring conditions, refer to AMPM Policy 570, Community Collaborative Care Teams.

Arizona State Hospital: For enrolled members who are inpatient at the Arizona State Hospital (AzSH), the Contractor is required to follow ACOM Policy 432 and AMPM Policy 1020 regarding medical care coordination for these members.

 

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Home Health Services: In the event that a member’s mental health status renders them incapable or unwilling to manage their medical condition and the member has a skilled medical need, the Contractor must arrange ongoing medically necessary nursing services. The Contractor shall also have a mechanism in place for tracking members for whom ongoing medically necessary services are required. This service shall be provided under the direction of a physician to prevent hospitalization or institutionalization and may include nursing, therapies, supplies and home health aide services. It shall be provided on a part-time or intermittent basis. The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) for home health care services provided by an agency or organization, unless AHCCCS Provider Registration verifies compliance with the surety bond requirements specified in Sections 1861(o)(7) and 1903(i)(18) of the Social Security Act.ix

Medication Management Services: The Contractor shall allow PCPs to treat members diagnosed with anxiety, depression and Attention Deficit Hyperactivity Disorder (ADHD). For purposes of medication management, it is not required that the PCP be the member’s assigned PCP. PCPs who treat members with these behavioral health conditions may provide medication management services including prescriptions, laboratory and other diagnostic tests necessary for diagnosis, and treatment. The Contractor shall make available, on the Contractor’s formulary, medications for the treatment of these disorders. The Contractor is responsible for these services both in the prospective and prior period coverage timeframes.

Tool Kits: Clinical tool kits for the treatment of anxiety, depression, and ADHD are available in the AMPM. Refer to AMPM Appendix E, Childhood and Adolescent Behavioral Health Tool Kits and Appendix F Behavioral Health Tool Kits. These tool kits are a resource only and may not apply to all patients and all clinical situations. The tool kits are not intended to replace clinical judgment. The Contractor shall ensure that PCPs who have an interest or are actively treating members with these disorders are aware of these resources and/or are utilizing other recognized, clinical tools/evidence-based guidelines. The Contractor shall develop a monitoring process to ensure that PCPs utilize evidence-based guidelines/recognized clinical tools when prescribing medications to treat depression, anxiety, and ADHD.

Step Therapy: The Contractor may implement step therapy for behavioral health medications used for treating anxiety, depression and ADHD disorders. The Contractor shall provide education and training for providers regarding the concept of step therapy. If the T/RBHA/behavioral health provider provides documentation to the Contractor that step therapy has already been completed for the conditions of anxiety, depression or ADHD, or that step therapy is medically contraindicated, the Contractor shall continue to provide the medication at the dosage at which the member has been stabilized by the behavioral health provider. In the event the PCP identifies a change in the member’s condition, the PCP may utilize step therapy until the member is stabilized for the condition of anxiety, depression or ADHD. The Contractor shall monitor PCPs to ensure that they prescribe medication at the dosage at which the member has been stabilized.

Access to Services: For member assigned to a T/RBHA, the Contractor is responsible for providing transportation to a member’s first T/RBHA evaluation appointment if the member is unable to provide their own transportation. The Contractor shall be responsible for meeting the appointment standards found in Section D, Paragraph 33, Appointment Standards.

Transfer of Care: When a PCP has initiated medication management services for a member to treat a behavioral health disorder, and it is subsequently determined by the PCP that the member should be transferred to a T/RBHA/ behavioral health provider for evaluation and/or continued medication management services, the Contractor shall require and ensure that the PCP coordinates the transfer of care. All affected subcontracts shall include this provision.

For members assigned to a T/RBHA, the Contractor shall establish policies and procedures for the transition of members to the T/RBHA for ongoing treatment. The Contractor shall ensure that PCPs maintain continuity of care for these members.

 

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The policies and procedures must address, at a minimum, the following:

 

1. Guidelines for when a transition of the member to the T/RBHA for ongoing treatment is indicated;

 

2. Protocols for notifying the T/RBHA of the member’s transfer, including reason for transfer, diagnostic information, and medication history;

 

3. Protocols and guidelines for the transfer or sharing of medical records information and protocols for responding to T/RBHA requests for additional medical record information;

 

4. Protocols for transition of prescription services, including but not limited to notification to the T/RBHA of the member’s current medications and timeframes for dispensing and refilling medications during the transition period. This coordination must ensure at a minimum, that the member does not run out of prescribed medications prior to the first appointment with a T/RBHA prescriber and that all relevant member medical information including the reason for transfer is forwarded to the receiving T/RBHA prescriber prior to the member’s first scheduled appointment with the T/RBHA prescriber; and

 

5. Contractor monitoring activities to ensure that members are appropriately transitioned to the T/RBHA for care.

Integrated Services: The Contractor is encouraged to develop specific strategies to promote care integration activities. These strategies may include but are not limited to contracting with T/RBHAs or behavioral health providers as well as establishing integrated settings which serve members’ primary care and behavioral health needs. The Contractor should consider the behavioral health needs, in addition to the primary health care needs, of members during network development to improve member access to care, care coordination and to reduce duplication of services.

ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

Effective, October 1, 2015, AHCCCS dual members 18 years of age and older who are receiving general mental health and substance abuse services and who are enrolled with the Contractor will receive behavioral health services through the Contractor. Prior to October 1, 2015, these services were provided through a T/RBHA. Choices for American Indian members are described in Section D, Paragraph 3, Enrollment and Disenrollment.

Behavioral Health services are described in detail in the AHCCCS Covered Behavioral Health Services Guide and the AMPM. Covered services include:

 

1. Behavior Management (personal care, family support/home care training, peer support)

 

2. Behavioral Health Case Management Services (with limitations)

 

3. Behavioral Health Nursing Services

 

4. Emergency Behavioral Health Care

 

5. Emergency and Non-Emergency Transportation

 

6. Evaluation and Assessment

 

7. Individual, Group and Family Therapy and Counseling

 

8. Inpatient Hospital Services

 

9. Behavioral Health Inpatient Facilities

 

10. Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosis

 

11. Opioid Agonist Treatment

 

12. Partial Care (Supervised day program, therapeutic day program and medical day program)

 

13. Psychosocial Rehabilitation (living skills training; health promotion; supportive employment services)

 

14. Psychotropic Medication

 

15. Psychotropic Medication Adjustment and Monitoring

 

16. Respite Care (with limitations)

 

17. Substance Abuse Transitional Facility Services

 

18. Screening

 

19. Home Care Training to Home Care Client

 

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The Contractor shall ensure that all behavioral health services provided are medically necessary as determined by a qualified behavioral health professional. Psychiatrists, psychologists, physician assistants, certified psychiatric nurse practitioners, licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists and licensed independent substance abuse counselors may bill independently. Other behavioral health professionals must be employed by or contracted with and bill through an AHCCCS registered behavioral health provider.

The Contractor’s network shall include Master’s level and doctoral trained clinicians in the fields of social work, counseling, and psychology that are trained in implementation of best practices for medically and behaviorally complex conditions such as intellectual/cognitive disabilities, trauma related disorders, substance abuse, sexual disorders, and special age groups such as transition age youth and members aged birth to five years old.

Behavioral health needs shall be assessed and services provided in collaboration with the member, the member’s family and all others involved in the member’s care, including other agencies or systems. Services shall be accessible and provided by competent individuals who are adequately trained and supervised. The strengths and needs of the member and their family shall determine the types and intensity of services. Services should be provided in a manner that respects the member and family’s cultural heritage and appropriately utilizes natural supports in the member’s community.

Transition: Transition of members for behavioral health services provided through the Contractor will occur under two circumstances:

 

1. Members who are dually eligible will be transitioned to the Contractor to receive their behavioral health services when turning 18 years of age and have a change in behavioral health category from ‘child’ to ‘general mental health/substance abuse’.

 

2. Members who have a behavioral health category of ‘general mental health/substance abuse’ will be transitioned to the Contractor to receive their behavioral health services when they become dually eligible.

SMI Eligibility Evaluation and Determination: Payment for evaluations for adult dual members who are receiving general mental health and substance abuse services conducted for the purpose of an SMI determination is the responsibility of the Contractor. The Contractor shall ensure evaluations are sent to the Crisis Response Network (CRN) which conducts all SMI eligibility determinations statewide.

Referrals: The Contractor shall develop, monitor and continually evaluate its processes for timely referral, evaluation and treatment planning for behavioral health services. Requests for behavioral health services made by the member, family, guardian, or any health care professional shall be assessed by the Contractor for appropriateness within three business days of the request. If it is determined services are needed, a referral for evaluation shall be made within one business day and the initial appointment shall be secured in accordance with appointment standards. See Paragraph 33, Appointment Standards.

Emergency Services: When members present in an emergency room setting, the Contractor is responsible for payment of all emergency room services and transportation for all members regardless of the principal diagnosis on the emergency room and/or transportation claim. In addition to those emergency services listed above, the Contractor is responsible for payment of the associated professional services regardless of the principal diagnosis on the claim, as delineated in ACOM Policy 432.

Crisis Services: Crisis services shall be community based, recovery-oriented, and member focused and shall work to stabilize individuals as quickly as possible to assist them in returning to their baseline of functioning. The Regional Behavioral Health Authorities (RBHAs) within the Contractor’s geographic service area(s) are responsible for the delivery of timely crisis services, including telephone, community-based mobile, and

 

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facility-based stabilization (including observation not to exceed 24 hours). See Covered Behavioral Health Services Guide, Section II. E. The RBHAs are responsible for notifying the Contractor within 24 hours of a member engaging in crisis services so subsequent services can be initiated by the Contractor.

The Contractor is responsible for all other medically necessary services related to a crisis episode. The Contractor shall develop policies and procedures to ensure timely communication with RBHAs for members that have engaged crisis services. The Contractor shall ensure timely follow up and care coordination for members after receiving crisis services, whether the member received services within, or outside the Contractor’s GSA at the time services were provided, to ensure stabilization of the member and appropriate delivery of ongoing necessary treatment and services.

The Contractor shall:

 

1. Assess the individual‘s needs, identify the supports and services that are necessary to meet those needs, and connect the individual to appropriate services;

 

2. Provide solution-focused and recovery-oriented interventions designed to avoid unnecessary hospitalization, incarceration, or placement in a more segregated setting; and

 

3. Utilize the engagement of peer and family support services in providing crisis services.

Court Ordered Treatment: The Contractor shall develop a collaborative process with the counties to ensure coordination of care and information sharing for timely access to court ordered evaluation services and treatment. Reimbursement for court ordered screening and evaluation services are the responsibility of the County pursuant to A.R.S. §36-545. Refer to ACOM Policy 437 for clarification regarding financial responsibility for the provision of medically necessary behavioral health services rendered after the completion of a court ordered evaluation, and ACOM Policy 423 for clarification regarding the financial responsibility for the provision of specific mental health treatment/care when such treatment is ordered as a result of a judicial ruling. For additional information regarding behavioral health services refer to Title 9 Chapter 22 Articles 2 and 12.

The Contractor shall develop policies that outline its role and responsibility related to the treatment of individuals who are unable or unwilling to consent to treatment. The policy must be submitted for review as specified in Attachment F3, Contractor Chart of Deliverables. The policy must address:

 

1. Involuntary evaluation/petitioning

 

2. Court ordered process, including tracking the status of court orders

 

3. Execution of court order, and

 

4. Judicial review

Community Service Agencies: The Contractor may contract with community service agencies for the delivery of covered behavioral health services. Refer to the AHCCCS Covered Behavioral Health Services Guide, available on the AHCCCS website, for more information and limitations.

Monitoring, Training and Education: The Contractor is responsible for training the Behavioral Health Coordinator/staff and providers, in sufficient detail and frequency, to identify and screen for members’ behavioral health needs. At a minimum, training shall include information regarding covered behavioral health services and referrals, how to access services, including the petitioning process, how to involve the member and their family in decision-making and service planning. The Contractor shall establish policies and procedures for referral and consultation and shall describe them in its provider manual. Training for Behavioral Health Coordinator/staff and providers may be provided through employee orientation, clinical in-services and/or information sharing via newsletters, brochures, etc. The Contractor shall maintain documentation of the behavioral health trainings in accordance with AMPM Policy 310.

 

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13. AHCCCS GUIDELINES, POLICIES AND MANUALS

All AHCCCS guidelines, policies and manuals, including but not limited to, ACOM, AMPM, Reporting Guides, and Manuals are hereby incorporated by reference into this contract. Guidelines, policies and manuals are available on the AHCCCS website. The Contractor is responsible for ensuring that its subcontractors are notified when modifications are made to the AHCCCS guidelines, policies, and manuals. The Contractor is responsible for complying with all requirements set forth in these sources as well as with any updates. In addition, linkages to AHCCCS rules, statutes and other resources are available through the AHCCCS website. Upon adoption by AHCCCS, updates will be available on the AHCCCS website.

 

14. MEDICAID SCHOOL BASED CLAIMING

Pursuant to an Intergovernmental Agreement with the Department of Education, and a contract with a Third Party Administrator, AHCCCS pays participating school districts for specifically identified Medicaid services when provided to Medicaid eligible children who are included under the Individuals with Disabilities Education Act (IDEA). The Medicaid services must be identified in the member’s Individual Education Plan (IEP) as medically necessary for the child to obtain a public school education. See AMPM Chapter 700.

Medicaid School Based (MSB) services are provided in a school setting or other approved setting specifically to allow children to receive a public school education. They do not replace medically necessary services provided outside the school setting or other MSB approved alternative setting. Currently, services include audiology, therapies (OT, PT and speech/language); behavioral health evaluation and counseling; nursing and attendant care (health aid services provided in the classroom); and specialized transportation to and from school on days when the child receives an AHCCCS-covered MSB service.

The Contractor’s evaluations and determinations of medical necessity shall be made independent of the fact that the child is receiving MSB services. If a request is made for services that also are covered under the MSB program for a child enrolled with the Contractor, the request shall be evaluated on the same basis as any request for a covered service.

The Contractor and its providers should coordinate with schools and school districts that provide MSB services to the Contractor’s enrolled members. Services should not be duplicative. Contractor case managers, working with special needs children, should coordinate with the appropriate school staff working with these members. Transfer of member medical information and progress toward treatment goals between the Contractor and the member’s school or school district is required as appropriate and should be used to enhance the services provided to members.

 

15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM

Through the Vaccines for Children (VFC) program, the Federal and State governments purchase, and make available to providers at no cost, vaccines for AHCCCS children under age 19. The Contractor shall not utilize AHCCCS funding to purchase vaccines for members under the age of 19. If vaccines are not available through the VFC program, the Contractor shall contact the AHCCCS Division of Health Care Management, Clinical Quality Management for guidance. Any provider licensed by the State to administer immunizations, may register with Arizona Department of Health Services (ADHS) as a VFC provider to receive these free vaccines. The Contractor shall not reimburse providers for the administration of the vaccines in excess of the maximum allowable as set by CMS. The Contractor shall comply with all VFC requirements and monitor contracted providers to ensure that physicians are registered as VFC providers when acting as Primary Care Providers (PCP) for members under the age of 19 years.

Due to low numbers of children in their panels providers in certain Geographic Service Areas (GSAs) may choose not to provide vaccinations. Whenever possible, members should be assigned to VFC registered providers within the same or a nearby community. When that is not possible, the Contractor must develop processes to ensure vaccinations are available through a VFC enrolled provider or through the appropriate County Health Department. In all instances, the vaccines are to be provided through the VFC program. The Contractor must develop processes to pay the administration fee to whoever administers the vaccine regardless of their contract status with the Contractor.

 

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Arizona State law requires the reporting of all immunizations given to children under the age of 19. Immunizations must be reported at least monthly to the ADHS Immunization Registry. Reported immunizations are held in a central database known as ASIIS (Arizona State Immunization Information System), which can be accessed by providers to obtain complete, accurate immunization records. Software is available from ADHS to assist providers in meeting this reporting requirement. The Contractor must educate its provider network about these reporting requirements and the use of this resource.

 

16. STAFF REQUIREMENTS AND SUPPORT SERVICES

The Contractor shall have in place the organizational, operational, managerial and administrative systems capable of fulfilling all contract requirements. For the purposes of this contract, the Contractor shall not employ or contract with any individual who has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order 12549 [42 CFR 438.610 (a) & (b), 42 CFR 1001.1901(b), 42 CFR 1003.102(a)(2)]. The Contractor is obligated to screen employees and subcontractors to determine whether they have been excluded from participation in Federal health care programs as outlined in Section D, Paragraph 62, Corporate Compliance.

The Contractor must employ sufficient staff and utilize appropriate resources to achieve contractual compliance. The Contractor’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with contractual and AHCCCS policy requirements. If the Contractor does not achieve the desired outcomes or maintain compliance with contractual obligations, additional monitoring and regulatory action may be employed by AHCCCS. This action may include, but is not limited to, requiring the Contractor to hire additional staff and actions specified in Section D, Paragraph 72, Sanctions.

The Contractor shall have local staff available 24 hours per day, seven days per week to work with AHCCCS and/or other State agencies, such as Arizona Department of Health Services/Office of Licensure, on urgent issue resolutions. Urgent issue resolutions include Immediate Jeopardies (IJ), fires, or other public emergency situations. These staff shall have access to information necessary to identify members who may be at risk and their current health/service status, the ability to initiate new placements/services, and have the ability to perform status checks at affected facilities and perform ongoing monitoring, if necessary. The Contractor shall supply AHCCCS, Clinical Quality Management (CQM) with the contact information for these staff, as specified in Attachment F3, Contractor Chart of Deliverables. At a minimum the contact information shall include a current 24/7 telephone number. CQM must be notified and provided back up contact information when the primary contact person will be unavailable.

For functions not required to be in State, the Contractor must notify AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables, prior to moving functions outside the State of Arizona. The notification must include an implementation plan for the transition.

The Contractor shall be responsible for costs associated with on-site audits or other oversight activities which result when functions are located outside of the State of Arizona.

An individual staff member is limited to occupying a maximum of two of the Key Staff positions listed below, unless prior approval is obtained by AHCCCS, Division of Health Care Management (DHCM). When submitting its functional organizational chart, as specified in Attachment F3, Contractor Chart of Deliverables, the Contractor must document, for each Key Staff position, the portion of time allocated to each Medicaid contract as well as all other lines of business. The Contractor shall also inform AHCCCS DHCM in writing as specified in Attachment F3, Contractor Chart of Deliverables, when an employee leaves one of the Key Staff

 

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positions listed below. The name of the interim contact person should be included with the notification. The name and resume of the permanent employee should be submitted as soon as the new hire has taken place along with a revised Organization Chart complete with Key Staff. If, at any point, the Contractor fails to maintain compliance with contractual obligations, AHCCCS reserves the right to evaluate staffing allocations and require staffing enhancements in order to ensure adherence to established requirements.

At a minimum, the following staff is required:

Key Staff Positions

 

a. Administrator/CEO/COO who is located in Arizona, oversees the entire operation of the Contractor, and have the authority to direct and prioritize work, regardless of where performed.

 

b. Medical Director/CMO who is located in Arizona and who is an Arizona-licensed physician in good standing. The Medical Director shall be actively involved in all major clinical programs and Quality Management and Medical Management components of the Contractor. The Medical Director shall ensure timely medical decisions, including after-hours consultation as needed (see Section D, Paragraph 27, Network Development).

 

c. Chief Financial Officer/CFO who is available to fulfill the responsibilities of the position and to oversee the budget, accounting systems, and financial reporting implemented by the Contractor.

 

d. Pharmacy Director/Coordinator who is an Arizona licensed pharmacist or physician who oversees and administers the prescription drug and pharmacy benefits. The Pharmacy Coordinator/Director may be an employee or Contractor of the Plan.

 

e. Dental Director must be an Arizona licensed general or pediatric dentist in good standing who is located in Arizona and is responsible for leading and coordinating the dental activities of the Contractor including review and denial of dental services, provider consultation, utilization review, and participation in tracking and trending of quality of care issues as related to dental services. The Dental Director must provide required communication between the Contractor and AHCCCS. The Dental Director may be an employee or Contractor of the plan but may not be from the Contractor’s delegated dental subcontractor.

 

f. Corporate Compliance Officer who is located in Arizona and who will implement and oversee the Contractor’s compliance program. The Corporate Compliance Officer shall be a management official, available to all employees, with designated and recognized authority to access records and make independent referrals to the AHCCCS Office of the Inspector General. See Section D, Paragraph 62, Corporate Compliance.

 

g. Dispute and Appeal Manager who is responsible for managing and adjudicating member grievances and appeals, and provider claim disputes, arising under the Grievance and Appeal System and for forwarding all requests for hearing to AHCCCS Office of Administrative Legal Services (OALS) with the requested information. The Dispute and Appeal Manager and any staff under this position who manage and adjudicate disputes and appeals must be located in Arizona. See Section D, Paragraph 26, Grievance and Appeal System.

 

h. Business Continuity Planning Coordinator as noted in ACOM Policy 104.

 

i. Contract Compliance Officer who is located in Arizona and who will serve as the primary point-of-contact for all Contractor operational issues. The primary functions of the Contract Compliance Officer may include but are not limited to coordinate the tracking and submission of all contract deliverables, fielding and coordinating responses to AHCCCS inquiries, and coordinating the preparation and execution of contract requirements such as Operational and Financial Reviews (OFRs), random and periodic audits and ad hoc visits.

 

j. Quality Management Manager who is an Arizona-licensed registered nurse, physician or physician’s assistant or a Certified Professional in Healthcare Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The QM Manager must be located in Arizona and have experience in quality management and quality improvement. Sufficient local staffing to meet the AHCCCS quality management contractual and policy requirements must also be in place. Staff must report directly to the Quality Management Manager. The primary functions of the Quality Management Manager position are:

 

    Ensure individual and systemic quality of care

 

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    Conduct comprehensive quality-of-care investigations

 

    Conduct onsite quality management visits/reviews

 

    Conduct Care Needed Today/Immediate Jeopardy investigations

 

    Integrate quality throughout the organization

 

    Implement process improvement

 

    Resolve, track and trend quality of care grievances

 

    Ensure a credentialed provider network

 

k. Performance/Quality Improvement Coordinator who is located in Arizona and who has a minimum qualification as a CPHQ or CHCQM or comparable education and experience in health plan data and outcomes measurement. Any staff under this position must be sufficient to meet the AHCCCS quality improvement contractual and policy requirements and must be located in Arizona. The primary functions of the Performance/Quality Improvement Coordinator are:

 

    Focus organizational efforts on improving clinical quality performance measures

 

    Develop and implement performance improvement projects

 

    Utilize data to develop intervention strategies to improve outcomes

 

    Report quality improvement/performance outcomes

 

l. Credentialing Coordinator who is located in Arizona and who has appropriate education and/or experience to effectively complete all requirements of the position. The primary functions of the Credentialing Coordinator are:

 

    Serve as the single point of contact to AHCCCS for credentialing-related questions and concerns

 

    Responsible for timely and accurate completion of all credentialing-related deliverables

 

    Ensure all credentialing requirements, including timeframes, are adhered to by the Contractor

 

    Provide a detailed, transparent description of the credentialing process to providers and serve as the single point of contact for the Contractor to address provider questions about the credentialing process

 

m. Maternal Child Health/EPSDT Coordinator who is located in Arizona and who is an Arizona licensed nurse, physician or physician’s assistant; or has a Master’s degree in health services, public health, health care administration or other related field, and/or a CPHQ or CHCQM certification. Any staff under this position must be sufficient to meet the AHCCCS MCH/EPSDT contractual and policy requirements and must be located in Arizona. Maternal Child Health (MCH)/EPSDT staff must either report directly to the MCH/EPSDT Coordinator or the MCH/EPSDT Coordinator must have sufficient ability to ensure that AHCCCS MCH/EPSDT requirements are met. Sufficient local staffing under this position must be in place to meet quality and performance measure goals. The primary functions of the MCH/EPSDT Coordinator are:

 

    Ensure receipt of EPSDT services

 

    Ensure receipt of maternal and postpartum care

 

    Promote family planning services

 

    Promote preventive health strategies

 

    Identify and coordinate assistance for identified member needs

 

    Interface with community partners

 

n. Medical Management Manager who is an Arizona licensed registered nurse, physician or physician’s assistant if required to make medical necessity determinations; or have a Master’s degree in health services, health care administration, or business administration if not required to make medical necessity determinations. This position is located in Arizona and manages all required medical management requirements under AHCCCS policies, rules, and contract. Sufficient local staffing under this position must be in place to meet medical management requirements. The primary functions of the Medical Management Manager are:

 

    Ensure adoption and consistent application of appropriate inpatient and outpatient medical necessity criteria

 

    Ensure appropriate concurrent review and discharge planning of inpatient stays is conducted

 

    Develop, implement and monitor the provision of care coordination, disease management and case management functions

 

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    Monitor, analyze and implement appropriate interventions based on utilization data, including identifying and correcting over or under utilization of services

 

    Monitor prior authorization functions and assure that decisions are made in a consistent manner based on clinical criteria and meet timeliness standards

 

o. Behavioral Health Coordinator who is a behavioral health professional as described in Health Services Rule A.A.C. R9-10-101, and is located in Arizona. The Behavioral Health Coordinator shall ensure AHCCCS behavioral health requirements are implemented. The primary functions of the Behavioral Health Coordinator are:

 

    Coordinate members behavioral health care needs including active involvement in all out of state placement decisions

 

    Develop processes to review and enhance network to reduce out of state placements

 

    Develop processes to coordinate behavioral health care and physical health care between all providers

 

    Participate in the identification of best practices for behavioral health services

 

    Coordinate and liaise for American Indians who exercise choice options regarding behavioral health

 

p. Member Services Manager who shall coordinate communications with members; serve in the role of member advocate; coordinate issues with appropriate areas within the organization; resolve member inquiries/problems and meet standards for resolution, telephone abandonment rates and telephone hold times.

 

q. Provider Services Manager who coordinates communications between the Contractor and its subcontractors and providers. This position is located in Arizona and ensures that providers receive prompt resolution to their problems or inquiries, appropriate education about participation in the AHCCCS program and maintain a sufficient provider network. Sufficient local staffing under this position must be in place to ensure appropriate provider responsiveness.

 

r. Claims Administrator who shall ensure prompt and accurate provider claims processing. The primary functions of the Claims Administrator are:

 

    Develop and implement claims processing systems capable of paying claims in accordance with State and Federal requirements

 

    Develop processes for cost avoidance

 

    Ensure minimization of claims recoupments

 

    Meet claims processing timelines

 

    Meet AHCCCS encounter reporting requirements

 

s. Provider Claims Educator who is located in Arizona and facilitates the exchange of information between the grievance, claims processing, and provider relations systems. The primary functions of the Provider Claims Educator are:

 

    Educate contracted and non-contracted providers (i.e., professional and institutional) regarding appropriate claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer, and available Contractor resources such as provider manuals, website, fee schedules, etc.

 

    Interface with the Contractor’s call center to compile, analyze, and disseminate information from provider calls

 

    Identify trends and guides the development and implementation of strategies to improve provider satisfaction. Frequently communicate (i.e.: telephonic and on-site) with providers to assure the effective exchange of information and gain feedback regarding the extent to which providers are informed about appropriate claims submission practices

 

t. Information Systems (IS) Administrator who is responsible for information system management including coordination of the technical aspects of application infrastructure, server and storage needs, reliability and survivability of all data and data exchange elements.

 

u. MSA Administrator who is responsible for oversight of the Management Services Agreement (MSA) subcontractor and is the Contractor’s Key Contact who is not employed by the MSA for AHCCCS coordination. This position is only required when the Contractor operates under a subcontract with a MSA.

 

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Additional Required Staff:

 

v. Prior Authorization staff to authorize health care services. This staff shall include but is not limited to Arizona-licensed nurses, physicians and/or physician’s assistants.

 

w. Concurrent Review staff who are located in Arizona and who conduct inpatient concurrent review. This staff shall consist of Arizona-licensed nurses, physicians, and/or physician’s assistants.

 

x. Member Services staff to enable members to receive prompt resolution of their inquiries/problems.

 

y. Provider Services staff who are located in Arizona and who enable providers to receive prompt responses and assistance. See Section D, Paragraph 29, Network Management.

 

z. Claims Processing staff to ensure the timely and accurate processing of original claims, resubmissions and overall adjudication of claims.

 

aa. Encounter Processing staff to ensure the timely and accurate processing and submission to AHCCCS of encounter data and reports.

 

bb. Case Management staff who are located in Arizona and who provide care coordination for members with special health care needs.

 

cc. IS Staff to ensure timely and accurate information system management to meet system and data exchange requirements.

 

dd. Quality Management staff who are located in Arizona and who ensure timely, comprehensive quality of care investigative processes including but not limited to onsite quality investigations.

The Contractor must submit the following items as specified in Attachment F3, Contractor Chart of Deliverables, and when there is a change in staffing or organizational functions:

 

1. An organization chart complete with the Key Staff positions. The chart must include the person’s name, title, location and portion of time allocated to each Medicaid contract and other lines of business.

 

2. A functional organization chart of the key program areas, responsibilities and reporting lines.

 

3. A listing of all Key Staff to include the following:

 

  a. Individual’s name,

 

  b. Individual’s title,

 

  c. Individual’s telephone number,

 

  d. Individual’s email address,

 

  e. Individual’s location(s),

 

  f. Documentation confirming applicable Key Staff functions are filled by individuals who are in good standing (for example, a printout from the Arizona Medical Board webpage showing the CMO’s active license), and

 

  g. A list of all Key Staff functions and their locations; and a list of any functions that have moved outside of the State of Arizona in the past contract year.

The Contractor is responsible for maintaining a significant local presence within the State of Arizona. Positions performing functions related to this contract must have a direct reporting relationship to the local Administrator/Chief Executive Officer (CEO). The local CEO shall have the authority to direct, implement and prioritize work to ensure compliance with contract requirements. The local CEO shall have the authority and ability to prioritize and direct work performed by Contractor staff and work performed under this contract through a management service agreement or through a delegated agreement. This significant presence includes staff listed below.

In State Positions:

 

    Administrator/CEO/COO

 

    Behavioral Health Coordinator

 

    Case Managers

 

    Concurrent Review staff

 

    Contract Compliance Officer

 

    Corporate Compliance Officer

 

    Credentialing Coordinator

 

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    Dental Director

 

    Dispute and Appeal Manager

 

    Maternal Child Health/EPSDT Coordinator

 

    Maternal Child Health/EPSDT staff

 

    Maternal Child Health/MCH staff

 

    Medical Director/CMO

 

    Medical Management Manager

 

    Performance/Quality Improvement Coordinator

 

    Performance/Quality Improvement staff

 

    Provider Claims Educator

 

    Provider Services Manager

 

    Provider Services staff

 

    Quality Management Manager

 

    Quality Management staff

Staff Training and Meeting Attendance: The Contractor shall ensure that all staff members have appropriate training, education, experience and orientation to fulfill the requirements of the position. AHCCCS may require additional staffing for a Contractor that has substantially failed to maintain compliance with any provision of this contract and/or AHCCCS policies.

The Contractor must provide initial and ongoing staff training that includes an overview of AHCCCS; AHCCCS Policy and Procedure Manuals, and contract requirements and State and Federal requirements specific to individual job functions. The Contractor shall ensure that all staff members having contact with members or providers receive initial and ongoing training with regard to the appropriate identification and handling of quality of care/service concerns.

All transportation, prior authorization and member services representatives must be trained in the geography of any/all GSA(s) in which the Contractor holds a contract and have access to mapping search engines (e.g. MapQuest, Yahoo Maps, Google Maps) for the purposes of authorizing services in, recommending providers in, and transporting members to, the most geographically appropriate location.

The Contractor shall provide the appropriate staff representation for attendance and participation in meetings and/or events scheduled by AHCCCS. AHCCCS may require attendance by subcontracted entities, as defined in Section D, Paragraph 37, Subcontracts, when deemed necessary. All meetings shall be considered mandatory unless otherwise indicated.

 

17. WRITTEN POLICIES AND PROCEDURES

The Contractor shall develop and maintain written policies and procedures for each functional area consistent in format and style. The Contractor shall maintain written guidelines for developing, reviewing and approving all policies and procedures. All policies and procedures shall be reviewed at least annually to ensure that the Contractor’s written policies reflect current practices. Reviewed policies shall be dated and signed by the Contractor’s Director or administrator. Minutes reflecting the review and approval of the policies by an appropriate committee, chaired by the Contractor Chief Executive Officer/Administrator, Chief Medical Officer or Chief Financial Officer are also acceptable documentation. All medical and quality management policies must be approved and signed by the Contractor’s Medical Director.

If AHCCCS deems a Contractor policy or process to be inefficient and/or place an unnecessary burden on the members or providers, the Contractor must work with AHCCCS to change the policy or procedure within a time period specified by AHCCCS. In addition, if AHCCCS deems a Contractor lacks a policy or process necessary to fulfill the terms of this contract, the Contractor must work with AHCCCS to adopt a policy or procedure within a time period specified by AHCCCS.

 

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18. MEMBER INFORMATION

The Contractor shall be accessible by phone for general member information during normal business hours. All enrolled members will have access to a toll free phone number. All informational materials, prepared by the Contractor, shall be approved by AHCCCS prior to distribution to members. The reading level and name of the evaluation methodology used shall be included. The Contractor should refer to ACOM Policy 404 for further information and requirements. See also Attachment F3, Contractor Chart of Deliverables.

All materials shall be translated when the Contractor is aware that a language is spoken by 3,000 or 10%, whichever is less, of the Contractor’s members, who also have Limited English Proficiency (LEP).

All vital materials shall be translated when the Contractor is aware that a language is spoken by 1,000 or 5%, whichever is less, of the Contractor’s members, who also have LEP [42 CFR 438.10(c)(3). Vital materials must include, at a minimum, but are not limited to the following:

 

  1. Member Handbooks

 

  2. Consent Forms

 

  3. Member notices

 

  4. Grievance, appeal, and request for State fair hearing information

 

  5. Written notices informing members of their right to interpretation and translation services

In addition, the following Vital Materials must include a tagline in all languages spoken by 1,000 or 5%, whichever is less, of the Contractor’s members, who also have LEP. The Vital Materials must be made available in the LEP language spoken by 1,000 or 5% of the population upon request by the member.

 

  1. Notices of Actions

 

  2. Notices of Appeal Resolution

 

  3. Communications requiring a response from the member

Oral interpretation services must be available and at no cost to all members and potential members regardless of the prevalence of the language. The Contractor must notify all members and potential members of their right to access oral interpretation services and how to access them. Refer to ACOM Policy 404 [42 CFR 438.10(c)(4) and (5)].

The Contractor shall make every effort to ensure that all information prepared for distribution to members is written using an easily understood language and format and as further described in ACOM Policy 404 [42 CFR. 438.10(b)(1)]. Regardless of the format chosen by the Contractor, the member information must be printed in a type, style and size, which can easily be read by members with varying degrees of visual impairment. The Contractor must notify its members that alternative formats are available and how to access them [42 CFR 438.10(d)]. The Contractor shall adhere to the requirements for Social Networking Activities as described in ACOM Policy 425.

When there are program changes, notification shall be provided to members at least 30 days before implementation.

Website Requirements

The Contractor shall develop and maintain a website that is focused, informational, user-friendly, functional, and provides the information as required in ACOM Policy 416 and ACOM Policy 404.

 

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Member Handbook and Provider Directory

The Contractor shall provide the following information to each member/representative or household within 12 business days of receipt of notification of the enrollment date [42 CFR 438.10(f)(3)]:

 

1. A Member Handbook which, at a minimum, shall include the items listed in ACOM Policy 404.

The Contractor shall review and update the Member Handbook at least once a year. The Handbook must be submitted to AHCCCS, Division of Health Care Management for approval as specified in Attachment F3, Contractor Chart of Deliverables.

The Contractor has the option of providing the Member Handbook in hard copy format with the new member packet, or providing the member written notification of how the Member Handbook information is available to the member on the Contractor’s website, via electronic mail or via postal mailing. Should the Contractor elect not to provide the Member Handbook in hard copy format with the member packet, the following provisions apply:

 

  1. The Contractor must submit a request for approval to forgo provision of the hard copy as specified in the Contract, Attachment F3, Contractor Chart of Deliverables.

 

  2. The member notification must be approved in accordance with ACOM Policy 404.

 

  3. The written notification must give the member the option to obtain a printed version of the Member Handbook.

 

2. A Provider Directory, which at a minimum, includes those items listed in ACOM Policy 404. The Contractor has the option of providing the Provider Directory in hard copy format or providing written notification of how the Provider Directory information is available on the Contractor’s website, via electronic mail, or via postal mailing as described in ACOM Policy 404. The written notification shall be sent to members within 12 business days of receipt of notification of the enrollment date [42 CFR 438.10(f)(3)].

The Contractor must give written notice about termination of a contracted provider, within 15 days after receipt or issuance of the termination notice, to each member who received their primary care from, or is seen on a regular basis by, the terminated provider [42 CFR 438.10(f)(5)]. The Contractor shall have information available for potential enrollees as described in ACOM Policy 404 [42 CFR 438.10(f)(4)].

Member Newsletter

The Contractor must develop and distribute, at a minimum, two member newsletters during the contract year.

The following types of information are to be contained in the newsletter:

 

1. Educational information on chronic illnesses and ways to self-manage care

 

2. Reminders of flu shots and other prevention measures at appropriate times

 

3. Medicare Part D issues

 

4. Cultural Competency, other than translation services

 

5. Contractor specific issues (in each newsletter)

 

6. Tobacco cessation information

 

7. HIV/AIDS testing for pregnant women

 

8. Other information as required by AHCCCS

Member Rights

The Contractor will, on an annual basis, inform all members of their right to request the following information [42 CFR 438.10(f)(6) and 42 CFR 438.100(a)(1) and (2)]. This information may be sent in a separate written communication or included with other written information such as in a member newsletter:

 

1. An updated Member Handbook at no cost to the member

 

2. The Provider Directory as described in ACOM Policy 404

 

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The Contractor shall ensure compliance with any applicable Federal and State laws that pertain to member rights and ensure that its staff and subcontractors take those rights into account when furnishing services to members.

The Contractor shall ensure that each member is guaranteed the right to request and receive one copy of the member’s medical record at no cost to the member and to request that the record be amended or corrected, as specified in 45 CFR Part 164.

The Contractor shall ensure that each member is free to exercise their rights and that the exercise of those rights does not adversely affect the way the Contractor or its subcontractors treat the member [42 CFR 438.100(c)].

 

19. SURVEYS

The Contractor may be required to perform surveys at AHCCCS’ request. AHCCCS may provide the survey tool or require the Contractor to develop the survey tool. The final survey tool shall be approved in advance by AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. The results and the analysis of the results shall be submitted to the Division of Health Care Management as specified in Attachment F3, Contractor Chart of Deliverables.

For non-AHCCCS required surveys, the Contractor shall provide notification as specified in Attachment F3, Contractor Chart of Deliverables, prior to conducting any Contractor initiated member or provider survey. The notification must include a project scope statement, project timeline and a copy of the survey. The results and analysis of the results of any Contractor initiated surveys shall be submitted to the Division of Health Care Management as specified in Attachment F3, Contractor Chart of Deliverables. Surveys performed by the Contractor to evaluate plan satisfaction for previous members (exit surveys), are subject to the above notification requirement for non-AHCCCS required surveys and are not subject to Marketing Committee approval.

AHCCCS may conduct surveys of a representative sample of the Contractor’s membership and providers. The results of AHCCCS conducted surveys will become public information and available to all interested parties on the AHCCCS website. The Contractor will be responsible for reimbursing AHCCCS for the cost of such surveys based on its share of AHCCCS enrollment.

As specified in Attachment F3, Contractor Chart of Deliverables, the Contractor is required to perform periodic surveys of its membership, as outlined in ACOM Policy 424, in order to verify that members have received services that have been paid for by the Contractor and to identify potential service/claim fraud [42 CFR 455.20 and 433.116].

 

20. CULTURAL COMPETENCY

The Contractor shall ensure compliance with a Cultural Competency Plan which meets the requirements of ACOM Policy 405. An annual assessment of the effectiveness of the plan, along with any modifications to the plan, must be submitted to the DHCM Operations Unit, as specified in Attachment F3, Contractor Chart of Deliverables. This plan shall address cultural considerations and limited English proficiency for all services and settings [42 CFR 438.206(c)(2)].

 

21. MEDICAL RECORDS

The member’s medical record is the property of the provider who generates the record. Medical records include those maintained by PCPs or other providers as well as but not limited to those kept in placement settings such as nursing facilities, assisted living facilities and other home and community based providers. Each member is entitled to one copy of his or her medical record at no cost annually. The Contractor shall have written policies and procedures to maintain the confidentiality of all medical records.

 

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The Contractor is responsible for ensuring that a medical record (hard copy or electronic) is established when information is received about a member. If the PCP has not yet seen the member such information may be kept temporarily in an appropriately labeled file, in lieu of establishing a medical record, but must be associated with the member’s medical record as soon as one is established.

The Contractor shall have written policies and procedures for the maintenance of medical records to ensure those records are documented accurately and in a timely manner, are readily accessible, and permit prompt and systematic retrieval of information. Medical records shall be maintained in a detailed and comprehensive manner, which conforms to professional standards, permits effective medical review and audit processes, and which facilitates an adequate system for follow-up treatment.

The Contractor shall have written standards for documentation on the medical record for legibility, accuracy and plan of care, which comply with the AMPM.

When a member changes PCPs, his or her medical records or copies of medical records must be forwarded to the new PCP within 10 business days from receipt of the request for transfer of the medical records.

AHCCCS is not required to obtain written approval from a member before requesting the member’s medical record from the PCP or any other organization or agency. The Contractor may obtain a copy of a member’s medical records without written approval of the member if the reason for such request is directly related to the administration of the AHCCCS program. AHCCCS shall be afforded access to all members’ medical records whether electronic or paper within 20 business days of receipt of request or more quickly if necessary.

Information related to fraud and abuse may be released, however, HIV-related information shall not be disclosed except as provided in A.R.S. §36-664, and substance abuse information shall only be disclosed consistent with Federal and State law, including but not limited to 42 CFR 2.1 et seq.

 

22. ADVANCE DIRECTIVES

The Contractor shall maintain policies and procedures addressing advanced directives for adult members as specified in 42 CFR 438.3(j) and 42 CFR 422.128, and AMPM Policy 640 and AMPM Policy 930:

 

1. Each contract or agreement with a hospital, nursing facility, hospice, and providers of home health care or personal care services,, must comply with Federal and State law regarding advance directives for adult members [42 CFR 438.3(j)(1)]. Requirements include:

 

  a. Maintain written policies that address the rights of adult members to make decisions about medical care, including the right to accept or refuse medical care, and the right to execute an advance directive. If the agency/organization has a conscientious objection to carrying out an advance directive, it must be explained in policies. A health care provider is not prohibited from making such objection when made pursuant to A.R.S. §36-3205.C.1,

 

  b. Provide written information to adult members regarding an individual’s rights under State law to make decisions regarding medical care, and the health care provider’s written policies concerning advance directives, including any conscientious objections [42 CFR 438.3(j)(3)],

 

  c. Documenting in the member’s medical record whether or not the adult member has been provided the information, and whether an advance directive has been executed,

 

  d. Preventing discrimination against a member because of his or her decision to execute or not execute an advance directive, and not place conditions on the provision of care to the member, because of his/her decision to execute or not execute an advance directive, and

 

  e. Providing education to staff on issues concerning advance directives including notification of direct care providers of services, such as home health care and personal care services, if any advanced directives are executed by members to whom they are assigned to provide services.

 

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2. The Contractor shall require PCPs, which have agreements with the entities described above, to comply with the requirements of subparagraphs 1 (a) through (e) above.

 

3. The Contractor shall require health care providers specified in subparagraph 1 above to provide a copy of the member’s executed advanced directive, or documentation of refusal, to the member’s PCP for inclusion in the member’s medical record and, provide education to staff on issues concerning advance directives.

 

4. The Contractor shall provide written information to adult members and when the member is incapacitated or unable to receive information, the member’s family or surrogate as defined in A.R.S. §36-3231, regarding the following [42 CFR 422.128]:

 

  a. A member’s rights regarding advance directives under Arizona State law,

 

  b. The organization’s policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience,

 

  c. A description of the applicable state law and information regarding the implementation of these rights,

 

  d. The member’s right to file complaints directly with AHCCCS, and

 

  e. Written policies including a clear and precise statement of limitations if the provider cannot implement an advance directive as a matter of conscience; This statement, at a minimum must do the following:

 

    Clarify institution-wide conscientious objections and those of individual physicians,

 

    Identify state legal authority permitting such objections, and

 

    Describe the range of medical conditions or procedures affected by the conscience objection, and

 

  f. Changes to State law as soon as possible, but no later than 90 days after the effective date of the change [42 CFR 438.6(i)(4)].

 

5. Written information regarding advance directives shall be provided to members at the time of enrollment with the Member Handbook. Refer to ACOM Policy 404 for member information and Member Handbook requirements.

 

6. The Contractor is not relieved of its obligation to provide the above information to the individual once he or she is no longer incapacitated or unable to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

 

23. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

The Contractor shall provide quality medical care and services to members, regardless of payer source or eligibility category. The Contractor shall promote improvement in the quality of care provided to enrolled members through established Quality Management and Performance Improvement (QM/PI) processes. The Contractor shall execute processes to assess, plan, implement, and evaluate QM/PI activities [42 CFR 438.240]. At a minimum, the Contractor’s QM/PI programs shall comply with the requirements outlined in the AMPM Chapters 400 and 900. See also Attachment F3, Contractor Chart of Deliverables.

The Contractor must ensure that the QM/PI Unit within the organizational structure is separate and distinct from any other units or departments such as Medical Management or Case Management. The Contractor is expected to integrate quality management processes, such as tracking and trending of issues, throughout all areas of the organization. Ultimate responsibility for QM/PI activities resides within the QM/PI Unit.

 

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QM/PI positions performing work functions related to the contract must have a direct reporting relationship to the local Chief Medical Officer (CMO) and the local Chief Executive Officer (CEO). The local CMO and CEO shall have the ability to direct, implement and prioritize interventions resulting from quality management and quality improvement activities and investigations. Contractor staff, including administrative services subcontractors’ staff, that performs functions under this contract related to QM and QI shall have the work directed and prioritized by the Contractor’s local CEO and CMO.

Federal regulation prohibits payment for Provider-Preventable Conditions that meet the definition of a Health Care-Acquired Condition (HCAC) or an Other Provider–Preventable Condition (OPPC) and that meet the following criteria:x

 

a. Is identified in the State plan

 

b. Has been found by the State, based upon a review of medical literature by qualified professionals, to be reasonably preventable through the application of procedures supported by evidence-based guidelines

 

c. Has a negative consequence for the beneficiary

 

d. Is auditable

 

e. Includes, at a minimum, 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 [42 CFR 438.6(f)(2)(i), 42 CFR 434.6(a)(12)(i), 42 CFR 447.26(b))]

If an HCAC or OPPC is identified, the Contractor must report the occurrence to AHCCCS and conduct a quality of care investigation as outlined in AMPM Chapter 900 and Attachment F3, Contractor Chart of Deliverables [42 CFR 438.6(f)(2)(ii) and 42 CFR 434.6(a)(12)(ii)].xi

Quality Management Program

The Contractor shall have an ongoing quality management program for the services it furnishes to members. The quality management program shall include but is not limited to:

 

1. A written QM/PI plan and an evaluation of the previous year’s QM/PI program;

 

2. Quality management quarterly reports that address strategies for QM/PI activities;

 

3. QM/PI program monitoring and evaluation activities which include Peer Review and Quality Management Committees which are chaired by the Contractor’s local Chief Medical Officer;

 

4. Protection of medical records and any other personal health and enrollment information that identifies a particular member, or subset of members, in accordance with Federal and State privacy requirements;

 

5. Member rights and responsibilities [42 CFR 238.100(b)(2)(iv)];

 

6. Uniform provisional credentialing, initial credentialing, re-credentialing and organizational assessment verification [42 CFR 438.206(b)(6)]. The Contractor shall demonstrate that its providers are credentialed and reviewed through the Contractor’s Credentialing Committee that is chaired by the Contractor’s local Medical Director [42 CFR 438.214]. The Contractor should refer to the AMPM Chapter 900 and Attachment F3, Contractor Chart of Deliverables for reporting requirements. The process:

 

  a. Shall follow a documented process for provisional credentialing, initial credentialing, re-credentialing and organizational credentialing verification of providers who have signed contracts or participation agreements with the Contractor;

 

  b. Shall not discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment; and

 

  c. Shall not employ or contract with providers excluded from participation in Federal health care programs.

 

7. Tracking and trending of member and provider issues, which includes, but is not limited to, investigation and analysis of quality of care issues, abuse, neglect, exploitation and unexpected deaths. The resolution process must include:

 

  a. Acknowledgement letter to the originator of the concern;

 

  b. Documentation of all steps utilized during the investigation and resolution process;

 

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  c. Follow-up with the member to assist in ensuring immediate health care needs are met;

 

  d. Closure/resolution letter that provides sufficient detail to ensure that the member has an understanding of the resolution of their issue, any responsibilities they have in ensuring all covered, medically necessary care needs are met, and a Contractor contact name/telephone number to call for assistance or to express any unresolved concerns;

 

  e. Documentation of implemented corrective action plan(s) or action(s) taken to resolve the concern; and

 

  f. Analysis of the effectiveness of the interventions taken.

 

8. Mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs;

 

9. Participation in community initiatives including applicable activities of the Medicare Quality Improvement Organization (QIO); and

 

10. Performance improvement programs including performance measures and performance improvement projects.

Credential Verification Organization Contract: The Arizona Association of Health Plans (AzAHP) has established a contract with a Credential Verification Organization (CVO) that is responsible for receiving completed applications, attestations and primary source verification documents. The CVO is also responsible for conducting annual entity site visits to ensure compliance with AHCCCS requirements. The AHCCCS Contractor must utilize the contracted CVO as part of its credentialing and recredentialing process regardless of membership in the AzAHP. This requirement eases the administrative burden for providers that contract with AHCCCS Contractors which often results in duplicative submission of information used for credentialing purposes. The Contractor shall follow the AHCCCS recredentialing timelines for providers that submit their credentialing data and forms to the AzAHP CVO. The Contractor is responsible for completing the credentialing process. The Contractor shall continue to include utilization, performance, complaint, and quality of care information, as specified in the AMPM, to complete the credentialing or recredentialing files that are brought to the Credentialing Committee for a decision. In addition, the Contractor must also meet the AMPM requirements for provisional/temporary credentialing.

Credentialing Timelines: The Contractor is required to process credentialing applications in a timely manner. To assess the timeliness of provisional and initial credentialing a Contractor shall calculate and report to AHCCCS as outlined in AMPM Policy 950. The Contractor must report the credentialing information with regard to all credentialing applications as specified in Attachment F3, Contractor Chart of Deliverables.

Quality Improvement: The Contractor’s quality management program shall be designed to achieve and sustain, through ongoing measurements and intervention, significant improvement in the areas of clinical care and nonclinical care which are expected to have a favorable effect on health outcomes and member satisfaction. The Contractor must [42 CFR 438.240(b)(2) and (c)]:

 

1. Measure and report to the State its performance, using standard measures required by the AHCCCS, or as required by CMS;

 

2. Submit specified data to the State that enables the State to measure the Contractor’s performance; or

 

3. Perform a combination of the above activities.

The Contractor shall have an ongoing program of performance improvement projects that focus on clinical and non-clinical areas, as specified in the AMPM, and that involve the following [42 CFR 438.240(b)(1) and (d)(1)]:

 

1. Measurement of performance using objective quality indicators

 

2. Implementation of system interventions to achieve improvement in quality

 

3. Evaluation of the effectiveness of the interventions

 

4. Planning and initiation of activities for increasing or sustaining improvement

 

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Performance Measures

The Contractor shall comply with AHCCCS quality management requirements to improve performance for all AHCCCS performance measures. Descriptions of the AHCCCS Clinical Quality Performance Measures and links to the CMS and the measure host sites can be found on the AHCCCS website. The EPSDT Participation performance measure description utilizes the methodology established in CMS “Form 416” which can also be found on the AHCCCS website.

The Contractor must comply with Federal performance measures and levels that may be identified and developed by CMS or those developed in consultation with AHCCCS and/or other relevant stakeholders. CMS has been working in partnership with states in developing core performance measures for Medicaid and CHIP programs. As the Core Measure sets are implemented, performance measures required by AHCCCS may be updated to include these measures.

AHCCCS may utilize a hybrid or other methodologies for collecting and reporting performance measure rates, as allowed by the National Committee of Quality Assurance NCQA, for selected Healthcare Effectiveness Data and Information Set (HEDIS) measures or as allowed by other entities for nationally recognized measure sets. The Contractor shall collect data from medical records, electronic records or through approved processes such as those utilizing a health information exchange and provide these data with supporting documentation, as instructed by AHCCCS, for each hybrid measure. The number of records that each Contractor collects will be based on HEDIS, External Quality Review Organization (EQRO), or other sampling guidelines and may be affected by the Contractor’s previous performance rate for the measure being collected.

The Contractor must have a process in place for monitoring performance measure rates. The Contractor shall utilize a standard methodology established or adopted by AHCCCS for measurement of each required performance measure. The Contractor’s QM/PI Program will report its measured performance on an ongoing basis to its Administration. The Contractor performance measure monitoring results shall also be reported to AHCCCS in conjunction with its EPSDT Improvement and Adult Quarterly Monitoring Report.

The Contractor must meet AHCCCS stated Minimum Performance Standards (MPS) for each population/eligibility category for which AHCCCS reports results. AHCCCS-reported rates are the official rates utilized for determination of Contractor compliance with performance requirements. It is equally important that, in addition to meeting the contractual MPS, the Contractor continually improve performance measure outcomes from year to year. Contractor calculated and/or reported rates will be used strictly for monitoring Contractor actions and not be used for official reporting or for consideration in corrective action purposes.

Minimum Performance Standard – MPS is the minimal expected level of performance by the Contractor. If a Contractor does not achieve this standard, the Contractor will be required to submit a corrective action plan and may be subject to a sanction of up to $100,000 dollars for each deficient measure.

A Contractor must show demonstrable and sustained improvement toward meeting AHCCCS Performance Standards. AHCCCS may impose sanctions on Contractors that do not show statistically significant improvement in a measure rate as calculated by AHCCCS. Sanctions may also be imposed for statistically significant declines of rates even if they meet or exceed the MPS, for any rate that does not meet the AHCCCS MPS, or a rate that has a significant impact to the aggregate rate for the State. AHCCCS may require the Contractor to demonstrate that they are allocating increased administrative resources to improving rates for a particular measure or service area. AHCCCS also may require a corrective action plan for measures that are below the MPS or that show a statistically significant decrease in its rate even if it meets or exceeds the MPS.

An evidence-based corrective action plan that outlines the problem, planned actions for improvement, responsible staff and associated timelines as well as a place holder for evaluation of activities must be received by AHCCCS within 30 days of receipt of notification of the deficiency from AHCCCS. This plan must be approved by AHCCCS prior to implementation. AHCCCS may conduct one or more follow-up desktop or on-site reviews to verify compliance with a corrective action plan.

 

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All Performance Measures apply to all member populations [42 CFR 438.240(a)(2), (b)(2) and (c)]. AHCCCS may analyze and report results by line of business, Geographical Service Area (GSA), or County, and/or other applicable demographic factors.

AHCCCS has established standards for the measures listed below.

The following table identifies the MPS for each measure:

Acute Care Performance Measures

 

Measure

  

MPS

ADULT MEASURES

Inpatient Utilization

   33 Per 1000 Member Months

ED Utilization

   55Per 1000 Member Months

Hospital Readmissions

   11%

Breast Cancer Screening (BCS)

   50%

Cervical Cancer Screening (CCS)

   64%

Chlamydia Screening in Women (CHL)

   63%

Colorectal Screening

   65%

CDC - HbA1c Testing

   77%

CHC - HbA1c Poor Control (>9.0%)

   41%

CDC - Eye Exam

   49%

Timeliness of Prenatal Care: Prenatal Care Visit in the First Trimester or Within 42 Days of Enrollment (PPC)

   80%

Timeliness of Prenatal Care: Postpartum Care Rate (PPC)

   64%

Mental Health Utilization

   Baseline Measurement Year

Use of Opioids From Multiple Providers at High dosage in Persons Without Cancer

   Baseline Measurement Year
CHILDRENS MEASURES

Children’s Access to PCPs, by age: 12-24 mo.

   93%

Children’s Access to PCPs, by age: 25 mo.- 6 yrs.

   84%

Children’s Access to PCPs, by age: 7 - 11 yrs.

   83%

Children’s Access to PCPs, by age: 12 - 19 yrs.

   82%

Well-Child Visits: 15 mo.

   65%

Well-Child Visits: 3 - 6 yrs.

   66%

Adolescent Well-Child Visits: 12–21 yrs.

   41%

Children’s Dental Visits: (ages 2-21)

   60%

Percentage of Eligibles Who Received Preventive Dental Services (1)

   46%

SEAL: Dental Sealants for Children Ages 6-9 at Elevated Caries Risk

   Baseline Measurement Year; CMS will be establishing MPS

Human Papillomavirus Vaccine for Female Adolescents

   50%

 

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Childhood Immunization Status

DTaP

   85%

IPV (2)

   91%

MMR (2)

   91%

Hib (2)

   90%

HBV (2)

   90%

VZV (2)

   88%

PCV (2)

   82%

Hepatitis A (HAV)

   40%

Rotavirus

   60%

Influenza

   45%

Combination 3 (4:3:1:3:3:1:4)*

   68%
Adolescent Immunizations

Adolescent Meningococcal

   75%

Adolescent Tdap/Td

   75%

Adolescent Combination 1

   75%

Notes:

 

(1)  EPSDT Dental Participation Standards (Preventive Dental) are based on the CMS-established goal that States improve their rates of children ages one through 20 enrolled in Medicaid and who received any preventive dental service by 10 percentage points over a five-year period.
(2)  AHCCCS will continue to measure and report results of these individual antigens; however, a Contractor may not be held accountable for specific Performance Standards unless AHCCCS determines that completion of a specific antigen or antigens is affecting overall completion of the childhood immunization series and/or systemic rates for that antigen.
* All immunization combinations will be run and reported to CMS; however, AHCCCS will only take regulatory action with the Contractors for Combination 3 (and/or individual antigens as described

 

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Performance Measures with Reserve Status*

Acute Performance Measures

 

Measure

  

MPS

Adults’ Access to Preventive/ Ambulatory Health Services

   75%

Flu Shots for Adults, Ages 18 and Older (FVA)

   50%

Diabetes Admissions, Short-Term Complications (PQI-01)

   244 Per 100,000 Member Months

Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults Admission Rate (PQI-05)

   1152 Per 100,000 Member Months

Asthma in Younger Adults Admissions (PQI-15)

   119 Per 100,000 Member Months

Heart Failure Admission Rate (PQI-08)

   278 Per 100,000 Member Months

Weight Assessment and counseling - Body Mass Index (BMI) Assessment for Children/Adolescents

   55%

EPSDT Participation (1)

   68%

Developmental Screening in the First Three Years of Life

   55%

 

* Performance measures remain important to AHCCCS and as such will continue to be monitored by AHCCCS. Should Contractor performance results for Performance Measures in Reserve Status decline, the Contractor may be subject to corrective action. AHCCCS may require individual Contractors to implement improvement actions for Performance Measures with Reserve Status in order to ensure quality of care to AHCCCS members. Measures deemed in Reserve Status will be reported out when appropriate.
(1)  The EPSDT Participation rate is the percent of all children and adolescents younger than 21 years who were due for at least one EPSDT visit, depending on their age and the state’s EPSDT Periodicity Schedule, and had an EPSDT visit during the contract year.

Contractor Performance is evaluated annually using the AHCCCS-reported rate for each measure. AHCCCS rates are considered the official measurement for each Performance Measure. AHCCCS calculated rates by Contractor for each measure will be compared with the MPS specified in the contract in effective during the measurement period. For instance, Performance Standards in the Contract Year Ending (CYE) 2015 contract apply to results calculated by AHCCCS for the CYE 2015 measurement period. AHCCCS will utilize methodologies that are reflective of the requirements for the measurement period. For instance, CYE 2014 performance measure data will be based on the published 2014 CMS Core Sets and 2014 HEDIS technical specifications. Contractors are responsible for monitoring and reporting to AHCCCS CQM the status of, and any discrepancies identified in encounters received by AHCCCS including paid, denied and pended for purposes of Performance Measure monitoring prior to the AHCCCS Performance Measure rate calculations being conducted.

The Contractor shall participate in immunization audits, at intervals specified by AHCCCS, based on random sampling to verify the immunization status of members at 24 months of age and by 13 years of age. If records are missing for more than five percent (5%) of the Contractor’s final sample, the Contractor is subject to sanctions by AHCCCS. An External Quality Review Organization (EQRO) may conduct a study to validate the Contractor’s reported rates.

 

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AHCCCS will measure and report the Contractor’s EPSDT Participation rate and Dental Participation (Preventive Dental) rate, utilizing the CMS 416 methodology. The EPSDT participation rate is the number of children younger than 21 years that receive medical screens in compliance with the State’s Periodicity Schedule, compared to the number of children expected to receive medical screens per the State’s Periodicity Schedule. The Preventive Dental Participation rate is the number of children aged one through 20 who have a preventive dental visit, compared to the number of children who has at least 90-days continuous enrollment during the Contract Year (measurement period).

The Contractor is responsible for applying the correct CMS-416 methodology as developed and maintained by CMS for its internal monitoring of performance measure results.

AHCCCS uses the national CMS 416 methodology to generate the EPSDT Participation and Dental Participation rates through a CMS-validated process. The rates are generated one time a year and reported to CMS within specified timeframes. Aggregate rates as well as Contractor-specific rates are included in this process.

The Contractor must participate in the delivery and/or results review of member surveys as requested by AHCCCS. Surveys may include Home and Community Based (HCBS) Member Experience surveys, HEDIS Experience of Care (Consumer Assessment of Healthcare Providers and Systems – CAHPS) surveys, and/or any other tool that AHCCCS determines will benefit quality improvement efforts. While not included as an official performance measure, survey findings or performance rates for survey questions may result in the Contractor being required to develop a Corrective Action Plan (CAP) and/or participate in technical assistance or AHCCCS-led workgroups to improve any areas of concern noted by AHCCCS. Failure to effectively develop or implement AHCCCS-approved CAPs and drive improvement may result in additional regulatory action.

The Contractor must monitor rates for postpartum visits and low/very low birth weight deliveries and implement interventions as necessary to improve or sustain these rates. The Contractor must implement processes to monitor and evaluate cesarean section and elective inductions rates prior to 39 weeks gestation to ensure medical necessity, and implement interventions to decrease the incidence of occurrence.

Performance Improvement Projects (PIPs): The Contractor shall have an ongoing program of performance improvement projects that focus on clinical and non-clinical areas as specified in the AMPM, and that involve the following: [42 CFR 438.240(b)(1) and (d)(1)]

 

a. Measurement of performance using objective quality indicators;

 

b. Implementation of system interventions to achieve improvement in quality;

 

c. Evaluation of the effectiveness of the interventions;

 

d. Planning and initiation of activities for increasing or sustaining improvement.

PIPs are mandated by AHCCCS, the Contractor should also self-select additional projects based on opportunities for improvement identified by internal data and information. The Contractor shall report the status and results of each project to AHCCCS as requested using the AHCCCS PIP Reporting Template included in the AMPM. Each PIP must be completed in a reasonable time period to allow information on the success of PIPs in the aggregate to produce new information on quality of care every year [42 CFR 438.240(d)(2)].

Data Collection Procedures: When requested by AHCCCS, the Contractor must submit data for standardized Performance Measures and/or PIPs within specified timelines and according to AHCCCS procedures for collecting and reporting the data. The Contractor is responsible for collecting valid and reliable data and using qualified staff and personnel to collect the data. The Contractor must ensure that data collected by multiple

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

parties/people for Performance Measures and/or PIP reporting is comparable and that an inter-rater reliability process was used to ensure consistent data collection. Data collected for Performance Measures and/or PIPs must be returned by the Contractor in a format specified by AHCCCS, and by the due date specified. Any extension for additional time to collect and report data must be made in writing in advance of the initial due date and is subject to approval by AHCCCS. Failure to follow the data collection and reporting instructions that accompany the data request may result in sanctions imposed on the Contractor.

 

24. MEDICAL MANAGEMENT

The Contractor shall implement processes to assess, plan, implement, evaluate, and as mandated, report Medical Management (MM) monitoring activities as specified in the AMPM Chapter 1000. This shall include the Quarterly Inpatient Hospital Showings report, HIV Specialty Provider List, Transplant Log and Prior Authorization Requirements report as specified in the AMPM and Attachment F3, Contractor Chart of Deliverables. The Contractor shall evaluate MM activities, as specified in the AMPM Chapter 1000, including:

 

1. Pharmacy Management; including the evaluation, reporting, analysis and interventions based on the data and reported through the MM Committee, which is chaired by the Contractor’s Chief Medical Officer.

 

2. Prior authorization and Referral Management; for the processing of requests for initial and continuing authorizations of services the Contractor shall:

 

  a. Have in effect mechanisms to ensure consistent application of review criteria for authorization decisions;

 

  b. Consult with the requesting provider when appropriate [42 CFR 438.210(b)(2)];

 

  c. Monitor and ensure that all enrollees with special health care needs have direct access to care;

 

  d. Review all prior authorization requirements for services, items or medications annually. The review will be reported through the MM Committee and will include the rationale for changes made to prior authorization requirements. A summary of the prior authorization requirement changes and the rationale for those changes must be included in the annual MM Evaluation submission; and

 

  e. Comply with all decision timelines as outlined in the ACOM and the AMPM.

 

3. Development and/or Adoption of Practice Guidelines [42 CFR 438.236(b)] that:

 

  a. Are based on valid and reliable clinical evidence or a consensus of providers in the particular field;

 

  b. Consider the needs of the Contractor’s members;

 

  c. Are adopted in consultation with contracting health care professionals;

 

  d. Are reviewed and updated periodically as appropriate;

 

  e. Are disseminated by the Contractor to all affected providers and, upon request, to enrollees and potential enrollees [42 CFR 438.236(c)]; and

 

  f. Provide a basis for consistent decisions for utilization management, member education, coverage of services, and other areas to which the guidelines apply [42 CFR 438.236(d)].

 

4. Concurrent review:

 

  a. Consistent application of review criteria; provide a basis for consistent decisions for utilization management, coverage of services, and other areas to which the guidelines apply;

 

  b. Contractors must have policies and procedures in place that govern the process for proactive discharge planning when members have been admitted into acute care facilities. The intent of the discharge planning policy and procedure would be to increase the utilization management of inpatient admissions and decrease readmissions within 30 days of discharge; and

 

  c. In addition, 42 CFR 447.26 prohibits payment for Provider-Preventable Conditions that meet the definition of a Health Care-Acquired Condition (HCAC) or an Other Provider–Preventable Condition (OPPC) (refer to AMPM Chapter 1000). If an HCAC or OPPC is identified, the Contractor must report the occurrence to AHCCCS and conduct a quality of care investigation.

 

5. Continuity and coordination of care:

 

  a. Establish a process to ensure coordination of member care needs across the continuum based on early identification of health risk factors or special care needs;

 

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  b. Establish a process for timely and confidential communication of clinical information among providers;

 

  c. Must proactively provide care coordination for members who have multiple complaints regarding services or the AHCCCS Program. This includes, but is not limited to, members who do not meet the Contractor’s criteria for case management;

 

  d. Must proactively provide care coordination for members who have both behavioral health and physical health needs. The Contractor must meet regularly with the Regional Behavioral Health Authorities to improve and address coordination of care issues. Meetings shall occur at least every other month or more frequently if needed to develop processes, implement interventions, and discuss outcomes. Care coordination meetings and staffings shall occur at least monthly or more often as necessary to affect change; and

 

  e. The Contractor must implement procedures to deliver primary care to and coordinate health care service for members. These procedures must ensure that each member has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the enrollee. [42 CFR 438.208(b)(1)].

The Contractor shall implement and report the following:

 

    Identify High Need/High Cost members for each Regional Behavioral Health Authority (RBHA) Geographic Service Area as specified in Section B, Capitation Rates and Contractor Specific Requirements in accordance with the standardized criteria developed by the AHCCCS/Contractor workgroup;

 

    Plan interventions for addressing appropriate and timely care for these identified members; and

 

    Report outcome summaries to AHCCCS utilizing the standardized template developed by the AHCCCS/Contractor workgroup as specified in Attachment F3, Contractor Chart of Deliverables.

 

6. Monitor and evaluate over and/or underutilization of services [42 CFR 438-240(b)(3)];

 

7. Evaluate new medical technologies, and new uses of existing technologies; and

 

8. Disease Management or Chronic Care Program that reports results and provides for analysis of the program through the MM Committee.

AHCCCS will provide a new Contractor (including an Incumbent Contractor new to a GSA) with three years of historical Acute Care Program encounter data for members enrolled with the Contractor as of December 1, 2013. Contractors should use this data to assist with identifying members in need of medical management.

On a recurring basis (no less than quarterly based on adjudication date), AHCCCS shall provide the Contractor an electronic file of claims and encounter data for members enrolled with the Contractor who have received services, during the member’s enrollment period, from another contractor or through AHCCCS FFS for purposes of member care coordination.

The Contractor shall develop a plan outlining short- and long-term strategies for improving care coordination using the physical and behavioral health care data available for members with behavioral health needs. In addition, the Contractor shall develop an outcome measurement plan to track the progress of the strategies. The plan outlining the strategies for improving care coordination and the outcome measurement must be reported in the annual MM Plan, Evaluation and Work Plan submitted to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables.

The Contractor shall have a process to report MM data and management activities through a MM Committee. The Contractor’s MM Committee will analyze the data, make recommendations for action, monitor the effectiveness of actions and report these findings to the Committee. The Contractor shall have in effect mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs [42 CFR 438.240(b)(4)].

 

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The Contractor will assess, monitor and report quarterly through the MM Committee medical decisions to assure compliance with timeliness, language, Notice of Action intent, and that the decisions comply with all Contractor coverage criteria. This includes quarterly evaluation of all Notice of Action decisions that are made by a subcontracted entity.

The Contractor shall maintain a written MM plan and Work Plan that addresses the monitoring of MM activities (AMPM Chapter 1000). The Plan and Work Plan must be submitted for review within timelines specified in Attachment F3, Contractor Chart of Deliverables.

Criminal Justice System Reach-in Care Coordination: To facilitate the transition of members transitioning out of jails and prisons into communities, AHCCCS is engaged in a data exchange process that allows AHCCCS to suspend eligibility upon incarceration, rather than terminate coverage. Upon the member’s release, the member’s AHCCCS eligibility is un-suspended allowing for immediate care coordination activities. To support this initiative the Contractor is required to participate in criminal justice system “reach-in” care coordination efforts.

Effective October 1, 2016, the Contractor shall implement reach-in care coordination for members who have been incarcerated in the adult correctional system for 30 days or longer, and have an anticipated release date. Reach-in care coordination activities shall begin upon knowledge of a member’s anticipated release date. The Contractor shall collaborate with criminal justice partners (e.g. Jails, Sherriff’s Office, Correctional Health Services, Arizona Department of Corrections, including Community Supervision, Probation, Courts), to identify justice-involved members in the adult criminal justice system with physical and/or behavioral health chronic and/or complex care needs prior to member’s release. When behavioral health needs are identified, the Contractor shall also collaborate with the member’s behavioral health Contractor (if the member’s care is not integrated).

For CYE17, the Contractor is required to submit a Reach-In Plan, due October 31, 2016. The Plan, at a minimum, must include the following:

Administrative Requirements:

 

    Designation of a Justice System Liaison who will be responsible for the reach-in initiative and who:

 

    Resides in Arizona,

 

    Is the single point of contact to communicate with justice systems and the RBHAs, if appropriate, and

 

    Is the interagency liaison with the Arizona Department of Corrections (ADOC), County Jails, Sherriff’s Office, Correctional Health Services, Arizona Office of the Courts (AOC) and Probation Departments

 

    Identification of the name(s) and contact information for all criminal justice system partner(s)

 

    Identification of the name(s) and contact information for RBHA partner(s) for purposes of coordinating care for both physical and behavioral health needs

 

    Description of the process for coordination with Maricopa County jail, if appropriate, for identification of those members in probation status

 

    Designation of parameters for identification of members requiring reach-in care coordination (e.g. definition of chronic and/or complex care needs) through agreement with reach-in partners

 

    Description of the process and timeframes for communicating with reach-in partners

 

    Description of the process and timeframes for initiating communication with reach-in members

 

    Description of methodology for assessment of anticipated cost savings to include analysis of medical expense for these identified members prior to incarceration and subsequent to reach in activities and release.

Care Coordination Requirements:

 

    Develop process for identification of members meeting the established parameters for reach-in care coordination (chronic and/or complex care needs). The Contractor must utilize the 834 file data provided to the Contractor by AHCCCS to assist with identification of members. The Contractor may also use additional data if available for this purpose.

 

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    Strategies for providing member education regarding care, services, resources, appointment information and health plan case management contact information

 

    Requirements for scheduling of initial appointments with appropriate provider(s) based on member needs; appointment to occur within 7 days of member release

 

    Strategies regarding ongoing follow up with the member after release from incarceration to assist with accessing and scheduling necessary services as identified in the member’s care plan

 

    Should re-incarceration occur, strategies to reengage member and maintain care coordination

 

    Strategies to improve appropriate utilization of services

 

    Strategies to reduce recidivism within the member population

 

    Strategies to address social determinants of health

Beginning CYE18, the Contractor shall report the Reach-In Plan to AHCCCS in the annual Medical Management Plan and report outcome summaries in the Medical Management Evaluation, as specified in Attachment F3, Contractor Chart of Deliverables. In addition, AHCCCS may run performance metrics such as emergency room utilization, inpatient utilization, reduction in recidivism and other access to care measures for the population to monitor care coordination activities and effectiveness.

The Contractor must notify AHCCCS upon becoming aware that a member may be an inmate of a public institution when the member’s enrollment has not been suspended, and will receive a file from AHCCCS as specified in Section D, Paragraph 55, Capitation Adjustment.

Outreach to Service Members, Veterans and Families: The Contractor shall partner with community organizations which provide care and support for service members, veterans and families. Utilizing a collaborative approach, the Contractor shall identify members who may benefit from outreach regarding available programs and services and shall develop and implement outreach activities which inform members and families of the benefits available and how to access those services. The Contractor shall train staff on the available community resources and appropriate actions to take to ensure members are afforded the ability to be connected to these resources. The Contractor shall report its activities regarding these services in the annual Medical Management Plan and Work Plan, as specified in Attachment F3, Contractor Chart of Deliverables.

Engaging Members through Technology: The Contractor shall engage its membership through web based applications. The Contractor shall identify populations who can benefit from web based applications used to assist members with self-management of health care needs such as, chronic conditions, pregnancy, or other health related topics the Contractor considers to be most beneficial to members. The Contractor shall submit an executive summary to AHCCCS, DHCM, Medical Management Unit by December 1, 2016 to include at a minimum:

 

  a. Criteria for identifying at least 10% of the Contractor’s members who can benefit from web based applications,

 

  b. Listing of identified population(s),

 

  c. Description of web applications in development or being utilized to engage members,

 

  d. Strategies used to engage the identified members in the use of the web applications, and

 

  e. Description of desired outcomes

Monitoring Controlled and Non-Controlled Medication Utilization: The Contractor must engage in activities to monitor controlled and non-controlled medication use as outlined in AMPM Policy 310-FF to ensure members receive clinically appropriate prescriptions. The Contractor is required to report to AHCCCS, as specified in Attachment F3, Contractor Chart of Deliverables, a Pharmacy and/or Prescriber - Member Assignment report which includes the number of members which on the date of the report are restricted to using a specific Pharmacy or Prescriber/Providers due to excessive use of prescriptive medications (narcotics and non-narcotics).

 

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Inappropriate Emergency Department Utilization: The Contractor must identify and track members who utilize Emergency Department (ED) services inappropriately four or more times within a six month period. Interventions must be implemented to educate the member on the appropriate use of the ED and divert members to the right care in the appropriate place of service. The Contractor shall submit a semi-annual report as specified in AMPM Policy 1020 and Attachment F3, Contractor Chart of Deliverables.

Transplant Services and Immunosuppressant Medications: AHCCCS covers medically necessary transplantation services and related immunosuppressant medications in accordance with Federal and State law and regulations. The Contractor shall not make payments for organ transplants not provided for in the State Plan except as otherwise required pursuant to 42 USC 1396 (d)(r)(5) for persons receiving services under EPSDT. The Contractor must follow the written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high quality care to enrollees per Sections (1903(i) and 1903(i)(1)) of the Social Security Act. Refer to the AMPM, Chapter 300, Exhibit 310-DD and the AHCCCS Reinsurance Policy Manual.xii

 

25. TELEPHONE PERFORMANCE STANDARDS

The Contractor must meet and maintain established telephone performance standards to ensure member and provider satisfaction as specified in ACOM Policy 435. The Contractor shall report on compliance with these standards as specified in Attachment F3, Contractor Chart of Deliverables and the policy identified above. All reported data is subject to validation through periodic audits and/or operational reviews.

 

26. GRIEVANCE AND APPEAL SYSTEM

The Contractor shall have in place a written Grievance and Appeal System process for subcontractors, enrollees and non-contracted providers, which define their rights regarding disputed matters with the Contractor. The Contractor’s Grievance and Appeal System for enrollees includes a grievance process (the procedures for addressing enrollee grievances), an appeals process and access to the State’s fair hearing process as outlined in Attachment F1, Enrollee Grievance and Appeal System Standards. The Contractor’s dispute process for subcontractors and non-contracted providers includes a claim dispute process and access to the State’s fair hearing process as outlined in Attachment F2, Provider Claim Dispute Standards. The Contractor shall remain responsible for compliance with all requirements set forth in Attachments F1, Enrollee Grievance and Appeal System Standards, F2, Provider Claim Dispute Standards, and 42 CFR Part 438 Subpart F.

Information to enrollees must meet cultural competency and limited English proficiency requirements as specified in Section D, Paragraph 18, Member Information and Paragraph 20, Cultural Competency.

The Contractor shall provide the appropriate professional, paraprofessional and clerical personnel for the representation of the Contractor in all issues relating to the Grievance and Appeal System and any other matters arising under this contract which rise to the level of administrative hearing or a judicial proceeding. Unless there is an agreement with the State in advance, the Contractor shall be responsible for all attorney fees and costs awarded to the claimant in a judicial proceeding.

The Contractor may delegate the Grievance and Appeal System process to subcontractors, however, the Contractor must ensure that the delegated entity complies with applicable Federal and State laws, regulations and policies, including, but not limited to 42 CFR Part 438 Subpart F. The Contractor shall remain responsible for compliance with all requirements. The Contractor shall also ensure that it timely provides written information to both enrollees and providers, which clearly explains the Grievance and Appeal System requirements. This information must include a description of: the right to a State fair hearing, the method for obtaining a State fair hearing, the rules that govern representation at the hearing, the right to file grievances, appeals and claim disputes, the requirements and timeframes for filing grievances, appeals and claim disputes, the availability of assistance in the filing process, the toll-free numbers that the enrollee can use to file a

 

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grievance or appeal by phone, that benefits will continue when requested by the enrollee in an appeal or State fair hearing request concerning certain actions which are timely filed, that the enrollee may be required to pay the cost of services furnished during the appeal/hearing process if the final decision is adverse to the enrollee, and that a provider may file an appeal on behalf of an enrollee with the enrollee’s written consent.

The Contractor must provide reports on the Grievance and Appeal System as required in the AHCCCS Grievance and Appeal System Reporting Guide available on the AHCCCS website. See also Attachment F3, Contractor Chart of Deliverables.

 

27. NETWORK DEVELOPMENT

The Contractor shall develop and maintain a provider network that is supported by written agreements which is sufficient to provide all covered services to AHCCCS members, including covered behavioral health services for adult dual members receiving general mental health and substance abuse services. The Contractor shall ensure covered services are reasonably accessible in terms of location and hours of operation. The Contractor must provide a comprehensive provider network that ensures its membership has access at least equal to community norms. Services shall be as accessible to AHCCCS members in terms of timeliness, amount, duration and scope as those services are available to non-AHCCCS persons within the same service area [42 CFR 438.210(a)(2)]. The Contractor is encouraged to have available non-emergent after-hours physician or primary care services within its network. If the Contractor’s network is unable to provide medically necessary services required under contract, the Contractor must adequately and timely cover these services through an out of network provider until a network provider is contracted. The Contractor shall ensure coordination with respect to authorization and payment issues in these circumstances [42 CFR 438.206(b)(4) and (5)]. The Contractor is expected to develop a provider network that supports the provision of covered behavioral health services for adult dual members receiving general mental health and substance abuse services. The Contractor may not subcontract for or delegate to another entity for the delivery of behavioral health services.

The Contractor is expected to design a network that provides a geographically convenient flow of patients among network providers to maximize member choice. The provider network shall be designed to reflect the needs and service requirements of AHCCCS’ culturally and linguistically diverse member population. The Contractor shall design its provider networks to maximize the availability of community based primary care and specialty care access and that reduces utilization of emergency services, one day hospital admissions, hospital based outpatient surgeries when lower cost surgery centers are available, and hospitalization for preventable medical problems.

There shall be sufficient personnel for the provision of covered services, including emergency medical care on a 24-hour-a-day, seven-days-a-week basis [42 CFR 438.206(c)(1)(iii)].

The Contractor shall develop and maintain a Provider Network Development and Management Plan which ensures that the provision of covered services will occur as stated above [42 CFR 438.207(b)]. The requirements for the Network Development and Management Plan are found in ACOM Policy 415. The Network Development and Management Plan shall be evaluated, updated annually and submitted to AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. The submission of the network management and development plan to AHCCCS is an assurance of the adequacy and sufficiency of the Contractor’s provider network. The Contractor shall also submit, as needed, an assurance when there has been a significant change in operations that would affect adequate capacity and services. These changes would include, but would not be limited to, changes in services, covered benefits, geographic service areas, payments or eligibility of a new population.

In accordance with the requirements specified in ACOM Policy 436 the network shall be sufficient to provide covered services within designated time and distance limits. This includes a network such that 90% of its members residing within Pima and Maricopa counties do not have to travel more than 15 minutes or 10 miles to visit a PCP, dentist or pharmacy, unless accessing those services through a Multi-Specialty Interdisciplinary Clinic (MSIC). The Contractor must obtain hospital contracts as specified in ACOM Policy 436.

 

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AHCCCS may impose sanctions for material deficiencies in the Contractor’s provider network.

The Contractor shall not discriminate with respect to participation in the AHCCCS program, reimbursement or indemnification against any provider based solely on the provider’s type of licensure or certification [42 CFR 438.12(a)(1)(2)]. In addition, the Contractor must not discriminate against particular providers that service high-risk populations or specialize in conditions that require costly treatment [42 CFR 438.214(c)]. This provision, however, does not prohibit the Contractor from limiting provider participation to the extent necessary to meet the needs of the Contractor’s members. This provision also does not interfere with measures established by the Contractor to control costs and quality consistent with its responsibilities under this contract nor does it preclude the Contractor from using different reimbursement amounts for different specialists or for different practitioners in the same specialty [42 CFR 438.12(b)(1)]. If a Contractor declines to include individuals or groups of providers in its network, it must give the affected providers timely written notice of the reason for its decision [42 CFR 438.12(a)(1)]. The Contractor may not include providers excluded from participation in Federal health care programs, under either section 1128 or section 1128A of the Social Security Act [42 CFR 438.214(d)].

MSICs are established facilities providing interdisciplinary services for members with qualifying CRS conditions and are under contract with the CRS Contractor. Contractors are encouraged to contract with MSICs for specialty care. Pediatric specialists that work in the MSIC are in limited quantity in Arizona. Contracting with the MSICs provides Contractors an opportunity to increase access to these pediatric specialists.

The Contractor must pay all AHCCCS registered Arizona Early Intervention Program (AzEIP) providers, regardless of their contract status with the Contractor, when Individual Family Service Plans identify and meet the requirement for medically necessary EPSDT covered services. Refer to AMPM Chapter 400, Exhibit 430-3. AHCCCS has developed an AzEIP Speech Therapy Fee Schedule and rates incorporating one procedure code, along with related modifiers, settings, and group sizes. The Contractor shall utilize this methodology and these rates for payment for the speech therapy procedure when provided to an AHCCCS member who is a child identified in the AHCCCS system as an AzEIP recipient.

The Contractor is also encouraged to develop non-financial incentive programs to increase participation in its provider network.

AHCCCS is committed to workforce development and support of the medical residency and dental student training programs in the State of Arizona. AHCCCS expects the Contractor to support these efforts. AHCCCS encourages plans to contract with or otherwise support the many Graduate Medical Education (GME) Residency Training Programs currently operating in the State and to investigate opportunities for resident participation in Contractor medical management and committee activities. In the event of a contract termination between the Contractor and a GME Residency Training Program or training site, the Contractor may not remove members from that program in such a manner so as to harm the stability of the program. AHCCCS reserves the right to determine what constitutes risk to the program. Further, the Contractor must attempt to contract with graduating residents and providers that are opening new practices in, or relocating to, Arizona, especially in rural or underserved areas.

Homeless Clinics: Contractors in Maricopa and Pima County must contract with homeless clinics at the AHCCCS Fee-For-Service rate for Primary Care services. Contracts must stipulate that:

 

1. Only those members who request a homeless clinic as a PCP may be assigned to them; and

 

2. Members assigned to a homeless clinic may be referred out-of-network for needed specialty services.

 

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The Contractor must make resources available to assist homeless clinics with administrative issues such as obtaining prior authorization, and resolving claims issues.

 

28. PROVIDER AFFILIATION TRANSMISSION

The Contractor must submit information quarterly regarding its provider network. This information must be submitted in the format described in the Provider Affiliation Transmission (PAT) User Manual which can be found on the AHCCCS website. The Contractor shall also validate its compliance with minimum network requirements against the network information provided in the PAT through the submission of a completed Minimum Network Requirements Verification Template (see ACOM Policy 436 for Template). The PAT and the Minimum Network Requirements Verification Template must be submitted as specified in Attachment F3, Contractor Chart of Deliverables.

 

29. NETWORK MANAGEMENT

The Contractor shall have policies on how the Contractor will [AMPM, 42 CFR 438.214(a)]:

 

a. Communicate with the network regarding contractual and/or program changes and requirements;

 

b. Monitor network compliance with policies and rules of AHCCCS and the Contractor, including compliance with all policies and procedures related to the grievance/appeal processes and ensuring the member’s care is not compromised during the grievance/appeal processes;

 

c. Evaluate the quality of services delivered by the network;

 

d. Provide or arrange for medically necessary covered services should the network become temporarily insufficient within the contracted service area;

 

e. Monitor the adequacy, accessibility and availability of its provider network to meet the needs of its members, including the provision of care to members with limited proficiency in English;

 

f. Process provisional credentials;

 

g. Recruit, select, credential, re-credential and contract with providers in a manner that incorporates quality management, utilization, office audits and provider profiling;

 

h. Provide training for its providers and maintain records of such training;

 

i. Track and trend provider inquiries/complaints/requests for information and take systemic action as necessary and appropriate; and

 

j. Ensure that provider calls are acknowledged within three business days of receipt, resolved and/or state the result communicated to the provider within 30 business days of receipt (this includes referrals from AHCCCS).

Contractor policies shall be subject to approval by AHCCCS, Division of Health Care Management, and shall be monitored through operational audits.

The Contractor shall hold a Provider Forum no less than semi-annually. The forum must be chaired by the Contractor’s Administrator/CEO or designee. The purpose of the forum is to improve communication between the Contractor and its providers. The forum shall be open to all providers including dental providers. The Provider Forum shall not be the only venue for the Contractor to communicate and participate in the issues affecting the provider network. Provider Forum meeting agendas and minutes must be made available to AHCCCS upon request. The Contractor shall report information discussed during these Forums to Executive Management within the organization.

Material Change to Provider Network: The Contractor is responsible for evaluating all provider network changes, including unexpected or significant changes, and determining whether those changes are material changes to the Contractor’s provider network [42 CFR 438.207 (c)]. All material changes to the provider network must be approved in advance by AHCCCS, Division of Health Care Management. A material change to the provider network is defined as one that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance and/or provider network standards as described in this contract including, but not limited to, any change that would cause or is likely to cause more than 5% of members in a GSA to change the location where services are received or rendered.

 

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The Contractor must submit the request for approval of a material change to the provider network with information including, but not limited to, how the change will affect the delivery of covered services, the Contractor’s plans for maintaining the quality of member care, and communications to providers and members, as outlined in ACOM Policy 439 and as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS will review and respond to the Contractor within 30 days of the submission. A material change in the Contractor’s provider network requires 30 days advance written notice from the Contractor to members and providers. In the event unforeseen circumstances prevent the Contractor from providing 30 days advance written notice to members and providers, the Contractor shall notify AHCCCS within one business day of identifying the material change to the provider network for AHCCCS determination of notification requirements.

For emergency situations, AHCCCS will expedite the approval process.

The requirements regarding material changes to the provider network do not apply to the contract negotiation process between the Contractor and a provider.

See Section D, Paragraph 44, regarding material changes by the Contractor that may impact business operations. See Section D, Paragraph 55, Capitation Adjustments regarding material changes by the Contractor that may impact capitation rates.

The Contractor shall give hospitals and provider groups 90 days’ notice prior to a contract termination without cause. Contracts between the Contractor and single practitioners are exempt from this requirement.

Provider/Network Changes Report: The Contractor must submit a Quarterly Provider/Network Changes Due to Rates Report as described in ACOM Policy 415 and Attachment F3, Contractor Chart of Deliverables.

 

30. PRIMARY CARE PROVIDER STANDARDS

The Contractor shall include in its provider network a sufficient number of Primary Care Providers (PCPs) to meet the requirements of this contract. Health care providers designated by the Contractor as PCPs shall be licensed in Arizona as allopathic or osteopathic physicians who generally specialize in family practice, internal medicine, obstetrics, gynecology, or pediatrics; certified nurse practitioners or certified nurse midwives; or physician’s assistants [42 CFR 438.206(b)(2)].

The Contractor shall assess the PCP’s ability to meet AHCCCS appointment availability and other standards when determining the appropriate number of its members to be assigned to a PCP. The Contractor shall adjust the size of a PCP’s panel, as needed, for the PCP to meet AHCCCS appointment and clinical performance standards. AHCCCS shall inform the Contractor when a PCP has a panel of more than 1,800 AHCCCS members, to assist in the assessment of the size of their panel. This information will be provided on a quarterly basis.

The Contractor shall have a system in place to monitor and ensure that each member is assigned to an individual PCP and that the Contractor’s data regarding PCP assignments is current. The Contractor is encouraged to assign members with complex medical conditions, who are age 12 and younger, to board certified pediatricians. PCPs with assigned members diagnosed with AIDS or as HIV positive, shall meet criteria and standards set forth in the AMPM.

The Contractor shall ensure that providers serving EPSDT-aged members utilize AHCCCS-approved EPSDT Tracking forms and standardized developmental screening tools and are trained in the use of the tools.

 

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EPSDT-aged members shall be assigned to providers who are trained on and who use AHCCCS approved developmental screening tools.

The Contractor shall offer members freedom of choice within its network in selecting a PCP consistent with 42 CFR 438.6(m) and 438.52(d) and this contract. Any American Indian who is enrolled with the Contractor and who is eligible to receive services from a participating I/T/U provider may elect that I/T/U as his or her primary care provider, if that I/T/U participates in the network as a primary care provider and has capacity to provide the services per ARRA Section 5006(d) and SMD letter 10-001).xiii The Contractor may restrict this choice when a member has shown an inability to form a relationship with a PCP, as evidenced by frequent changes, or when there is a medically necessary reason. When a new member has been assigned to the Contractor, the Contractor shall inform the member in writing of his enrollment and of his PCP assignment within 12 business days of the Contractor’s receipt of notification of assignment by AHCCCS. See ACOM Policy 404 for member information requirements.

At a minimum, the Contractor shall hold the PCP responsible for the following activities [42 CFR 438.208(b)(1)]:

 

a. Supervising, coordinating and providing care to each assigned member (except for well woman exams and children’s dental services when provided without a PCP referral);

 

b. Initiating referrals for medically necessary specialty care;

 

c. Maintaining continuity of care for each assigned member;

 

d. Maintaining the member’s medical record, including documentation of all services provided to the member by the PCP, as well as any specialty or referral services including behavioral health;

 

e. Utilizing the AHCCCS approved EPSDT Tracking form;

 

f. Providing clinical information regarding member’s health and medications to the treating provider (including behavioral health providers) within 10 business days of a request from the provider; and

 

g. If serving children, for enrolling as a Vaccines for Children (VFC) provider.

The Contractor shall establish and implement policies and procedures to monitor PCP activities and to ensure that PCPs are adequately notified of, and receive documentation regarding, specialty and referral services provided to assigned members by specialty physicians, and other health care professionals.

 

31. MATERNITY CARE PROVIDER STANDARDS

The Contractor shall ensure that a maternity care provider is designated for each pregnant member for the duration of her pregnancy and postpartum care and that those maternity services are provided in accordance with the AMPM. The Contractor may include in its provider network the following maternity care providers:

 

a. Arizona licensed allopathic and/or osteopathic physicians who are obstetricians or general practice/family practice providers who provide maternity care services

 

b. Physician Assistants

 

c. Nurse Practitioners

 

d. Certified Nurse Midwives

 

e. Licensed Midwives

Pregnant members may choose, or be assigned, a PCP who provides obstetrical care. Such assignment shall be consistent with the freedom of choice requirements for selecting health care professionals while ensuring that the continuity of care is not compromised. Members receiving maternity services from a certified nurse midwife or a licensed midwife must also be assigned to a PCP for other health care and medical services. A certified nurse midwife may provide primary care services that he or she is willing to provide and that the member elects to receive from the certified nurse midwife. Members receiving care from a certified nurse midwife may elect to receive some or all of her primary care from the assigned PCP. Licensed midwives may not provide any additional medical services as primary care is not within their scope of practice.

 

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All physicians and certified nurse midwives who perform deliveries shall have hospital privileges for obstetrical services. Practitioners performing deliveries in alternate settings shall have a documented hospital coverage agreement. Licensed midwives perform deliveries only in the member’s home. Labor and delivery services may be provided in the member’s home by physicians, nurse practitioners, and certified nurse midwives who include such services within their practice.

 

32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS

The Contractor shall have adequate written procedures regarding referrals to specialists, to include, at a minimum, the following:

Use of referral forms clearly identifying the Contractor;

 

a. A process in place that ensures the member’s PCP receives all specialist and consulting reports and a process to ensure PCP follow-up of all referrals including EPSDT referrals for behavioral health services;

 

b. A referral plan for any member who is about to lose eligibility and who requests information on low-cost or no-cost health care services;

 

c. Referral to Medicare;

 

d. Women shall have direct access to in-network gynecological providers, including physicians, physician assistants and nurse practitioners within the scope of their practice [42 CFR 438.206(b)(2)];

 

e. For members with special health care needs determined to need a specialized course of treatment or regular care monitoring, the Contractor must have a mechanism in place to allow such members to directly access a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified needs; and

 

f. Allow for a second opinion from a qualified health care professional within the network, or if one is not available in network, arrange for the member to obtain one outside the network, at no cost to the member [42 CFR 438.206(b)(3)].

The Contractor shall comply with all applicable physician referral requirements and conditions defined in Sections 1903(s) and 1877 of the Social Security Act and their implementing regulations which include, but are not limited to, 42 CFR Part 411, Part 424, Part 435 and Part 455. Sections 1903(s) and 1877 of the Act prohibits physicians from making referrals for designated health services to health care entities with which the physician or a member of the physician’s family has a financial relationship. Designated health services include:

 

a. Clinical laboratory services

 

b. Physical therapy services

 

c. Occupational therapy services

 

d. Radiology services

 

e. Radiation therapy services and supplies

 

f. Durable medical equipment and supplies

 

g. Parenteral and enteral nutrients, equipment and supplies

 

h. Prosthetics, orthotics and prosthetic devices and supplies

 

i. Home health services

 

j. Outpatient prescription drugs

 

k. Inpatient and outpatient hospital services

 

33. APPOINTMENT STANDARDS

The Contractor shall actively monitor and track provider compliance with appointment availability standards as required in ACOM Policy 417 [42 CFR 438.206]. The Contractor shall ensure that providers offer a range of appointment availability, per appointment timeliness standards, for intakes and ongoing services based upon the clinical need of the member. The exclusive use of same-day only appointment scheduling and/or open access is prohibited within the contractor’s network. The Contractor is required on a quarterly basis to conduct review of the availability of the below listed providers in sufficient quantity to ensure results are meaningful and representative of the Contractor’s network as specified in Attachment F3, Contractor Chart of Deliverables.

 

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For purposes of this section, “urgent” is defined as an acute, but not necessarily life-threatening disorder, which, if not attended to, could endanger the patient’s health. The Contractor shall have procedures in place that ensure the following standards are met.

For Primary Care Provider Appointments, the Contractor shall be able to provide:

 

a. Immediate Need appointments the same day or within 24 hours of the member’s phone call or other notification

 

b. Urgent care appointments within 2 days of request

 

c. Routine care appointments within 21 days of request

For Specialty Provider Referrals, the Contractor shall be able to provide:

 

a. Immediate Need appointments within 24 hours of referral

 

b. Urgent care appointments within 3 days of referral

 

c. Routine care appointments within 45 days of referral

For Dental Provider Appointments, the Contractor shall be able to provide:

 

a. Immediate Need appointments within 24 hours of request

 

b. Urgent care appointments within 3 days of request

 

c. Routine care appointments within 45 days of request

For Maternity Care Provider Appointments, the Contractor shall be able to provide initial prenatal care appointments for enrolled pregnant members as follows:

 

a. First trimester - within 14 days of request

 

b. Second trimester - within 7 days of request

 

c. Third trimester - within 3 days of request

 

d. High risk pregnancies - within 3 days of identification of high risk by the Contractor or maternity care provider, or immediately if an emergency exists

ADULT DUAL MEMBERS RECEIVING GENERAL MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

For Behavioral Health Provider Appointments, the Contractor shall be able to provide:

 

a. Immediate Need appointments within 24 hours of the referral or request

 

b. Routine Care Appointments:

 

    Initial assessment within 7 days of referral

 

    The first behavioral health service following the initial assessment within the timeframe indicated by the behavioral health condition, but no later than 23 days after the initial assessment

 

    All subsequent behavioral health services within the timeframe indicated by the behavioral health condition, but no later than 45 days from identification of need

For Referrals for Psychotropic Medications:

 

a. Assess the urgency of the need immediately

 

b. For Psychotropic Medications the Contractor shall provide:

 

    An appointment, if clinically indicated, with a Behavioral Health Medical Professional within a timeframe that ensures the member a) does not run out of needed medications; or b) does not decline in his/her behavioral health condition prior to starting medication, but no later than 30 days from the identification of need.

 

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For wait time in the office, the Contractor shall actively monitor and ensure that a member’s waiting time for a scheduled appointment at the PCP’s or specialist’s office is no more than 45 minutes, except when the provider is unavailable due to an emergency.

For medically necessary non-emergent transportation, the Contractor shall schedule transportation so that the member arrives on time for the appointment, but no sooner than one hour before the appointment; nor have to wait more than one hour after the conclusion of the treatment for transportation home; nor be picked up prior to the completion of treatment. Also see Section D, Paragraph 11, Special Health Care Needs. The Contractor must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standards above for all subcontracted transportation vendors/brokers and require corrective action if standards are not met.

The Contractor must use the results of appointment standards monitoring to assure adequate appointment availability in order to reduce unnecessary emergency department utilization. The Contractor is also encouraged to contract with or employ the services of non-emergency facilities to address member non-emergency care issues occurring after regular office hours or on weekends.

The Contractor shall establish processes to monitor and reduce the appointment “no-show” rate by provider and service type. As best practices are identified, AHCCCS may require implementation by the Contractor.

The Contractor shall have written policies and procedures about educating its provider network regarding appointment time requirements. The Contractor must develop a corrective action plan when appointment standards are not met. In addition, the Contractor must develop a corrective action plan in conjunction with the provider when appropriate [42 CFR 438.206(c)(1)(iv), (v) and (vi)]. Appointment standards shall be included in the Provider Manual. The Contractor is encouraged to include the standards in the provider subcontracts.

 

34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS

The Contractor is encouraged to use Federally Qualified Health Centers and Rural Health Clinics (FQHCs/RHCs) and FQHC Look-Alikes in Arizona to provide covered services. FQHCs/RHCs and FQHC Look-Alikes are paid unique, cost-based Prospective Payment System (PPS) rates for non-pharmacy ambulatory Medicaid-covered services. The PPS rate is an all-inclusive per visit rate.xiv

To ensure compliance with the requirement of 42 USC 1396b(m)(2)(A)(ix) that the Contractor’s payments, in aggregate, will not be less than the level and amount of payment which the Contractor would make for the services if the services were furnished by a provider which is not a FQHC or RHC:xv

 

1. For dates of service from October 1, 2014 through March 31, 2015, the Contractor shall negotiate rates of payment with FQHCs/RHCs and FQHC Look-Alikes for non-pharmacy ambulatory services that are comparable to the rates paid to providers that provide similar services.

 

2. For dates of service on and after April 1, 2015, the Contractor shall pay the unique PPS rates, or negotiate sub-capitated agreements comparable to the unique PPS rates, to FQHCs/RHCs and FQHC Look-Alikes for PPS-eligible visits.

AHCCCS reserves the right to review a Contractor’s rates with an FQHC/RHC and FQHC Look-Alikes for reasonableness and to require adjustments when rates are found to be substantially less than those being paid to other, non-FQHC/RHC/FQHC Look-Alikes providers for comparable services, or not equal to or substantially less than the PPS rates.

 

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The Contractor may be required to submit member information for Title XIX and Title XXI members for each FQHC/RHC/FQHC Look-Alikes as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS will perform periodic audits of the member information submitted. The Contractor should refer to the AHCCCS Financial Reporting Guide for Acute Care Contractors with the Arizona Health Care Cost Containment System for further guidance. The FQHCs/RHCs/FQHC Look-Alikes registered with AHCCCS are listed on the AHCCCS website.

See Section D, Scope of Services Paragraph 10, Prescription Medications for more information related to 340B Drug Pricing.

 

35. PROVIDER MANUAL

The Contractor shall develop, distribute and maintain a provider manual as described in ACOM Policy 416.

 

36. PROVIDER REGISTRATION

The Contractor shall ensure that all of its subcontractors register with AHCCCS as an approved service provider. For specific requirements on Provider Registration refer to the AHCCCS website.

The National Provider Identifier (NPI) is required on all claim submissions and subsequent encounters from providers who are eligible for an NPI. The Contractor shall work with providers to obtain their NPI.

Except as otherwise required by law or as otherwise specified in a contract between a Contractor and a provider, the AHCCCS Fee-For-Service provisions referenced in the AHCCCS Provider Participation Agreement located on the AHCCCS website (e.g. billing requirements, coding standards, payment rates) are in force between the provider and Contractor.

 

37. SUBCONTRACTS

The Contractor shall be legally responsible for contract performance whether or not subcontracts are used [42 CFR 438.230(a) and 434.6(c)]. 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 this contract. The Contractor shall be held fully liable for the performance of all contract requirements and shall develop and maintain a system for regular and periodic assessment of all subcontractors’ compliance with its terms. Subject to such conditions, any function required to be provided by the Contractor pursuant to this contract may be subcontracted to a qualified person or organization [42 CFR 438.6]. All such subcontracts must be in writing [42 CFR 438.6(l)]. All subcontracts entered into by the Contractor are subject to prior review and written approval by AHCCCS, Division of Health Care Management, and shall incorporate by reference the applicable terms and conditions of this contract.

Before entering into a subcontract which delegates duties or responsibilities to a subcontractor the Contractor must evaluate the prospective subcontractor’s ability to perform the activities to be delegated. If the Contractor delegates duties or responsibilities then the Contractor shall establish a written agreement that specifies the activities and reporting responsibilities delegated to the subcontractor. The written agreement shall also provide for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate. The Contractor’s local CEO must retain the authority to direct and prioritize any delegated contract requirements. In order to determine adequate performance, the Contractor shall monitor the subcontractor’s performance on an ongoing basis and subject it to formal review at least annually or more frequently if requested by AHCCCS. As a result of the performance review, any deficiencies must be communicated to the subcontractor in order to establish a corrective action plan [42 CFR 438.230(b)]. The results of the performance review and the correction plan shall be communicated to AHCCCS upon completion.

 

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The Contractor shall maintain a fully executed original or electronic copy of all subcontracts, which shall be accessible to AHCCCS within five business days of the request by AHCCCS. All requested subcontracts must have full disclosure of all terms and conditions and must fully disclose all financial or other requested information. Information may be designated as confidential but may not be withheld from AHCCCS as proprietary. Information designated as confidential may not be disclosed by AHCCCS without the prior written consent of the Contractor except as required by law. All subcontracts shall comply with the applicable provisions of Federal and State laws, regulations and policies.

AHCCCS may, at its discretion, communicate directly with the governing body or Parent Corporation of the Contractor regarding the performance of a subcontractor or Contractor respectively.

Minimum Subcontract Provisions: All subcontracts must reference and require compliance with the Minimum Subcontract Provisions. See Minimum Subcontract Provisions on the AHCCCS Website.

In addition, each subcontract must contain the following:

 

1. Full disclosure of the method and amount of compensation or other consideration to be received by the subcontractor;

 

2. Identification of the name and address of the subcontractor;

 

3. Identification of the population, to include patient capacity, to be covered by the subcontractor;

 

4. The amount, duration and scope of medical services to be provided, and for which compensation will be paid;

 

5. The term of the subcontract including beginning and ending dates, methods of extension, termination and re-negotiation;

 

6. The specific duties of the subcontractor relating to coordination of benefits and determination of third-party liability;

 

7. A provision that the subcontractor agrees to identify Medicare and other third-party liability coverage and to seek such Medicare or third party liability payment before submitting claims to the Contractor;

 

8. A description of the subcontractor’s patient, medical, dental and cost record keeping system;

 

9. Specification that the subcontractor shall cooperate with quality management programs, and comply with the utilization control and review procedures specified in 42 CFR Part 456, as specified in the AMPM;

 

10. A provision stating that a merger, reorganization or change in ownership of an Administrative Services subcontractor of the Contractor shall require a contract amendment and prior approval of AHCCCS;

 

11. A provision that indicates that AHCCCS is responsible for enrollment, re-enrollment and disenrollment of the covered population;

 

12. A provision that the subcontractor shall be fully responsible for all tax obligations, Worker’s Compensation Insurance, and all other applicable insurance coverage obligations which arise under this subcontract, for itself and its employees, and that AHCCCS shall have no responsibility or liability for any such taxes or insurance coverage;

 

13. A provision that the subcontractor must obtain any necessary authorization from the Contractor or AHCCCS for services provided to eligible and/or enrolled members;

 

14. A provision that the subcontractor must comply with encounter reporting and claims submission requirements as described in the subcontract;

 

15. Provision(s) that allow the Contractor to suspend, deny, refuse to renew or terminate any subcontractor in accordance with the terms of this contract and applicable law and regulation;

 

16. A provision that the subcontractor may provide the member with factual information, but is prohibited from recommending or steering a member in the member’s selection of a Contractor; and

 

17. A provision that compensation to individuals or entities that conduct utilization management and concurrent review activities is not structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any enrollee [42 CFR 438.210(e)].

 

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In the event of a modification to the AHCCCS Minimum Subcontract Provisions the Contractor shall issue a notification of the change to its subcontractors within 30 days of the published change and ensure amendment of affected subcontracts. Affected subcontracts shall be amended on their regular renewal schedule or within six calendar months of the update, whichever comes first. See also ACOM Policy 416.

Administrative Services Subcontracts: Administrative Services subcontracts shall be submitted to AHCCCS, Division of Health Care Management for prior approval as specified in ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. If at any time during the period of the subcontract, the subcontractor is found to be in non-compliance, the Contractor shall notify AHCCCS as specified in ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. The Contractor will submit this in writing and provide the corrective action plan and any measures taken by the Contractor to bring the subcontractor into compliance.

The Contractor must submit an annual Administrative Services Subcontractor Evaluation Report as specified in ACOM Policy 438 and Attachment F3, Contractor Chart of Deliverables. The report shall include any findings of subcontract non-compliance and any corrective action plans and/or measures taken by the Contractor to bring the subcontractor into compliance.

The Contractor shall require Administrative Services Subcontractors to adhere to screening and disclosure requirements as described in Paragraph 62, Corporate Compliance.

A merger, acquisition, reorganization or change in ownership of an Administrative Services subcontractor of the Contractor requires prior approval of AHCCCS, as outlined in ACOM Policy 438.

AHCCCS will not permit one organization to own or manage more than one contract within the same program in the same GSA.

Provider Agreements: The Contractor shall not include covenant-not-to-compete requirements in its provider agreements. Specifically, the Contractor shall not contract with a provider and require that the provider not provide services for any other AHCCCS Contractor. In addition, the Contractor shall not enter into subcontracts that contain compensation terms that discourage providers from serving any specific eligibility category.

The Contractor must make reasonable efforts to enter into a written agreement with any provider providing services at the request of the Contractor more than 25 times during the previous contract year and/or are anticipated to continue providing services for the Contractor. The Contractor must follow ACOM Policy 415 and consider the repeated use of providers operating without a written agreement when assessing the adequacy of its network.

For all subcontracts in which the Contractor and subcontractor have a capitated arrangement/risk sharing arrangement, the following provision must be included verbatim in every contract:

If <the Subcontractor> does not bill <the Contractor>, < the subcontractor’s> encounter data that is required to be submitted to <the Contractor> pursuant to contract is defined for these purposes as a “claim for payment”. <The Subcontractor’s> provision of any service results in a “claim for payment” regardless of whether there is any intention of payment. All said claims shall be subject to review under any and all fraud and abuse statutes, rules and regulations, including but not limited to Arizona Revised Statute (A.R.S.) §36-2918, §36-2932, and §36-2957.

 

38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM

The Contractor shall develop and maintain claims processes and systems that ensure the accurate collection and processing of claims, analysis, integration, and reporting of data. These processes and systems shall result in information on areas including, but not limited to, service utilization, claim disputes and appeals [42 CFR 438.242(a)].

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

General Claims Processing Requirements

The Contractor must include nationally recognized methodologies to correctly pay claims including but not limited to:

 

a. Medicaid National Correct Coding Initiative (NCCI) for Professional, ASC and Outpatient services

 

b. Multiple Procedure/Surgical Reductions

 

c. Global Day E & M Bundling standards

The Contractor’s claims payment system must be able to assess and/or apply data related edits including but not limited to:

 

a. Benefit Package Variations

 

b. Timeliness Standards

 

c. Data Accuracy

 

d. Adherence to AHCCCS Policy

 

e. Provider Qualifications

 

f. Member Eligibility and Enrollment

 

g. Over-Utilization Standards

The Contractor must produce a remittance advice related to the Contractor’s payments and/or denials to providers and each must include at a minimum:

 

a. The reason(s) for denials and adjustments

 

b. A detailed explanation/description of all denials, payments and adjustments

 

c. The amount billed

 

d. The amount paid

 

e. Application of COB and copays

 

f. Provider rights for claim disputes

Additionally, the Contractor must include information in its remittance advice which informs providers of instructions and timeframes for the submission of claim disputes and corrected claims. All paper remittance advices must describe this information in detail. Electronic remittance advices must either direct providers to the link where this information is explained or include a supplemental file where this information is explained.

The related remittance advice must be sent with the payment, unless the payment is made by electronic funds transfer (EFT). Any remittance advice related to an EFT must be sent to the provider, no later than the date of the EFT. See Section D, Paragraph 64, Systems and Data Exchange Requirements, for specific standards related to remittance advice and EFT payment.

AHCCCS requires the Contractor to attend and participate in AHCCCS workgroups including Technical Consortium meetings to review upcoming initiatives and other technical issues.

Per A.R.S. §36-2904, unless a shorter time period is specified in contract, the Contractor shall not pay a claim initially submitted more than six months after the date of service or date of eligibility posting whichever is later, or pay a clean claim submitted more than 12 months after date of service or date of eligibility posting, whichever is later; except as directed by AHCCCS or otherwise noted in this contract. Regardless of any subcontract with an AHCCCS Contractor, when one AHCCCS Contractor recoups a claim because the claim is the payment responsibility of another AHCCCS Contractor (responsible Contractor), the provider may file a claim for payment with the responsible Contractor. The responsible Contractor shall not deny a claim on the basis of lack of timely filing if the provider submits a clean claim to the responsible Contractor no later than 60 days from the date of the recoupment, 12 months from the date of service, or 12 months from date that eligibility is posted, whichever date is later.

Claim payment requirements pertain to both contracted and non-contracted providers. The receipt date of the claim is the date stamp on the claim or the date electronically received. The receipt date is the day the claim is

 

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received at the Contractor’s specified claim mailing address, received through direct electronic submission to the Contractor, or received by the Contractor’s designated Clearinghouse. The paid date of the claim is the date on the check or other form of payment [42 CFR 447.45(d)]. Claims submission deadlines shall be calculated from the claim end date of service, inpatient claim date of discharge or the effective date of eligibility posting, whichever is later as stated in A.R.S. §36-2904. Additionally, unless a subcontract specifies otherwise, the Contractor shall ensure that for each form type (Dental/Professional/Institutional), 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim and 99% are adjudicated within 60 days of receipt of the clean claim.

In accordance with the Deficit Reduction Act of 2005, Section 6085, SMD letter 06-010, and Section 1932 (b)(2)(D) of the Social Security Act, the Contractor is required to reimburse non-contracted emergency services providers at the AHCCCS Fee-For-Service rate. This applies to in State as well as out of State providers.xvi

In accordance with A.R.S. §36-2904 the Contractor is required to reimburse providers of hospital and non hospital services at the AHCCCS fee schedule in the absence of a contract or negotiated rate. This requirement applies to services which are directed out of network by the Contractor or to emergency services. For inpatient stays at urban hospitals pursuant to A.R.S. §36-2905.01 for non-emergency services, the Contractor is required to reimburse non-contracted providers at 95% of the AHCCCS fee schedule specified in A.R.S. §36-2903.01. All payments are subject to other limitations that apply, such as provider registration, prior authorization, medical necessity, and covered service.

The Contractor is required to reimburse providers for previously denied or recouped claims if the provider was subsequently denied payment by the primary insurer based on timely filing limits or lack of prior authorization and the member failed to initially disclose additional insurance coverage other than AHCCCS.

The provider shall have 90 days from the date they become aware that payment will not be made to submit a new claim to the Contractor which includes the documentation from the primary insurer that payment will not be made. Documentation includes but is not limited to any of the following items establishing that the primary insurer has or would deny payment based on timely filing limits or lack of prior authorization; an EOB, policy or procedure, Provider Manual excerpt, etc.

For hospital clean claims, in the absence of a contract specifying otherwise, a Contractor shall apply a quick pay discount of 1% on claims paid within 30 days of receipt of the clean claim. For hospital clean claims, in the absence of a contract specifying other late payment terms, a Contractor is required to pay slow payment penalties (interest) on payments made after 60 day of receipt of the clean claim. Interest shall be paid at the rate of 1% per month for each month or portion of a month from the 61st day until the date of payment (A.R.S. §36-2903.01).

For all non-hospital clean claims, in the absence of a contract specifying other late payment terms, a Contractor is required to pay interest on payments made after 45 days of receipt of the clean claim (as defined in this contract). Interest shall be at the rate of 10% per annum (prorated daily) from the 46th day until the date of payment.

In the absence of a contract specifying other late payment terms, a claim for an authorized service submitted by a licensed skilled nursing facility, assisted living ALTCS provider or a home and community based ALTCS provider shall be adjudicated within 30 calendar days after receipt by the Contractor. A Contractor is required to pay interest on payments made after 30 days of receipt of the clean claim. Interest shall be paid at the rate of 1% per month (prorated on a daily basis) from the date the clean claim is received until the date of payment (A.R.S. §36- 2943.D).

The Contractor shall pay interest on all claim disputes as appropriate based on the date of the receipt of the original clean claim submission (not the claim dispute).

 

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When interest is paid, the Contractor must report the interest as directed in the AHCCCS Encounter Manual and the AHCCCS Claims Dashboard Reporting Guide.

See ACOM Policy 203 for additional information regarding requirements for the adjudication and payment of claims.

Recoupments: The Contractor’s claims processes, as well as its prior authorization and concurrent review process, must minimize the likelihood of having to recoup already-paid claims.

Any individual recoupment in excess of $50,000 per provider, or Tax Identification Number within a contract year or greater than 12 months after the date of the original payment must be approved as specified in Attachment F3, Contractor Chart of Deliverables and as further described in ACOM Policy 412.

When recoupment amounts for a Provider TIN cumulatively exceed $50,000 during a contract year (based on recoupment date), the Contractor must report the cumulative recoupment monthly to the designated AHCCCS Operations and Compliance Officer as outlined in the AHCCCS Claims Dashboard Reporting Guide and Attachment F3, Contractor Chart of Deliverables.

The Contractor must void encounters for claims that are recouped in full. For recoupments that result in a reduced claim value or adjustments that result in an increased claim value, replacement encounters must be submitted. AHCCCS may validate the submission of applicable voids and replacement encounters upon completion of any approved recoupment that meets the qualifications of this section. All replaced or voided encounters must reach adjudicated status within 120 days of the approval of the recoupment. The Contractor should refer to ACOM Policy 412 and AHCCCS Encounter Manual for further guidance.

Appeals: If the Contractor or a Director’s Decision reverses a decision to deny, limit, or delay authorization of services, and the member received the disputed services while an appeal was pending, the Contractor shall process a claim for payment from the provider in a manner consistent with the Contractor’s or Director’s Decision and applicable statutes, rules, policies, and contract terms. The provider shall have 90 days from the date of the reversed decision to submit a clean claim to the Contractor for payment. For all claims submitted as a result of a reversed decision, the Contractor is prohibited from denying claims for untimeliness if they are submitted within the 90 day timeframe. The Contractor is also prohibited from denying claims submitted as a result of a reversed decision because the member failed to request continuation of services during the appeals/hearing process: a member’s failure to request continuation of services during the appeals/hearing process is not a valid basis to deny the claim.

ICD-10 Readiness: In 2009 the Federal government published the final regulation that adopted the ICD-10 code sets as HIPAA standards (45 CFR 162.1002). As HIPAA covered entities, State Medicaid programs must comply with use of the ICD-10 code sets by the deadline established by CMS. The compliance date published in the final rule is October 1, 2013. However, in 2014 the compliance effective date was further delayed to October 1, 2015, though AHCCCS did not amend its requirement that the Contractor be ready to implement ICD-10 effective October 1, 2014.

Claims Processing Related Reporting: The Contractor shall submit a monthly Claims Dashboard as specified in the AHCCCS Claims Dashboard Reporting Guide and Attachment F3, Contractor Chart of Deliverables.

AHCCCS may require the Contractor to review claim requirements, including billing rules and documentation requirements, and submit a report to AHCCCS that will include the rationale for specified requirements. AHCCCS shall determine and provide a format for the reporting of this data at the time of the request.

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

Claims System Audits: The Contractor shall develop and implement an internal ongoing claims audit function that will include, at a minimum, the following:

 

a. Verification that provider contracts are loaded correctly

 

b. Accuracy of payments against provider contract terms

Audits of provider contract terms must be performed on a regular and periodic basis and consist of a random, statistically significant sampling of all contracts in effect at the time of the audit. The audit sampling methodology must be documented in policy and the Contractor should review the contract loading of both large groups and individual practitioners at least once every five year period in addition to any time a contract change is initiated during that timeframe. The findings of the audits described above must be documented and any deficiencies noted in the resulting reports must be met with corrective action.

In addition, in the event of a system change or upgrade, as specified in Attachment F3, Contractor Chart of Deliverables, the Contractor may also be required to initiate an independent audit of the Claim Payment/Health Information System. The Division of Health Care Management will approve the scope of this audit, and may include areas such as a verification of eligibility and enrollment information loading, contract information management (contract loading and auditing), claims processing and encounter submission processes, and will require a copy of the final audit findings.

Recovery Audit Contractor Audits: A Recovery Audit Contractor (RAC) is a private entity that is contracted to identify underpayments and overpayments, and to recoup overpayments made to providers. The Affordable Care Act of 2010 required States to establish Medicaid RAC programs. CMS promulgated rules regarding the implementation of the Medicaid RAC requirements (42 CFR 455.500 et seq.), including the provision that Medicaid RACs are only required to review Fee-For-Service claims until a permanent Medicare managed care RAC program is fully operational or a viable State managed care model is identified and CMS undertakes rules regarding managed care RAC efforts.

AHCCCS is exploring what opportunities may exist in the marketplace regarding a methodology for conducting a recovery audit of its services delivered through its managed care contracts (excluding reinsurance). The Contractor shall participate in any RAC activities mandated by AHCCCS, via contract amendment or policy, upon determination of the method of approach.

 

39. SPECIALTY CONTRACTS

AHCCCS may at any time negotiate or contract on behalf of the Contractor and AHCCCS for specialized hospital and medical services. AHCCCS will consider existing Contractor resources in the development and execution of specialty contracts. AHCCCS may require the Contractor to modify its delivery network to accommodate the provisions of specialty contracts. AHCCCS may consider waiving this requirement in particular situations if such action is determined to be in the best interest of the State; however, in no case shall reimbursement exceeding that payable under the relevant AHCCCS specialty contract be considered in capitation rate development or risk sharing arrangements, including reinsurance.

During the term of specialty contracts, AHCCCS may act as an intermediary between the Contractor and specialty Contractors to enhance the cost effectiveness of service delivery, medical management, and adjudication of claims related to payments provided under specialty contracts shall remain the responsibility of the Contractor. AHCCCS may provide technical assistance prior to the implementation of any specialty contracts.

AHCCCS has specialty contracts, including but not limited to, transplant services, anti-hemophilic agents and pharmaceutical related services. AHCCCS shall provide at least 60 days advance written notice to the Contractor prior to the implementation of any specialty contract.

 

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40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT

In the absence of a contract between the Contractor and a hospital providing otherwise, the Contractor shall reimburse hospitals for inpatient and outpatient hospital services as required by A.R.S. §§36-2904 and 2905.01, and 9 A.A.C. 22, Article 7, which includes without limitation: reimbursement of the majority of inpatient hospital services with discharge dates on and after October 1, 2014, using the APR-DRG payment methodology in A.A.C. R9-22-712.60 through A.A.C. R9-22-712.81; reimbursement of limited inpatient hospital services with discharge dates on and after October 1, 2014, using per diem rates described in A.A.C. R9-22-712.61; and, in Pima and Maricopa Counties, payment to non-contracted hospitals at 95% of the amounts otherwise payable for inpatient services.

The Contractor is encouraged to obtain subcontracts with hospitals in all GSAs. A Contractor serving out-of-state border communities (excluding Mexico) is strongly encouraged to establish contractual agreements with those out-of-state hospitals in counties that are identified by GSA in ACOM Policy 436. The Contractor, upon request, shall make available to AHCCCS, all hospital subcontracts and amendments.

The Contractor may conduct prepayment, concurrent and post-payment medical reviews of all hospital claims including outlier claims. Erroneously paid claims may be subject to recoupment. If the Contractor fails to identify lack of medical necessity through prepayment and/or concurrent medical review, lack of medical necessity shall not constitute a basis for recoupment of paid hospital claims, including outlier claims, unless the Contractor identifies the lack of medical necessity through a post-payment medical review of information that the Contractor could not have discovered during a prepayment and/or concurrent medical review through the exercise of due diligence. The Contractor shall comply with Section D, Paragraph 38, Claims Payment/Health Information System.

For information on Value Based Purchasing Differential Adjusted Payments see Paragraph 76, Value-Based Purchasing.

 

41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT

The Contractor shall provide medically necessary nursing facility services as outlined in Section D, Paragraph 10, Scope of Services. The Contractor shall also provide medically necessary nursing facility services for any enrolled member who has a pending ALTCS application who is currently residing in a nursing facility and is eligible for services provided under this contract. If the member becomes ALTCS eligible and is enrolled with an ALTCS Contractor before the end of the maximum 90 days per contract year of nursing facility coverage, the Contractor is only responsible for nursing facility reimbursement during the time the member is enrolled with the Contractor as shown in the PMMIS. Nursing facility services covered by another liable party (including Medicare) while the member is enrolled with the Contractor, shall be applied to the 90 day per contract year limitation.

The Contractor shall not deny nursing facility services when the member’s eligibility, including prior period coverage, had not been posted at the time of admission. In such situations the Contractor shall impose reasonable authorization requirements. There is no ALTCS enrollment, including prior period coverage that occurs concurrently with AHCCCS acute enrollment.

The Contractor shall notify the Assistant Director of the Division of Member Services when a member has been residing in a nursing facility, alternative residential facility or receiving home and community based services for 45 days as specified in Section D, Paragraph 10, Scope of Services, under the heading Nursing Facility. This will allow AHCCCS time to follow-up on the status of the ALTCS application and to consider potential Fee-For-Service coverage if the stay goes beyond the 90 day per contract year maximum.

For information on Value Based Purchasing Differential Adjusted Payments see Paragraph 87, Value-Based Purchasing.

 

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SECTION D: ACUTE CARE PROGRAM REQUIREMENTS    Contract No. YH14-0001

 

 

 

42. INCENTIVES/PAY FOR PERFORMANCE

Physician Incentives

The Contractor must comply with all applicable physician incentive requirements and conditions defined in 42 CFR 417.479. These regulations prohibit physician incentive plans that directly or indirectly make payments to a doctor or a group as an inducement to limit or refuse medically necessary services to a member. The reporting requirements under 42 CFR 417.479 have been suspended. No reporting to CMS is required until the suspension is lifted.

The Contractor shall disclose to AHCCCS the information on physician incentive plans listed in 42 CFR 417.479(h)(1) through 417.479(i) upon request from AHCCCS or CMS and to AHCCCS members who request them. AHCCCS shall also review the Value-Based Purchasing (VBP) deliverables required under Section D, Paragraph 76, and may request supplemental information from the Contractor in fulfillment of the requirements in 42 CFR 417.479(h)(1) through 417.479(i).

The Contractor shall not enter into contractual arrangements that place providers at substantial financial risk as defined in 42 CFR 417.479 unless specifically approved in advance by the AHCCCS, Division of Health Care Management. In order to obtain approval when the contractual arrangements meet the definition of substantial financial risk, the following must be submitted to the AHCCCS, Division of Health Care Management 45 days prior to the implementation of the contract as specified in Attachment F3, Contractor Chart of Deliverables, [42 CFR 438.6(g)]:

 

1. The type of incentive arrangement

 

2. A plan for the member satisfaction survey;

 

3. Details of the stop-loss protection provided;

 

4. A summary of the compensation arrangement that meets the substantial financial risk definition; and

 

5. Any other items as requested by AHCCCS

Any Contractor-selected and/or developed pay for performance initiative that meets the requirements of 42 CFR 417.479 must be approved by AHCCCS, Division of Health Care Management prior to implementation as specified in Attachment F3, Contractor Chart of Deliverables.

The Contractor shall also comply with all physician incentive plan requirements as set forth in 42 CFR 422.208, 422.210 and 438.6(h). These regulations apply to contract arrangements with subcontracted entities that provide utilization management services.

 

43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN

If a Contractor has subcontracted for management services, the management service agreement must be approved in advance by AHCCCS, Division of Health Care Management. If there is a cost allocation plan as part of the management services agreement, it is subject to review by AHCCCS as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS reserves the right to perform a thorough review of actual management fees charged and/or corporate allocations made.

If there is a change in ownership of the entity with which the Contractor has contracted for management services, AHCCCS must review and provide prior approval of the assignment of the subcontract to the new owner. AHCCCS may offer open enrollment to the members assigned to the Contractor should a change in ownership occur. AHCCCS will not permit two Acute Care Contractors to utilize the same management service company in the same GSA.

The performance of management service subcontractors must be evaluated and included in the Annual Subcontractor Assignment and Evaluation Report required by Section D, Paragraph 37, Subcontracts and as specified in Attachment F3, Contractor Chart of Deliverables.

 

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44. MATERIAL CHANGE TO BUSINESS OPERATIONS

The Contractor is responsible for evaluating all operational changes, including unexpected or significant changes, and determining whether those changes are material changes to the Contractor’s business operations [42 CFR 438.207 (c)]. All material changes to the business operations must be approved in advance by AHCCCS, Division of Health Care Management. A material change to business operations is defined as any change in overall business operations (e.g., policy, process, protocol, such as prior authorization or retrospective review) that affects, or can reasonably be foreseen to affect, the Contractor’s ability to meet the performance standards as described in this contract including, but not limited to, any changes that would impact or is likely to impact more than 5% of total membership and/or provider network in a specific GSA.

The Contractor must submit the request for approval of a material change to business operations with information including, but not limited to, how the change will affect the delivery of covered services, the Contractor’s plans for maintaining the quality of member care, and communications to providers and members, as outlined in ACOM Policy 439 and as specified in Attachment F3, Contractor Chart of Deliverables. AHCCCS will respond to the Contractor within 30 days of the submission. A material change in the Contractor’s business operations requires 30 days advance written notice to providers and members. For emergency situations, AHCCCS will expedite the approval process.

The Contractor may be required to conduct meetings with providers to address issues (or to provide general information, technical assistance, etc.) related to Federal and State requirements, changes in policy, reimbursement matters, prior authorization and other matters as identified or requested by the AHCCCS.

See Section D, Paragraph 29, regarding material changes by the Contractor that may impact the provider network.

See Section D, Paragraph 64, for additional submission requirements regarding system changes and upgrades.

 

45. MINIMUM CAPITALIZATION

The Contractor is required to meet a minimum capitalization requirement within 30 days after contract award. Details regarding this requirement are included in AHCCCS’ solicitation, released prior to the expiration of the current contract period. Once the new contract period commences, the minimum capitalization may be applied to the Contractor’s equity per member standard, which continues throughout the contract period. See Section D, Paragraph 50, Financial Viability Standards.

 

46. PERFORMANCE BOND OR BOND SUBSTITUTE

In addition to the minimum capitalization requirements, the Contractor shall be required to establish and maintain a performance bond for as long as the Contractor has liabilities of $50,000 or more outstanding, or 15 months following the termination date of this contract, whichever is later, to guarantee: 1) payment of the Contractor’s obligations to providers, and 2) performance by the Contractor of its obligations under this contract [42 CFR 438.116]. The Performance Bond shall be in a form acceptable to AHCCCS. See ACOM Policy 305.

In the event of a default by the Contractor, AHCCCS shall, in addition to any other remedies it may have under this contract, obtain payment under the Performance Bond or substitute security for the purposes of the following:

 

a. Paying any damages sustained by providers, non-contracting providers and non-providers by reason of a breach of the Contractor’s obligations under this contract;

 

b. Reimbursing AHCCCS for any payments made by AHCCCS on behalf of the Contractor; and

 

c. Reimbursing AHCCCS for any extraordinary administrative expenses incurred by reason of a breach of the Contractor’s obligations under this contract, including, but not limited to, expenses incurred after termination of this contract for reasons other than the convenience of the State by AHCCCS.

 

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In the event AHCCCS agrees to accept substitute security in lieu of the security types outlined in ACOM Policy 305, the Contractor agrees to execute any and all documents and perform any and all acts necessary to secure and enforce AHCCCS’ security interest in such substitute security including, but not limited to, security agreements and necessary UCC filings pursuant to the Arizona Uniform Commercial Code. The Contractor must request approval from AHCCCS before a substitute security in lieu of the security types outlined in ACOM Policy 305 is established. In the event such substitute security is agreed to and accepted by AHCCCS, the Contractor acknowledges that it has granted AHCCCS a security interest in such substitute security to secure performance of its obligations under this contract. The Contractor is solely responsible for establishing the credit-worthiness of all forms of substitute security. AHCCCS may, after written notice to the Contractor, withdraw its permission for substitute security, in which case the Contractor shall provide AHCCCS with a form of security described in ACOM Policy 305.

The Contractor may not change the amount, duration or scope of the performance bond without prior written approval from AHCCCS, Division of Health Care Management. The Contractor shall not leverage the bond for another loan or create other creditors using the bond as security.

 

47. AMOUNT OF PERFORMANCE BOND

The initial amount of the Performance Bond shall be equal to 100% of the total capitation payment expected to be paid to the Contractor in the first month of the contract year, or as determined by AHCCCS. The total capitation amount (including delivery supplement) excludes premium tax. This requirement must be satisfied by the Contractor no later than 30 days after notification by AHCCCS of the amount required. Thereafter, AHCCCS shall review the capitation amounts of the Contractor on a monthly basis to determine if the Performance Bond must be increased. The Contractor shall have 30 days following notification by AHCCCS to increase the amount of the Performance Bond. The Performance Bond amount that must be maintained after the contract term shall be sufficient to cover all outstanding liabilities and will be determined by AHCCCS. The Contractor may not change the amount of the performance bond without prior written approval from AHCCCS, Division of Health Care Management. Refer to ACOM Policy 305 for more details.

 

48. ACCUMULATED FUND DEFICIT

The Contractor and its owners must review for accumulated fund deficits on a quarterly and annual basis. In the event the Contractor has a fund deficit, the Contractor and its owners shall fund the deficit through capital contributions in a form acceptable to AHCCCS. The capital contributions must be for the period in which the deficit is reported and shall occur within 30 days of the financial statement due to AHCCCS. AHCCCS at its sole discretion may impose a different timeframe other than the 30 days required in this paragraph. AHCCCS may, at its option, impose enrollment caps in any or all GSA’s as a result of an accumulated deficit, even if unaudited.

 

49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS

The Contractor shall not, without the prior approval of AHCCCS, make any advances, distributions, loans, loan guarantees, or investments, including, but not limited to those to related parties or affiliates including another fund or line of business within its organization. The Contractor shall not, without prior approval of AHCCCS, make loans or advances to providers in excess of $50,000. All requests for prior approval are to be submitted to the AHCCCS, Division of Health Care Management, as specified in Attachment F3, Contractor Chart of Deliverables. Refer to ACOM Policy 418 for further information.

 

50. FINANCIAL VIABILITY STANDARDS

The Contractor must comply with the AHCCCS-established financial viability standards. On a quarterly basis, AHCCCS will review the following ratios with the purpose of monitoring the financial health of the Contractor: current ratio; equity per member; medical expense ratio; and the administrative cost percentage. These same standards will be reviewed for the financial statements applicable to the Contractor’s Medicare line of business if the Contractor is certified by AHCCCS.

 

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Sanctions may be imposed if the Contractor does not meet these financial viability standards. AHCCCS will take into account the Contractor’s unique programs for managing care and improving the health status of members when analyzing medical expense and administrative ratio results. However, if a critical combination of the financial viability standards is not met, or if the Contractor’s experience differs significantly from other Contractors, additional monitoring, such as monthly reporting, may be required.

FINANCIAL VIABILITY STANDARDS – Acute Care

 

Current Ratio    Current assets divided by current liabilities. “Current assets” includes any long-term investments that can be converted to cash within 24 hours without significant penalty (i.e., greater than 20%).
   Standard: At least 1.00
   If current assets include a receivable from a parent company, the parent company must have liquid assets that support the amount of the inter-company loan.
Equity per Member    Unrestricted equity, less on-balance sheet performance bond, divided by the number of members enrolled at the end of the period.
   Standard: At least     $170 for Contractors with enrollment < 100,000
                                     $115 for Contractors with enrollment of 100,000+
   Additional information regarding the Equity per Member requirement may be found in ACOM Policy 305.
Medical Expense Ratio    Total medical expenses less TPL divided by the sum of total PPC and prospective capitation + Delivery Supplement + All Reconciliation Settlements + Reinsurance less premium tax
   Standard: At least 85%
Administrative Cost Percentage    Total administrative expenses divided by the sum of total PPC and prospective capitation + Delivery Supplement + All Reconciliation Settlements + Reinsurance less premium tax
   Standard: No greater than 10%
FINANCIAL VIABILITY STANDARD – Medicare Advantage Plan Certified by AHCCCS
Equity per Member    Unrestricted equity, less on-balance sheet performance bond, divided by the number of Medicare Advantage Plan dual eligible members enrolled at the end of the period.
   Standard: At least $350

Additional information regarding the Equity per Member requirement may be found in ACOM Policy 313.

 

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The Contractor shall comply with all financial reporting requirements contained in Attachment F3, Contractor Chart of Deliverables and the AHCCCS Financial Reporting Guide for Acute Care Contractors, a copy of which may be found on the AHCCCS website. This reporting is required for both the Acute Care and Medicare lines of business, regardless of the licensing or certifying entity for the Medicare Advantage Plan. If the Contractor is a Medicare Advantage Plan licensed through the Department of Insurance, quarterly reporting to AHCCCS is required for informational purposes only. The required reports are subject to change during the contract term and are summarized in Attachment F3, Contractor Chart of Deliverables. See ACOM Policy 305 for more detail.

 

51. SEPARATE INCORPORATION

Within 120 days of contract award, a non-governmental Contractor shall have established a separate corporation for the purposes of this contract, whose sole activity is the performance of the requirements of this contract or other contracts with AHCCCS.

 

52. MERGER, ACQUISITION, REORGANIZATION, JOINT VENTURE AND CHANGE IN OWNERSHIP

A merger, acquisition, reorganization, joint venture, and change in ownership of the Contractor shall require prior approval of AHCCCS, as specified in ACOM Policy 317 and Attachment F3, Contractor Chart of Deliverables. The Contractor must submit notification and a detailed transition plan to AHCCCS 180 days prior to the effective date as outlined in ACOM Policy 317. The purpose of the plan review is to ensure uninterrupted services to members, evaluate the new entity’s ability to maintain and support the contract requirements, and to ensure that services to members are not diminished and that major components of the organization and AHCCCS programs are not adversely affected by such merger, reorganization, joint venture or change in ownership.

A merger, acquisition, reorganization, joint venture, and change in ownership of the Contractor may require a contract amendment. If the Contractor does not obtain prior approval, or AHCCCS determines that a merger, acquisition, reorganization, joint venture or change in ownership is not in the best interest of the State, AHCCCS may terminate this contract pursuant to Section E, Contract Terms and Conditions, Paragraph 44, Temporary Management/Operation of a Contractor and Termination. AHCCCS may offer open enrollment to the members assigned to the Contractor should a merger, acquisition, reorganization, joint venture, or change in ownership occur. AHCCCS will not permit one organization to own or manage more than one contract within the same program in the same GSA.

 

53. COMPENSATION

The method of compensation under this contract will be Prior Period Coverage (PPC) capitation, prospective capitation, delivery supplement, and reinsurance, as described and defined within this contract and appropriate laws, regulations or policies.

Actuaries establish the capitation rates using practices established by the Actuarial Standards Board. AHCCCS provides the following data to its actuaries for the purposes of rebasing and/or updating the capitation rates:

 

a. Utilization and unit cost data derived from adjudicated encounters

 

b. Both audited and unaudited financial statements reported by the Contractor

 

c. Market basket inflation trends

 

d. AHCCCS Fee-For-Service schedule pricing adjustments

 

e. Programmatic or Medicaid covered service changes that affect reimbursement

 

f. Other changes to medical practices or administrative requirements that affect reimbursement

AHCCCS adjusts its rates to best match payment to risk. This further ensures the actuarial basis for the capitation rates. AHCCCS utilizes a national episodic/diagnostic risk adjustment model that will be applied to all prospective capitation rates for all risk groups (excluding supplemental payments). AHCCCS’ actuaries shall determine if Adults > 106% FPL will or will not be included in risk adjustment. Additional risk factors that may be considered in capitation rate development include:

 

a. Reinsurance (as described in Section D, Paragraph 57, Reinsurance)

 

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b. Age/Gender

 

c. Medicare enrollment

 

d. Delivery supplemental payment

 

e. Geographic Service Area adjustments

 

f. Risk sharing arrangements for specific populations

 

g. Member specific statistics, e.g. member acuity, member choice, member diagnosis, etc.

The above information is reviewed by AHCCCS’ actuaries in renewal years to determine if adjustments are necessary. A Contractor may cover services that are not covered under the State Plan or the Arizona Medicaid Section 1115 Demonstration Waiver Special Terms and Conditions approved by CMS; however those services are not included in the data provided to actuaries for setting capitation rates [42 CFR 438.6(e)] (Section 1903(i) and 1903(i)(17) of the Social Security Act).xvii Graduate Medical Education payments (GME) are not included in the capitation rates but paid out separately consistent with the terms of Arizona’s State Plan.xviii Likewise, because AHCCCS does not delegate any of its responsibilities for administering Electronic Health Record (EHR) incentive payments to the Contractor, EHR payments are also excluded from the capitation rates and are paid out separately by AHCCCS pursuant to Section 4201 of the HITECH Act , 42 USC 1396b(t), and 42 CFR 495.300 et seq.xix

In instances in which AHCCCS has specialty contracts or legislation/policy limits the allowable reimbursement for certain services or pharmaceuticals, the amount to be used in the capitation rate setting process and reconciliations will be the lesser of the contracted/mandated amount or the Contractor paid amount.

Prospective Capitation: The Contractor will be paid capitation for all prospective member months, including partial member months. This capitation includes the cost of providing medically necessary covered services to members during the prospective period coverage.

Prior Period Coverage (PPC) Capitation: Except for SOBRA Family Planning services, and KidsCare, the Contractor will be paid capitation for all PPC member months, including partial member months. This capitation includes the cost of providing medically necessary covered services to members during prior period coverage. The PPC capitation rates will be set by AHCCCS and will be paid to the Contractor along with the prospective capitation described above. The Contractor will not receive PPC capitation for newborns of members who are enrolled at the time of delivery. There is no PPC capitation for members enrolled with the Contractor who are initially found eligible for AHCCCS through Hospital Presumptive Eligibility. These members will receive coverage of services during the PPC period through AHCCCS Fee-For-Service.

Reconciliation of Prospective Costs to Reimbursement: AHCCCS will reconcile the Contractor’s prospective medical cost expenses to prospective net capitation paid to the Contractor. Refer to ACOM Policy 311 CYE 14 AND FORWARD for further details. This reconciliation will limit the Contractor’s profits and losses as follows:

 

Profit

   MCO Share     State Share     Max MCO
Profit
    Cumulative
MCO Profit
 

<= 3%

     100     0     3     3

> 3% and <= 6 %

     50     50     1.5     4.5

> 6%

     0     100     0     4.5

 

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Loss

   MCO Share     State Share     Max MCO
Loss
    Cumulative
MCO Loss
 

<= 3%

     100     0     3     3

> 3%

     0     100     0     3

Reconciliation of PPC Costs to Reimbursement: AHCCCS will reconcile the Contractor’s PPC medical cost expenses to PPC capitation paid to the Contractor during the year. This reconciliation will limit the Contractor’s profits and losses to 2%. Any losses in excess of 2% will be reimbursed to the Contractor, and likewise, profits in excess of 2% will be recouped. Refer to ACOM Policy 302 CYE 14 AND FORWARD for further details.

Reconciliation of Adult Group above 106% Federal Poverty Level Costs to Reimbursement (Adults > 106%): AHCCCS will reconcile the Contractor’s Prospective and PPC medical cost expenses to Prospective and PPC capitation paid to the Contractor during the contract year for the Adults > 106%. This reconciliation will limit the Contractor’s profits and losses to 1%. Any losses in excess of 1% will be reimbursed to the Contractor, and likewise, profits in excess of 1% will be recouped. Refer to ACOM Policy 316 CYE14 AND FORWARD for further details.

Reconciliation of Value-Based Purchasing Initiative: AHCCCS will settle the Contractor’s quality contributions and quality distributions through a reconciliation. Quality distributions in excess of quality contributions will be paid to the Contractor. Quality contributions in excess of quality distributions will be recouped from the Contractor. Value-Based Purchasing (VBP) payments made by the Contractor to providers will be incorporated in the reconciliation. Refer to ACOM Policy 315 CYE16 for further details.

Cost Settlement for Primary Care Payment Parity: The Patient Protection and Affordable Care Act (ACA) requires that the Contractor make enhanced payments for primary care services delivered by, or under the supervision of, a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.400(a)] The Contractor shall base enhanced primary care payments on the Medicare Part B fee schedule rate or, if greater, the payment rate that would be applicable in 2013 and 2014 using the CY 2009 Medicare physician fee schedule conversion factor. If no applicable rate is established by Medicare, the Contractor shall use the rate specified in a fee schedule established by CMS. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.405] The Contractor shall make enhanced primary care payments for all Medicaid-covered Evaluation and Management (E&M) billing codes 99201 through 99499 and Current Procedural Terminology (CPT) vaccine administration codes 90460, 90461, 90471, 90472, 90473, and 90474, or their successor codes. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi), 42 CFR 447.405(c)]xx AHCCCS has developed an enhanced fee schedule containing the qualifying codes using the 2009 Medicare conversion factor in compliance with the greater-of requirement. The enhanced payments apply only to services provided on and after January 1, 2013 by qualified providers, who self-attest to AHCCCS as defined in the federal regulations. These reimbursement requirements for the enhanced payments apply to payments made for dates of service January 1, 2013 through December 31, 2014. The Contractor shall reprocess all qualifying claims for qualifying providers back to January 1, 2013 dates of service with no requirements that providers re-submit claims or initiate any action. The Contractor shall not apply any discounts to the enhanced rates.

In the event that a provider retroactively loses his/her qualification for enhanced payments, the Contractor shall identify impacted claims and automatically reprocess for the recoupment of enhanced payments. It is expected that this reprocessing will be conducted by the Contractor without requirement of further action by the provider.

AHCCCS will make quarterly cost-settlement payments to the Contractor. The cost-settlement payment is a separate payment arrangement from the capitation payment. (CMS Medicaid Managed Care Payment for PCP Services in 2013 and 2014: Technical Guide and Rate Setting Practices) Cost Settlement payments will be based upon adjudicated/approved encounter data.xxi This data will provide the necessary documentation to AHCCCS, sufficient to enable AHCCCS and CMS to ensure that primary care enhanced payments were made

 

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to network providers. [11/06/2012 final rule, 42 CFR 438.6(c)(5)(vi)(B)] xxii The Contractor will be required to refund payments to AHCCCS for any reduced claim payments in the event that a provider is subsequently “decertified” for enhanced payments due to audit or other reasons.

Refer to ACOM Policy 207 for further details.

Delivery Supplement: When the Contract