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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-10.14 - EX-10.14 - IASIS Healthcare LLCd275632dex1014.htm
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EX-10.12 - EX-10.12 - IASIS Healthcare LLCd275632dex1012.htm

Exhibit 10.17

 

LOGO    CONTRACT AMENDMENT   

ARIZONA DEPARTMENT OF HEALTH SERVICES

1740 West Adams, Room 303

Phoenix, Arizona 85007

(602) 542-1040

(602) 542-1741 FAX

   Contract No: ADHS15-085892    Amendment No: 1   

Procurement Officer

Ana Shoshtarikj

Behavioral Health Services Administration

Effective upon signature, it is mutually agreed that the Contract referenced is amended to incorporate all changes identified herein.

All other Provisions shall remain in their entirety.

 

Contractor hereby acknowledges receipt and acceptance of above amendment and that a signed copy must be filed with the Procurement Office before the effective date.      The above referenced Contract Amendment is hereby executed this 5th day of October, 2015 at Phoenix, Arizona
LOGO 10/5/15      LOGO 10/7/2015

 

    

 

Signature / Date      Procurement Officer

Shawn Nau, CEO

    
Authorized Signatory’s Name and Title     

Health Choice Integrated Care

    
Contractor’s Name     

 

1


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

INTRODUCTION

     10   

1.1

  

Overview

     10   

1.2

  

System Values and Guiding Principles

     11   

1.3

  

Integrated Health Care Service Delivery Principles for Persons with Serious Mental Illness

     11   

2

  

MEDICAID ELIGIBILITY

     13   

2.1

  

Medicaid Eligible Populations

     13   

2.2

  

Special Medicaid Eligibility-Members Awaiting Transplants

     14   

2.3

  

Non-Medicaid Eligible Populations

     15   

2.4

  

Eligibility and Member Verification

     15   

2.5

  

Medicaid Eligibility Determination

     16   

3

  

ENROLLMENT AND DISENROLLMENT

     17   

3.1

  

Enrollment and Disenrollment of Populations

     17   

3.2

  

Opt-Out for Cause

     19   

3.3

  

Prior Quarter Coverage

     20   

3.4

  

Prior Period Coverage

     20   

4

  

SCOPE OF SERVICES

     21   

4.1

  

Overview

     21   

4.2

  

General Requirements for the System of Care

     21   

4.3

  

Behavioral Health Covered Services

     23   

4.4

  

Behavioral Health Service Delivery Approach

     24   

4.5

  

Behavioral Health Service Delivery for Adult Members

     24   

4.6

  

Behavioral Health Service Delivery for Child Members

     24   

4.7

  

Physical Health Care Covered Services

     26   

4.8

  

Integrated Health Care Service Delivery for SMI Members

     34   

4.9

  

Health Education and Health Promotion Services

     35   

4.10

  

American Indian Member Services

     36   

4.11

  

Medications

     36   

4.12

  

Laboratory Testing Services

     37   

4.13

  

Crisis Services Overview

     38   

4.14

  

Crisis Services-General Requirements

     38   

4.15

  

Crisis Services-Telephone Response

     40   

 

2


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

4.16

  

Crisis Services-Mobile Crisis Teams

     40   

4.17

  

Crisis Services-Crisis Stabilization Settings

     41   

4.18

  

Prevention Services

     41   

4.19

  

Pediatric Immunizations and the Vaccines for Children Program

     42   

4.20

  

Medicaid School Based Claiming Program (MSBC)

     42   

4.21

  

Special Health Care Needs

     43   

4.22

  

Special Assistance for SMI Members

     44   

4.23

  

Psychiatric Rehabilitative Services-Housing

     44   

4.24

  

Psychiatric Rehabilitative Services-Employment

     45   

4.25

  

Psychiatric Rehabilitative Services-Peer Support

     45   

4.26

  

Centers of Excellence

     45   

5

  

CARE COORDINATION AND COLLABORATION

     46   

5.1

  

Care Coordination

     46   

5.2

  

Care Coordination for Dual Eligible SMI Members

     48   

5.3

  

Coordination with AHCCCS Contractors and Primary Care Physicians

     49   

5.4

  

Collaboration with System Stakeholders

     51   

5.5

  

Collaboration to Improve Health Care Service Delivery

     53   

5.6

  

Collaboration with Peers and Family Members

     54   

5.7

  

Collaboration with Tribal Nations

     54   

5.8

  

Coordination for Transitioning Members

     55   

6

  

PROVIDER NETWORK

     56   

6.1

  

Network Development

     56   

6.2

  

Network Development for Integrated Health Care Service Delivery

     59   

6.3

  

Network Management

     60   

6.4

  

Out of Network Providers

     61   

6.5

  

Network Reporting Requirements

     62   

7

  

PROVIDER REQUIREMENTS

     63   

7.1

  

Provider General Requirements

     63   

7.2

  

Provider Registration Requirements

     63   

7.3

  

Provider Manual Policy Requirements

     63   

7.4

  

Provider Manual Policy Network Requirements

     66   

 

3


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

7.5

  

Specialty Service Providers

     67   

7.6

  

Primary Care Provider Standards

     67   

7.7

  

Maternity Care Provider Standards

     69   

7.8

  

Federally Qualified Health Centers and Rural Health Clinics

     70   

7.9

  

Homeless Clinics:

     71   

8

  

MEDICAL MANAGEMENT

     72   

8.1

  

General Requirements

     72   

8.2

  

Utilization Data Analysis and Data Management

     75   

8.3

  

Prior Authorization

     76   

8.4

  

Concurrent Review

     76   

8.5

  

Additional Authorization Requirements

     76   

8.6

  

Discharge Planning

     77   

8.7

  

Inter-rater Reliability

     77   

8.8

  

Retrospective Review

     77   

8.9

  

Practice Guidelines

     77   

8.10

  

New Medical Technologies and New Uses of Existing Technologies

     78   

8.11

  

Care Coordination

     78   

8.12

  

Disease Management

     78   

8.13

  

Care Management Program-Goals

     79   

8.14

  

Care Management Program-General Requirements

     79   

8.15

  

Drug Utilization Review

     80   

8.16

  

Pre-Admission Screening and Resident Review (PASRR) Requirements

     81   

8.17

  

Nursing Facility Service Requirements

     81   

8.18

  

Medical Management Reporting Requirements

     82   

9

  

APPOINTMENT AND REFERRAL REQUIREMENTS

     82   

9.1

  

Appointments

     82   

9.2

  

Additional Appointment Requirements for SMI Members

     83   

9.3

  

Referral Requirements

     85   

9.4

  

Disposition of Referrals

     85   

9.5

  

Provider Directory

     85   

9.6

  

Referral for a Second Opinion

     86   

9.7

  

Additional Referral Requirements for SMI Members

     86   

 

4


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

10

  

QUALITY MANAGEMENT

     87   

10.1

  

General Requirements

     87   

10.2

  

Credentialing

     90   

10.3

  

Incident, Accident and Death Reports

     90   

10.4

  

Quality of Care Concerns and Investigations

     91   

10.5

  

Performance Measures

     92   

10.6

  

Performance Improvement Projects

     96   

10.7

  

Data Collection Procedures

     97   

10.8

  

Member Satisfaction Survey

     97   

10.9

  

Provider Monitoring

     97   

10.10

  

Quality Management Reporting Requirements

     98   

11

  

COMMUNICATIONS

     99   

11.1

  

Member Information

     99   

11.2

  

Member Handbooks

     100   

11.3

  

Member Newsletters

     101   

11.4

  

Outreach and Social Marketing

     101   

11.5

  

Web Site and Social Media Requirements

     102   

11.6

  

Materials Approval

     104   

11.7

  

Review of Materials

     104   

11.8

  

Identification Cards for SMI Members Receiving Physical Health Care Services

     104   

11.9

  

Communications Reporting Requirements

     104   

12

  

CULTURAL COMPETENCY

     105   

12.1

  

General Requirements

     105   

12.2

  

Cultural Competency Program

     105   

12.3

  

Translation Services

     107   

13

  

GRIEVANCE SYSTEM REQUIREMENTS

     107   

13.1

  

General Requirements

     107   

13.2

  

Member Grievances

     109   

13.3

  

SMI Grievances

     109   

13.4

  

SMI Appeals and TXIX/XXI Member Appeals

     109   

 

5


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

13.5

  

Claim Disputes

     110   

13.6

  

Grievance System Reporting Requirements

     110   

14

  

CORPORATE COMPLIANCE PROGRAM

     110   

14.1

  

General Requirements

     110   

14.2

  

Corporate Compliance Officer

     111   

14.3

  

Fraud, Waste and Program Abuse Audits

     112   

14.4

  

Reporting Suspected Fraud, Waste and Program Abuse

     113   

14.5

  

Excluded Providers

     114   

14.6

  

False Claims Act

     115   

14.7

  

Disclosure of Ownership and Control

     115   

14.8

  

Disclosure of Information on Persons Convicted of Crimes

     116   

14.9

  

Corporate Compliance Reporting Requirements

     119   

15

  

FINANCIAL MANAGEMENT

     120   

15.1

  

General Requirements

     120   

15.2

  

Financial Reports

     120   

15.3

  

Financial Viability/Performance Standards

     120   

15.4

  

Sources of Revenue

     121   

15.5

  

Compensation

     123   

15.6

  

Capitation Adjustments

     126   

15.7

  

Payments

     127   

15.8

  

Profit Limit for Non-Title XIX/XXI Funds

     129   

15.9

  

Non-Title XIX/XXI Encounter Valuation for Grant, County, Non-Title XIX and Other Funds

     130   

15.10

  

Community Reinvestment

     130   

15.11

  

Recoupments

     131   

15.12

  

Financial Responsibility for Referrals and Coordination with Acute Health Plans and the Courts

     131   

15.13

  

Advancement, Distributions, Loans, and Investments of Funds by the Contractor

     132   

15.14

  

Management of Federal Block Grant Funds and other Federal Grants

     132   

15.15

  

Mortgages and Financing of Property

     134   

15.16

  

Member Billing and Liability for Payment

     134   

15.17

  

Medicare Services and Cost Sharing Requirements

     134   

 

6


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

15.18

  

Capitalization Requirements

     136   

15.19

  

Coordination of Benefits and Third Party Liability Requirements

     137   

15.20

  

Post-payment Recovery Requirements

     139   

15.21

  

Retroactive Recoveries

     140   

15.22

  

Total Plan Case Requirements

     140   

15.23

  

Other Financial Obligations

     141   

15.24

  

Financial Management Reporting Requirements

     141   

16

  

PROVIDER AGREEMENT REIMBURSEMENT

     142   

16.1

  

Physician Incentive Requirements

     142   

16.2

  

Nursing Facility Reimbursement

     142   

17

  

INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

     143   

17.1

  

Overview

     143   

17.2

  

Systems Function and Capacity

     143   

17.3

  

Management Information System (MIS)

     145   

17.4

  

Data and Document Management Requirements

     146   

17.5

  

System and Data Integration Requirements

     147   

17.6

  

Contractor User Registration and Access to ADHS/DBHS and AHCCCS Systems

     147   

17.7

  

Electronic Transactions

     147   

17.8

  

System Upgrade Plan

     147   

17.9

  

Participation in Information Systems Work Groups/Committees

     148   

17.10

  

Enrollment and Eligibility Data Exchange

     149   

17.11

  

Claims and Encounter Submission and Processing Requirements

     150   

17.12

  

Encounter Reporting

     152   

17.13

  

Encounter Corrections

     152   

17.14

  

AHCCCS Encounter Data Validation Study (EDVS)

     153   

17.15

  

Claims Payment System Requirements

     154   

17.16

  

General Claims Processing Requirements

     155   

17.17

  

Claims System Reporting

     158   

17.18

  

Claims Audits

     158   

17.19

  

Demographic Data Submission

     158   

17.20

  

SMI Grievance, Appeals, and Claims Dispute Data Submissions

     159   

 

7


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

17.21

  

Other Electronic Data Requests

     159   

17.22

  

Security Rule Compliance Checklist

     159   

18

  

ADMINISTRATIVE REQUIREMENTS

     159   

18.1

  

General Requirements

     159   

18.2

  

Documents Incorporated by Reference

     160   

18.3

  

Organizational Structure

     160   

18.4

  

Peer Involvement and Participation

     163   

18.5

  

Key Staff

     164   

18.6

  

Organizational Staff

     166   

18.7

  

Liaisons and Coordinators

     174   

18.8

  

Training Program Requirements

     177   

18.9

  

Training Reporting Requirements

     179   

18.10

  

Medical Records

     179   

18.11

  

Consent and Authorization

     180   

18.12

  

Advance Directives

     180   

18.13

  

Business Continuity/Recovery Plan and Emergency Response

     180   

18.14

  

Emergency Preparedness

     181   

18.15

  

Emergency Preparedness; Business Continuity/Recovery Plan and Emergency Response Reporting Requirements

     182   

18.16

  

Legislative, Legal and Regulatory Issues

     182   

18.17

  

Pending Legislation and Other Issues

     183   

18.18

  

Copayments

     185   

18.19

  

Administrative Performance Standards

     185   

18.20

  

SMI Eligibility Determination

     187   

18.21

  

Material Change to Operations

     187   

18.22

  

Integrated Health Care Development Program

     188   

18.23

  

Governance Board

     189   

18.24

  

Offshore Performance of Work Prohibition

     189   

18.25

  

Implementation

     189   

18.26

  

Readiness Review

     191   

 

8


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GA

HEALTH CHOICE INTEGRATED CARE_HCIC/NARBHA

CONTRACT NO: ADHS15-085892

 

19

  

MONITORING

     191   

19.1

  

General Monitoring Requirements

     191   

19.2

  

Reporting Requirements

     191   

19.3

  

Surveys

     192   

19.4

  

Independent Review of the Contractor

     193   

19.5

  

Corrective Action, Notice to Cure, Sanctions and Technical Assistance Provisions

     195   

20

  

SUBCONTRACTING REQUIREMENTS

     198   

20.1

  

Subcontract Relationships and Delegation

     198   

20.2

  

Hospital Subcontracts and Reimbursement

     200   

20.3

  

Management Services Subcontracts

     202   

20.4

  

Prevention Subcontracts

     203   

20.5

  

Prior Approval

     203   

20.6

  

Training Subcontracts

     203   

20.7

  

Subcontract Template Provisions

     204   

20.8

  

Subcontracting Reporting Requirements

     207   

 

9


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

1 INTRODUCTION

 

1.1 Overview

The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) is responsible for administering Arizona’s publicly funded behavioral health programs and services for children, adults and their families. For this Contract, ADHS/DBHS and Arizona’s Medicaid agency, the Arizona Health Care Cost Containment System Administration (AHCCCS), have entered into an Intergovernmental Agreement (IGA) to design a new health care service delivery system that provides integrated physical and behavioral health services to Medicaid eligible adults with Serious Mental Illness (SMI). AHCCCS, as the single state Medicaid agency, is currently working with the Centers for Medicare and Medicaid Services (CMS) and seeking approval to obtain a waiver to not offer a choice of Integrated RBHAs serving individuals with SMI for both behavioral and physical health services. In the event that CMS does not grant a Waiver of Choice members will be auto enrolled in the integrated plan and may have the option to “opt out” and be enrolled in an approved AHCCCS acute care plan for their physical health care coverage. The Contractor will operate as the Regional Behavioral Health Authority (RBHA) to coordinate the delivery of health care services to eligible persons in Greater Arizona, which includes all counties except Maricopa County.

Integrating the delivery of behavioral and physical health care to SMI members is a significant step forward in improving the overall health of SMI members. Under this Contract, the Contractor is the single entity that is responsible for administrative and clinical integration of health care service delivery, which includes coordinating Medicare and Medicaid benefits for dual eligible members. From a member perspective, this approach will improve individual health outcomes, enhance care coordination and increase member satisfaction. From a system perspective, it will increase efficiency, reduce administrative burden and foster transparency and accountability.

The Contractor shall be responsible for ensuring the delivery of medically necessary covered services as follows:

 

  1.1.1 Behavioral health services to Medicaid eligible children and adults;

 

  1.1.2 Behavioral health services to Non-Medicaid eligible children and adults, for which ADHS/DBHS receives funding; and

 

  1.1.3 Integrated behavioral and physical health services to Medicaid eligible adults with SMI, including Medicare benefits for SMI members who are eligible for both Medicare and Medicaid (dual eligible members), as a Dual Eligible Special Needs Plan, as specified by the State.

 

  1.1.4 Medicare Benefits for SMI members who are eligible for both Medicaid and Medicare (Dual eligible members) using a Dual Eligible Special Needs Plan (D-SNP).

 

10


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  1.1.5 To the following populations as identified on the chart below:

 

Contractor Responsibilities 10.1.15

    

GMH/SA (18+ Years)

  

SMI (18+ Years)

  

Children (0-17 Years)

Population

  

NON DUAL -
Behavioral Hlth

  

DUAL - Behavioral
Hlth

  

Behavioral Hlth

  

Physical Hlth

  

Behavioral Hlth

ACUTE    RBHA    Acute Plan    RBHA    RBHA    RBHA
ALTCS EPD    ALTCS Plan    ALTCS Plan    ALTCS Plan    ALTCS Plan    ALTCS Plan
ALTCS DD    RBHA    RBHA    RBHA    DD (Acute Plan contractor)    RBHA
CRS (2)    CRS    CRS    CRS    CRS    CRS
CRS and CMDP(4)    CRS    CRS    CRS    CMDP    CRS
CRS and DD    CRS    CRS    CRS    DD (Acute Plan contractor)    CRS
CMDP (0-17)    N/A    N/A    N/A    N/A    RBHA
Kidscare    RBHA    Acute Plan    RBHA    Acute Plan    RBHA
AIHP (1)    T/RBHA    T/RBHA Integrated Acute    T/RBHA   

AIHP

Acute Plan

Integrated RBHA

   T/RBHA
State Only(3)    RBHA    RBHA    RBHA    N/A    RBHA

 

(1) American Indian members can always choose to receive services through IHS/638 facilities.
(2) This represents CRS members not enrolled with DD or CMDP. RBHAs only have responsibility for state only services for CRS members.
(3) State only members and State only services
(4) Responsibilities for the CRS members also enrolled in DD and CMDP remain the same with the exception of DD providing LTC services.

 

1.2 System Values and Guiding Principles

The following values, guiding system principles and goals are the foundation for the development of this Contract. Contractor shall administer and ensure delivery of services consistent with these values, principles and goals:

 

  1.2.1 Member and family member involvement at all system levels;

 

  1.2.2 Collaboration with the greater community;

 

  1.2.3 Effective innovation promoting evidence-based practices;

 

  1.2.4 Expectation for continuous quality improvement;

 

  1.2.5 Cultural competency;

 

  1.2.6 Improved health outcomes;

 

  1.2.7 Reduced health care costs;

 

  1.2.8 System transformation;

 

  1.2.9 Transparency;

 

  1.2.10 Prompt and easy access to care;

 

  1.2.11 The Nine (9) Guiding Principles for Wellness, Resiliency and Recovery-Oriented Adult Behavioral Health Services and Systems in Exhibit 6; and

 

  1.2.12 The Arizona Vision-Twelve (12) Principles for Children Service Delivery in Exhibit 5.

 

1.3 Integrated Health Care Service Delivery Principles for Persons with Serious Mental Illness

Coordinating and integrating primary and behavioral health care is expected to produce improved access to primary care services, increased prevention, early identification, and intervention to reduce the incidence of serious physical illnesses, including chronic disease. Increasing and promoting the availability of integrated, holistic care for members with chronic behavioral and physical health conditions will help members achieve better overall health and an improved quality of life. Beginning in 1.3.1 the principles below describe ADHS/DBHS’ vision for integrated care service delivery. However, many of them apply to all populations for all services in all settings. For example, concepts such as recovery,

 

11


SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

member input, family involvement, person-centered care, communication and commitment are examples that describe well-established expectations ADHS/DBHS has in all of its behavioral health care service delivery contracts.

While these principles have served as the foundation for successful behavioral health service delivery, providing whole-health integrated care services to individuals with SMI- primarily because of chronic, preventable, physical conditions-is a challenge that calls for a new approach that will improve health care outcomes in a cost-effective manner. To meet this challenge, the Contractor must be creative and innovative in its oversight and management of the integrated service delivery system. ADHS/DBHS expects the Contractor to embrace the principles below and demonstrate an unwavering commitment to treat each and every member with dignity and respect as if that member were a relative or loved one seeking care.

The Contractor shall comply with all terms, conditions and requirements in this Contract while embedding the following principles in the design and implementation of an integrated health care service delivery system:

 

  1.3.1 Behavioral, physical, and peer support providers must share the same mission to place the member’s whole-health needs above all else as the focal point of care.

 

  1.3.2 All aspects of the member experience from engagement, treatment planning, service delivery and customer service must be designed to promote recovery and wellness as communicated by the member.

 

  1.3.3 Member input must be incorporated into developing individualized treatment goals, wellness plans, and services.

 

  1.3.4 Peer and family voice must be embedded at all levels of the system.

 

  1.3.5 Recovery is personal, self-directed, and must be individualized to the member.

 

  1.3.6 Family member involvement, community integration and a safe affordable place to live are integral components of a member’s recovery and must be as important as any other single medicine, procedure, therapy or treatment.

 

  1.3.7 Providers of integrated care must operate as a team that functions as the single-point of whole-health treatment and care for all of a member’s health care needs. Co-location or making referrals without coordinating care through a team approach does not equate to integrated care.

 

  1.3.8 The team must involve the member as an equal partner by using appropriate levels of care management, comprehensive transitional care, care coordination, health promotion and use of technology as well as provide linkages to community services and supports and individual and family support to help a member achieve his or her whole health goals.

 

  1.3.9 The Contractor’s overarching system goals for individual SMI members and the SMI population are to improve whole health outcomes and reduce or eliminate health care disparities between SMI members and the general population in a cost-effective manner.

 

  1.3.10 System goals shall be achieved using the following strategies:

 

  1.3.10.1 Earlier identification and intervention that reduces the incidence and severity of serious physical, and mental illness;

 

  1.3.10.2 Use of health education and health promotion services;

 

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  1.3.10.3 Increased use of primary care prevention strategies;

 

  1.3.10.4 Use of validated screening tools;

 

  1.3.10.5 Focused, targeted, consultations for behavior health conditions;

 

  1.3.10.6 Cross-specialty collaboration;

 

  1.3.10.7 Enhanced discharge planning and follow-up care between provider visits;

 

  1.3.10.8 Ongoing outcome measurement and treatment plan modification;

 

  1.3.10.9 Care coordination through effective provider communication and management of treatment;

 

  1.3.10.10 Member, family and community education;

 

  1.3.10.11 Achievement of system goals shall result in the following outcomes;

 

  1.3.10.12 Reduced rates of unnecessary or inappropriate Emergency Room use;

 

  1.3.10.13 Reduced need for repeated hospitalization and re-hospitalization;

 

  1.3.10.14 Reduction or elimination of duplicative health care services and associated costs; and

 

  1.3.10.15 Improved member’s experience of care and individual health outcomes.

 

2 MEDICAID ELIGIBILITY

 

2.1 Medicaid Eligible Populations

The Contractor shall:

 

  2.1.1 Be responsible for ensuring the delivery of covered services to the following Title XIX/XXI eligible children and adult populations:

 

  2.1.1.1 American Indians, whether they live on or off reservation, may choose to receive services through a RBHA, Tribal Regional Behavioral Health Authority (TRBHA) or at an Indian Health Services (IHS) or Tribally owned or operated facility;

 

  2.1.1.2 Eligible individuals and families under Section 1931 of the Social Security Act (also referred to as AFDC-related and/or Aid to Families with Dependent Children);

 

  2.1.1.3 Supplemental Security Income (SSI) and SSI Related Groups;

 

  2.1.1.4 SSI Medical Assistance Only (SSI MAO) and Related Groups: Eligible individuals who are aged, blind or disabled and have household income levels at or below 100% of the Federal Poverty level (FPL);

 

  2.1.1.5 Freedom to Work (Ticket to Work);

 

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  2.1.1.6 Breast and Cervical Cancer Treatment Program (BCCTP);

 

  2.1.1.7 Title XIX Waiver Group—AHCCCS Care;

 

  2.1.1.8 Foster children enrolled in the Comprehensive Medical and Dental Program;

 

  2.1.1.9 Young Adult Transitional Insurance (YATI) Program: Individuals age 18 through age 25 who were enrolled in the foster care program under jurisdiction of Department of Economic Security (DES) Division of Children Youth and Families (DCYF) in Arizona on their 18th birthday;

 

  2.1.1.10 Acute TXIX Waiver Group (also known as Childless Adults); Individuals and couples whose income is at or below 100% of the Federal Poverty Level who are not categorically linked to another Title XIX program; and

 

  2.1.1.11 Kidscare (TXXI); Federal and State Children’s Health Insurance Program administered by AHCCCS.

 

  2.1.2 Not be responsible for providing services under this Contract to the following Medicaid eligible populations:

 

  2.1.2.1 Members enrolled in the Children’s Rehabilitative Services (CRS) Integrated AHCCCS Health Plan;

 

  2.1.2.2 Arizona Long Term Care System (Elderly and Physically Disabled) ALTCS-EPD eligible members; and

 

  2.1.2.3 Dual eligible adults receiving General Mental Health/Substance Abuse (GMH/SA) services transitioned to Acute Health plans for services.

 

  2.1.3 Not be responsible to provide physical health care services to the following Medicaid eligible SMI members:

 

  2.1.3.1 Members enrolled with Arizona Department of Economic Security/Division of Developmental Disabilities (ADES/DDD);

 

  2.1.3.2 American Indians who elect to receive physical health services from the American Indian Health Program (AHIP) or another AHCCCS health plan; and

 

  2.1.3.3 Members enrolled in KidsCare.

 

2.2 Special Medicaid Eligibility-Members Awaiting Transplants

 

  2.2.1 The Contractor shall be responsible for the following:

 

  2.2.1.1 SMI members eligible to receive physical health care services under this Contract;

 

  2.2.1.2 For whom medical necessity for a transplant has been established; and

 

  2.2.1.3 Members who lose Title XIX eligibility.

 

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  2.2.2 These members may become eligible for and select one (1) of two (2) extended eligibility options as specified in A.R.S. §§ 36-2907.10 and 36-2907.11. The extended eligibility is authorized only for those individuals who have met all of the following conditions:

 

  2.2.2.1 The individual has been determined Title XIX ineligible due to excess income;

 

  2.2.2.2 The individual has been placed on a donor waiting list before eligibility expired; and

 

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

 

  2.2.3 The following options are available for extended eligibility:

 

  2.2.3.1 Option 1: Extended eligibility is for one twelve (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.

 

  2.2.3.2 Option 2: As long as medical eligibility for a transplant, that is, status on a transplant waiting list, is maintained, at the time that the transplant is scheduled to be performed the transplant candidate will be re-enrolled with the Contractor to receive all covered transplant services. Option 2-eligible individuals are not eligible for any non-transplant related health care services from AHCCCS.

 

2.3 Non-Medicaid Eligible Populations

The Contractor shall:

 

  2.3.1 Be responsible to provide covered behavioral health services to non-Medicaid eligible children and adults subject to available funding allocated to the Contractor.

 

2.4 Eligibility and Member Verification

For all populations eligible for services under this Contract the Contractor shall:

 

  2.4.1 Verify the Medicaid eligibility status for persons referred for covered health services.

 

  2.4.2 Coordinate with other involved contractors, for example, AHCCCS Acute Plans or ALTCS, service providers, subcontractors and eligible persons to share specific information regarding Medicaid eligibility.

 

  2.4.3 Notify AHCCCS of a Medicaid-eligible member’s death, incarceration or relocation out-of-state that may affect a member’s eligibility status.

 

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  2.4.4 Utilize one (1) or more of the following systems to verify AHCCCS eligibility and service coverage twenty-four (24) hours a day, seven (7) days a week in conformance with the ADHS/DBHS Policy on Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program:

 

  2.4.4.1 AHCCCS’ web-based verification;

 

  2.4.4.2 AHCCCS’ Prepaid Medical Management Information System (PMMIS);

 

  2.4.4.3 AHCCCS’ contracted Medicaid Eligibility Verification Service (MEVS);

 

  2.4.4.4 AHCCCS’ Interactive Voice Response (IVR) system; or

 

  2.4.4.5 ADHS/DBHS 270/271 Eligibility Look-up.

 

  2.4.5 Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with the ADHS/DBHS Policy on Eligibility Screening for AHCCCS Health Insurance, Medicare Part D Prescription Drug Coverage, and the Limited Income Subsidy Program. A person who receives behavioral health services pursuant to A.R.S. Title 36, Chapter 34 and who has not been determined eligible for Title XVIII (Medicare) and for the Medicare Part D prescription drug benefit, Title XIX or Title XXI services shall comply with the eligibility determination process annually. A.R.S. § 36-3408.

 

  2.4.6 Comply with the requirements in Section 17.10, Enrollment and Eligibility Data Exchange.

 

  2.4.7 The Contractor is not responsible for determining eligibility.

 

2.5 Medicaid Eligibility Determination

The Contractor shall:

Accept a Medicaid eligibility determination for AHCCCS coverage groups as determined by one (1) of the following agencies:

 

  2.5.1 Social Security Administration (SSA): SSA determines eligibility for the Supplemental Security Income (SSI) cash program. SSI cash recipients are automatically eligible for AHCCCS coverage.

 

  2.5.2 Arizona Department of Economic Security (ADES): ADES determines eligibility for families with children under Section 1931 of the Social Security Act, the Adoption Subsidy Program, Title IV-E foster care children, Young Adult Transitional Insurance Program, the Federal Emergency Services program (FES) and Title XIX Waiver Members.

 

  2.5.3 AHCCCS: AHCCCS determines eligibility for the SSI/Medical Assistance Only groups, including the FES program for this population (aged, disabled, and blind), the Arizona Long Term Care System (ALTCS), the Medicare Savings program, BCCTP, the Freedom to Work program, the Title XXI KidsCare program and the State-Only Transplant program.

 

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3 ENROLLMENT AND DISENROLLMENT

 

3.1 Enrollment and Disenrollment of Populations

The Contractor shall:

 

  3.1.1 Defer to AHCCCS, which has exclusive authority to enroll and disenroll Medicaid eligible members in accordance with the rules set forth in A.A.C., R9-22, Article 17 and R9-31, Articles 3 and 17.

 

  3.1.2 Defer to ADHS/DBHS, which has exclusive authority to designate who will be enrolled and disenrolled as Non-Medicaid eligible members.

 

  3.1.3 Comply with the requirements in the ADHS/DBHS Policy on Enrollment, Disenrollment and Other Data Submission.

 

  3.1.4 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].

 

  3.1.5 American Indians determined to be SMI can choose to enroll as follows:

 

  3.1.5.1 In an Integrated RBHA to receive both physical health services and behavioral services;

 

  3.1.5.2 In an Acute Care Contractor for physical health services and receive behavioral health services from a TRBHA; or

 

  3.1.5.3 In AIHP for physical health services and receive behavioral health services from a T/RBHA.

 

  3.1.6 American Indians enrolled in Medicaid and Medicare and receiving general mental health and substance abuse services, can choose to enroll as follows:

 

  3.1.6.1 In an Acute Care Contractor to receive both physical health services and behavioral services (adults 18 and over only);

 

  3.1.6.2 In an Acute Care Contractor for physical health services and receive behavioral health services from a TRBHA; or

 

  3.1.6.3 In AIHP for physical health services and receive behavioral health services from a T/RBHA.

 

  3.1.7 Not end a member’s Episode of Care (EOC) because of an adverse change in the member’s health status or because of the member’s utilization of medical services, diminished capacity, or uncooperative or disruptive behavior.

 

  3.1.8 Accept AHCCCS’ decision to disenroll a Medicaid eligible member from TXIX/XXI services when:

 

  3.1.8.1 The member becomes ineligible for Medicaid;

 

  3.1.8.2 The member moves out of the Contractor’s geographical service area; or

 

  3.1.8.3 There is a change in AHCCCS’ enrollment policy.

 

  3.1.9 Honor the effective date of enrollment for a new Title XIX member as the day AHCCCS takes the enrollment action.

 

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  3.1.10 Be responsible for payment of medically necessary covered services retroactive to the member’s beginning date of eligibility, as reflected in PMMIS including services provided during prior period coverage; this can include services prior to the Contract start date and in subsequent years of the Contract.

 

  3.1.11 Honor the effective date of enrollment for a Title XXI member as the first (1st) day of the month following notification to the Contractor. In the event that eligibility is determined on or after the twenty-fifth (25th) day of the month, eligibility will begin on the first (1st) day of the second (2nd) month following the determination. See Exhibit 1, Definitions, for an explanation of “Prior Period Coverage”.

 

  3.1.12 The Contractor is responsible for notifying AHCCCS of a child’s birth to an enrolled member.

 

  3.1.12.1 Notification must be received no later than one (1) day from the date of birth. AHCCCS is available to receive notification twenty-four (24) hours a day, seven (7) days a week via the AHCCCS website.

 

  3.1.12.2 Failure of the Contractor to notify AHCCCS within the one (1) day timeframe may result in sanctions. The Contractor shall ensure that newborns born to a member determined to be SMI are not enrolled with the Contractor for the delivery of health care services.

 

  3.1.12.3 Babies born to mothers enrolled with the Contractor 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 Acute Care Contractor for their child, which allows them thirty (30) days to make a choice.

 

  3.1.13 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).

 

  3.1.14 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.

 

  3.1.15 AHCCCS members eligible under this contract will be enrolled as follows:

 

  3.1.15.1 TXIX eligible adults with an SMI determination will be enrolled to receive all medically necessary physical and behavioral health services through an Integrated RBHA unless they request and are approved to opt-out for cause from the Integrated RBHA for physical health services.

 

  3.1.15.2 Members eligible for Children’s Rehabilitative Services (CRS) 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 the CRS Program. This includes members who are eligible for CRS who are determined to have a Serious Mental Illness (SMI).

 

  3.1.15.3 Members eligible for ALTCS/EPD will be enrolled with a Contractor in their GSA and will be offered choice for Maricopa and Pima counties.

 

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3.2 Opt-Out for Cause

 

  3.2.1 Effective October 1, 2015, individuals with an SMI determination will have the option to opt-out of enrollment with the Integrated RBHA for physical health services and be transferred to an AHCCCS Acute Care Contractor to receive physical health services, under the following conditions only:

 

  3.2.1.1 The member, member’s guardian, or member’s physician successfully dispute the member’s diagnosis as SMI,

 

  3.2.1.2 Network limitations and restrictions,

 

  3.2.1.3 Physician or provider course of care recommendation, or

 

  3.2.2 The member established that due to the enrollment and affiliation with the Integrated RBHA as a person with a SMI, and in contrast to persons enrolled with an Acute Care Contractor, there is demonstrable evidence to establish actual harm or the potential for discriminatory or disparate treatment in:

 

  3.2.2.1 The access to, continuity or availability of acute care covered services,

 

  3.2.2.2 Exercising client choice in provider,

 

  3.2.2.3 Privacy rights,

 

  3.2.2.4 Quality of services provided, or

 

  3.2.2.5 Client rights under Arizona Administrative Code, Title 9, Chapter 21.

 

  3.2.3 In regards to above language, a member must either demonstrate that the discriminatory or disparate treatment has already occurred, or establish the plausible potential of such treatment. It is insufficient for a member to establish actual harm or the potential for discriminatory or disparate treatment solely on the basis that they are enrolled in the Integrated RBHA.

 

  3.2.4 The Contractor shall take the following actions:

 

  3.2.4.1 Responsibility for reducing to writing the member’s assertions of the actual or perceived disparate treatment of individuals as a result of their enrollment in the integrated plan.

 

  3.2.4.2 Responsibility for completing ADHS transfer of a RBHA member to an approved Acute Care Contractor form.

 

  3.2.4.3 Confirmation and documentation that the member is enrolled in SMI RBHA program.

 

  3.2.4.4 Providing documentation of efforts to investigate and resolve member’s concern.

 

  3.2.4.5 Inclusion of any evidence provided by the member of actual or reasonable likelihood of discriminatory or disparate treatment.

 

  3.2.4.6 Recommendation of approval or denial of request, and forward completed packet to ADHS for approval or denial within seven (7) calendar days of request.

 

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ADHS shall:

 

  3.2.4.7 Review completed request packets received from the Contractor.

 

  3.2.4.8 Approve or deny the request in writing within ten (10) calendar days of request from the member.

 

  3.2.4.9 Provide notice that includes the reasons for the denial and appeal/hearing rights to the member for requests which are denied.

 

3.3 Prior Quarter Coverage

The Contractor acknowledges that:

 

  3.3.1 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.

 

  3.3.2 AHCCCS Contractors are not responsible for payment for covered services received during the prior quarter.

 

  3.3.3 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.

 

3.4 Prior Period Coverage

The Contractor acknowledges that:

 

  3.4.1 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.

 

  3.4.2 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.

 

  3.4.3 The Contractor receives notification from AHCCCS of the member’s enrollment.

 

  3.4.4 The Contractor is responsible for payment of all claims for medically necessary covered 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.

 

  3.4.5 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.

 

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4 SCOPE OF SERVICES

 

4.1 Overview

The Contractor’s ability to ensure the delivery of services requires a complete and thorough understanding of the intricate, multi-layered service delivery system in order to create a system of care that addresses the member’s needs. The type, amount, duration, scope of services and method of service delivery depends on a wide variety of factors including:

 

  4.1.1 Eligible populations,

 

  4.1.2 Covered services benefit package,

 

  4.1.3 Approach,

 

  4.1.4 Funding, and

 

  4.1.5 Member need.

Specific details for service delivery are contained in Exhibit 7, Documents Incorporated by Reference (DIBR). The Contractor is required to comply with all terms in this Contract and all applicable requirements in each document listed in Exhibit 7; however, particular attention to requirements for effective service delivery should be paid to the following:

 

  4.1.6 ADHS/DBHS Covered Behavioral Health Services Guide,

 

  4.1.7 ADHS/DBHS Policy and Procedures Manual,

 

  4.1.8 AHCCCS Medical Policy Manual, and

 

  4.1.9 AHCCCS Contractor Operations Manual.

 

4.2 General Requirements for the System of Care

Regardless of the type, amount, duration, scope, service delivery method and population served, Contractor’s service delivery system shall incorporate the following elements:

 

  4.2.1 Coordinate and provide access to quality health care services informed by evidence-based practice guidelines in a cost effective manner.

 

  4.2.2 Coordinate and provide access to quality health care services that are culturally and linguistically appropriate, maximize personal and family voice and choice, and incorporate a trauma-informed care approach.

 

  4.2.3 Coordinate and provide access to preventive and health promotion services, including wellness services.

 

  4.2.4 Coordinate and provide access to comprehensive care coordination and transitional care across settings; follow-up from inpatient to other settings; participation in discharge planning; and facilitating transfer from the children’s system to the adult system of health care.

 

  4.2.5 Coordinate and provide access to chronic disease management support, including self-management support.

 

  4.2.6 Coordinate and provide access to peer and family delivered support services.

 

  4.2.7 Develop service plans that maximize personal and family voice and choice.

 

  4.2.8 Coordinate and integrate clinical and non-clinical health-care related needs and services.

 

  4.2.9 Implement health information technology to link services, facilitate communication among treating professionals, and between the health team and individual and family caregivers.

 

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  4.2.10 Deliver services by providers that are appropriately licensed or certified, operating within their scope of practice, and registered as an AHCCCS provider.

 

  4.2.11 Apply the same standard of care for all members, regardless of the member’s eligibility category.

 

  4.2.12 Deliver services that are sufficient in amount, duration and scope to reasonably be expected to achieve the purpose for which the services are furnished.

 

  4.2.13 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) (iii)).

 

  4.2.14 Have the discretion to place appropriate limits on a service on the basis of criteria such as medical necessity or for utilization control, subject to ADHS/DBHS review and approval, provided the services furnished can reasonably be expected to achieve their purpose (42 CFR 438.210(a)(3)(i) and (iii)) and [42 CFR 438.210(a) (4)].

 

  4.2.15 Require subcontracted providers to notify the Contractor if, on the basis of moral or religious grounds the subcontractor elects to not provide or reimburse for a covered service (42 CFR 438.102(b)(i)).

 

  4.2.16 Require subcontracted providers to offer the services described in Section 4.9, Health Education and Health Promotion Services.

 

  4.2.17 Require covered services to be medically necessary and cost effective and to be provided by or coordinated by a primary care provider except for annual well woman exams, behavioral health and children’s dental services.

 

  4.2.18 Provide covered services to members in accordance with all applicable Federal and State laws, regulations and policies, including those listed by reference in attachments and this Contract.

 

  4.2.19 Create and submit to ADHS/DBHS according to instructions provided by ADHS/DBHS, a System of Care Plan that contains both Children’s and Adult System of Care Sections with the following:

 

  4.2.19.1 Action steps and measurable outcomes that are aligned with the goals and objectives in the statewide ADHS/DBHS Annual System of Care Plan;

 

  4.2.19.2 Identifies and addresses regional needs and incorporates region-wide program specific goals and objectives; and

 

  4.2.19.3 Incorporates changes to the service delivery system based upon recommendations from the annual System of Care planning process that has Contractor, member, family member and other community stakeholder attendance and input.

 

  4.2.20 Submit to ADHS/DBHS for approval, case manager ratio plans based on national standards that will take into account member acuity, legal, and environmental needs.

 

  4.2.21 Implement Adult Clinical Teams consistent with Substance Abuse and Mental Health Service Administration (SAMHSA) Best Practices.

 

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  4.2.22 Ensure that its providers, acting within the lawful scope of their practice, are not prohibited or otherwise restricted from communicating freely with members regarding their health care, medical needs and treatment options, even if needed services are not covered by the Contractor. [42 CFR 438.102]:

 

  4.2.22.1 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)];

 

  4.2.22.2 Information the member needs in order to decide among all relevant treatment options;

 

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

 

  4.2.23.1 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)].

 

  4.2.24 Deliver covered health services in accordance with the requirements of any other funding source.

 

4.3 Behavioral Health Covered Services

The Contractor shall ensure the delivery of:

 

  4.3.1 Medically necessary and clinically appropriate covered behavioral health services to eligible members in conformance with the ADHS/DBHS Covered Behavioral Health Services Guide.

 

  4.3.2 Covered behavioral health services under the Mental Health Block Grant (MHBG), Substance Abuse Block Grant (SABG) and other grant funding as available.

 

  4.3.3 Annual reports on use of MHBG and SABG funds in accordance with Block Grant reporting requirements.

 

  4.3.4 Covered behavioral health services in accordance with the terms of the IGA between ADHS/DBHS and all County agreements for court ordered evaluations.

 

  4.3.5 For the Southern GSA the Contractor shall:

 

  4.3.5.1 Utilize the Liquor fee funding listed in the allocation schedule Pima County IGA for court ordered evaluations; and

 

  4.3.5.2 Provide services as prescribed in this Contract and A.R.S. 4-203.01 (1) and A.R.S. 36-2021 through A.R.S. 36-2031 for substance abuse services in Pima County including crisis, detoxification services, and outpatient services utilizing the Liquor Fees funding listed in the allocation schedule.

 

  4.3.6 For the Northern GSA the Contractor shall:

 

  4.3.6.1 Utilize the Coconino County funding listed in the allocation schedule for court ordered evaluations.

 

  4.3.7 All required documentation in accordance with any funding source including discretionary grants.

 

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4.4 Behavioral Health Service Delivery Approach

The Contractor shall:

 

  4.4.1 Provide each member with a behavioral health assessment in accordance with the ADHS/DBHS Policy on Assessment and Service Planning.

 

  4.4.2 Develop and revise the member’s individual service plan in conformance with the ADHS/DBHS Policy on Assessment and Service Planning.

 

  4.4.3 Make referrals to service providers.

 

  4.4.4 Coordinate care as described in Section 5.1, Care Coordination.

 

  4.4.5 Develop and implement transition, discharge and aftercare plans for each person prior to discontinuation of covered services.

 

  4.4.6 Require subcontractors and providers to actively engage and involve family members in service planning and service delivery.

 

4.5 Behavioral Health Service Delivery for Adult Members

The Contractor shall:

 

  4.5.1 Ensure services are delivered to adults in conformance with Exhibit 6, Nine Guiding Principles for Recovery-Oriented Adult Behavioral Health Services and Systems.

 

  4.5.2 Implement the American Society of Addiction Medicine Patient Placement Criteria (ASAM).

 

  4.5.3 Implement the following service delivery programs for SMI members consistent with U.S. Department of Health and Human Services (DHHS), Substance Abuse and Mental Health Services Administration’s (SAMHSA) established program models:

 

  4.5.3.1 Assertive Community Treatment (ACT),

 

  4.5.3.2 Supported Employment,

 

  4.5.3.3 Permanent Supportive Housing, and

 

  4.5.3.4 Consumer Operated Programs.

 

  4.5.4 Monitor fidelity to the service delivery programs described in Section 4.5.3 annually using the ADHS/DBHS adopted measurement instrument, for example, the SAMHSA Fidelity Scale and General Organizational Index and report findings to ADHS/DBHS.

 

4.6 Behavioral Health Services for Child Members

The Contractor shall:

 

  4.6.1 Ensure delivery of services to children in conformance with:

 

  4.6.1.1 Exhibit 7, Clinical Guidance Documents (The Child and Family Team); and

 

  4.6.1.2 Exhibit 5, The Arizona Vision-Twelve (12) Principles for Children Service Delivery.

 

  4.6.2 Comply with established caseload ratios for case managers assigned to serve children identified as having high/complex needs.

 

  4.6.3 Utilize a network of generalist support and rehabilitation providers.

 

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  4.6.4 Utilize Home Care Training to the Home Care Client (HCTC) as an alternative to more restrictive levels of care when clinically indicated.

 

  4.6.5 Implement ADHS/DBHS’ method for in-depth review of Child and Family Team (CFT) practice.

 

  4.6.6 Utilize acuity measure instruments as directed by ADHS/DBHS.

 

  4.6.7 Implement service delivery models as directed by ADHS/DBHS.

 

  4.6.8 Maintain Designated Email Addresses to Streamline Communication:

 

  4.6.8.1 RBHA must establish a standardized email address as a single point of contact for the Department of Child Safety (DCS) and foster families. Email address must format of DCS@ followed by the RBHA’s standard email suffix. RBHA must monitor inbox and respond to inquiries during each business day.

 

  4.6.9 Monitor Extensive Trauma-Informed Assessment:

 

  4.6.9.1 Upon notification by DCS that a child has been taken into custody, ensure that each child and family is referred for ongoing behavioral health services for a period of at least six (6) months unless services are refused by the guardian or the child is no longer in DCS custody. Services must be provided to:

 

  4.6.9.2 Mitigate and address the child’s trauma;

 

  4.6.9.3 Support the child’s temporary caretakers;

 

  4.6.9.4 Promote stability and well-being; and

 

  4.6.9.5 Address the permanency goal of the child and family.

 

  4.6.10 A minimum of one (1) monthly documented service is required.

 

  4.6.11 Provide a monthly reconcile DCS Removal List with Individuals Receiving a Rapid Response:

 

  4.6.12 CMDP will provide a monthly listing of children placed in Department of Child Safety (DCS) custody and the RBHA shall compare it with their own listing of DCS children receiving a rapid response service. For any listed children still in DCS custody who have not yet been engaged in behavioral health services, RBHA shall ensure that a rapid response service is delivered. By close of business on the 30th of each reporting month (beginning in June of 2015), RBHA will deliver a DCS Rapid Response Monthly Reconciliation Report that will minimally include:

 

  4.6.12.1 The number of individuals removed by DCS;

 

  4.6.12.2 The number of individuals referred by DCS for a rapid response service;

 

  4.6.12.3 The number of individuals receiving a rapid response service;

 

  4.6.12.4 The number of individuals placed in DCS custody who were not initially referred by DCS for a rapid response service, and

 

  4.6.12.5 The number of children receiving a behavioral health service following reconciliation of the monthly list.

 

  4.6.13 The report must also include a specific listing of each individual who was not initially referred for a rapid response along with the current status of connection to behavioral health services.

 

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4.7 Physical Health Care Covered Services

The Contractor, when medically necessary, shall ensure the delivery of the following physical health care services to SMI members eligible to receive physical health care services:

 

  4.7.1 Ambulatory Surgery includes 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.

 

  4.7.2 Anti-hemophilic Agents and Related Services includes services for the treatment of hemophilia Von Willebrand’s disease, and Gaucher’s Disease.

 

  4.7.3 Audiology includes 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, age eighteen (18) through twenty (20) receiving Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.

 

  4.7.4 Chiropractic Services includes chiropractic services to members age eighteen (18) through twenty (20) in order to ameliorate the member’s medical condition, subject to limitations specified in 42 CFR 410.21, for Qualified Medicare Beneficiaries, regardless of age, if prescribed by the member’s primary care provider (PCP) and approved by the Contractor.

 

  4.7.5 Dialysis includes medically necessary dialysis, hemodialysis, peritoneal dialysis, hemoperfusion, 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.

 

  4.7.6 EPSDT includes comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illness discovered by the screenings for members, age eighteen (18) through (20). The Contractor shall ensure that these members receive required screenings including a comprehensive history, developmental/behavioral health screening, comprehensive unclothed physical examination, appropriate vision testing, hearing testing, laboratory tests, dental screenings and immunizations in compliance with the AHCCCS EPSDT periodicity schedule, and the AHCCCS dental periodicity schedule (Exhibit 430-1 in the AHCCCS Medical Policy Manual) and submit all applicable EPSDT reports as required by the AHCCCS Medical Policy Manual to ADHS/DBHS. EPSDT providers must document immunizations into the Arizona State Immunization Information System (ASIIS) and enroll every year in the Vaccine for Children (VFC) program.

 

  4.7.7

Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention includes primary prevention health education and health care services through screening, diagnostic and medically necessary treatment for members twenty-one (21) years of age and older. These services include, but are not limited to, screening and treatment for hypertension; elevated cholesterol; colon cancer; sexually

 

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  transmitted diseases; tuberculosis; HIV/AIDS; breast and cervical cancer; and prostate cancer. Nutritional assessment and treatment are covered when medically necessary to meet the over and under nutritional needs of members who may have a chronic debilitating disease. Physical examinations, diagnostic work-ups and medically necessary immunizations are also covered in accordance with A.A.C. R9-22-205.

 

  4.7.8 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.

 

  4.7.9 Emergency Services include emergency services specified in the AHCCCS Medical Policy Manual Policy and, at a minimum, as follows:

 

  4.7.9.1 Emergency services facilities adequately staffed by qualified medical professionals to provide pre-hospital, emergency care on a twenty-four (24) hour a day, seven (7) day a week basis, for an emergency medical condition as defined by A.A.C. Title, 9, Chapter 22, Article 1;

 

  4.7.9.2 Emergency medical services are covered without prior authorization;

 

  4.7.9.3 All medical services necessary to rule out an emergency condition;

 

  4.7.9.4 Emergency transportation; and

 

  4.7.9.5 Additional emergency services information and requirements is contained in AAC R9-22-201, et seq. and 42 CFR 438.114.

 

  4.7.10 Per Medicaid Managed Care regulations, 42 CFR 438.114; 42 CFR 422.113; and 42 CFR 422.133, the following conditions apply with respect to coverage and payment of emergency services for TXIX/XXI members the Contractor shall:

 

  4.7.10.1 Be financially responsible for all emergency medical services including triage, physician assessment and diagnostic tests, when members present in an emergency room setting;

 

  4.7.10.2 Reimburse ambulance transportation and/or other medically necessary transportation provided to a member. Refer to ACOM Policy 432;

 

  4.7.10.3 Cover the cost of ambulance transportation and/or other medically necessary transportation provided to a member who requires behavioral services after medical stabilization;

 

  4.7.10.4 Cover cost for medically necessary professional psychiatric consultations in either emergency room or inpatient settings; and

 

  4.7.10.5 Cover and pay for emergency services regardless of whether the provider that furnishes the service has a subcontract with the Contractor.

 

  4.7.11 The Contractor may not deny payment for treatment obtained under either of the following circumstances for TXIX/XXI members:

 

  4.7.11.1 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; or

 

  4.7.11.2 Contractor’s representative, an employee or subcontracting provider, instructs the member to seek emergency medical services.

 

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  4.7.12 The Contractor may not limit what constitutes an emergency medical condition as defined in 42 CFR 438.114, on the basis of lists of diagnoses or symptoms.

 

  4.7.13 The Contractor may not 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 ten (10) calendar days of presentation for emergency services. Claims submission by the hospital within ten (10) calendar days of presentation for the emergency services constitutes notice to the Contractor. This notification requirement applies only to the provision of emergency services.

 

  4.7.14 The Contractor may not require notification of Emergency Department treat and release visits as a condition of payment unless the Contractor has prior approval from ADHS/DBHS.

 

  4.7.15 The Contractor may not hold a member who has an emergency medical condition 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 post-stabilization care.

 

  4.7.16 Family Planning includes family planning services in accordance with the AHCCCS Medical Policy Manual, for all members (male and female) who choose to delay or prevent pregnancy. These include medical, surgical, pharmacological, laboratory services, and contraceptive devices. Information and counseling, which allow members to make informed decisions regarding family planning methods, shall also be included. If the Contractor does not provide family planning services, it must subcontract for these services through another health care delivery system.

 

  4.7.17 Foot and Ankle Services for members age eighteen (18) through twenty (20) includes foot and ankle care services for members age eighteen (18) through twenty (20) 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 nonprofessional person.

 

  4.7.18 Foot and Ankle Services for member age twenty-one (21) and older includes 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 nonprofessional person as described in the AHCCCS Medical Policy Manual. Services are not covered for members twenty-one (21) years of age and older, when provided by a podiatrist or podiatric surgeon.

 

  4.7.19 Home and Community Based Services (HCBS) includes Assisted Living facility, alternative residential setting, or home and community based services as defined in A.A.C. Title, 9, Chapter 22, Article 2 and A.A.C. Title, 9, Chapter 28, Article 2 that meet the provider standards described in A.A.C. Title, 9, Chapter 28, Article 5, and subject to the limitations set forth in the AHCCCS Medical Policy Manual. These services are covered in lieu of a nursing facility.

 

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

 

  4.7.21 Hospice includes covered services for members that are certified by a physician as being terminally ill and having six months or less to live. Additional detail on covered hospice services is contained in AHCCCS Medical Policy Manual.

 

  4.7.22 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 such as laboratory, radiology, therapies and ambulatory surgery. 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 other staff to evaluate, stabilize or treat medical conditions of a significant degree of instability and disability. Additional detail on limitations on hospital stays is contained in the AHCCCS Medical Policy Manual.

 

  4.7.23 Immunizations include immunizations for adults age twenty-one (21) years and older including but not limited to: medically necessary diphtheria, tetanus, pertussis vaccine (DTap), influenza, pneumococcus, rubella, measles and hepatitis-B and others as medically indicated. Immunizations for members age eighteen (18) through twenty (20) include, but are not limited to: diphtheria, tetanus, pertussis vaccine (DTaP), inactivated polio vaccine (IPV), measles, mumps, rubella vaccine (MMR), H. influenza, type B (HIB), hepatitis B (Hep B), hepatitis A (Hep A), Human Pappiloma virus (HPV) through age twenty (20) for both males and females, pneumococcal conjugate (PCV) and varicella zoster virus (VZV) vaccine. Additional detail on current immunization requirements is contained in the AHCCCS Medical Policy Manual.

 

  4.7.24 The Contractor is required to report to AHCCCS, as specified in Exhibit 9, a monthly Hepatitis C Virus (HCV) Medication Report. Data is reported for all HCV medication activity for the month being reported. The total number of requests received, approvals, denials, and appeals for any given month are to be included in the report. As outcome information becomes available, it is to also be included in the report for the month received. The Contractor will be reporting as a January activity (due February 10th) any information received regarding outcomes, appeals, hearings, and so forth for medication approvals from past months.

 

  4.7.25 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. Incontinence Supplies includes incontinence supplies as specified in A.A.C. R9-22-212 and the AHCCCS Medical Policy Manual.

 

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  4.7.26 Laboratory including 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 CLIA (Clinical Laboratory Improvement Act) approved free-standing laboratory or hospital laboratory, clinic, physician office or other health care facility laboratory. 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 approved by ADHS/DBHS.

 

  4.7.27 Maternity includes pre-conception counseling, 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. Additional details for maternity services are contained in Scope of Work, Section 7.6. The Contractor shall allow women to receive up to forty-eight (48) hours of inpatient hospital care after a routine vaginal delivery and up to ninety-six (96) hours of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the mother, may discharge the mother prior to the minimum length of stay. The Contractor shall inform all pregnant members of voluntary prenatal HIV 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 ADHS, the number of pregnant women who have been identified as HIV/AIDS-positive. This report is due no later than thirty (30) days after the end of the second and fourth quarters of the Contract Year. 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.

 

  4.7.28 Medical Foods includes foods subject to the limitations in the AHCCCS Medical Policy Manual for members diagnosed with a metabolic condition and specified in the AHCCCS Medical Policy Manual.

 

  4.7.29 Medical Supplies, Durable Medical Equipment (DME), and Prosthetic Devices: includes services prescribed by the member’s PCP, attending physician or practitioner, or by a dentist as described in the AHCCCS Medical Policy Manual. Prosthetic devices must be medically necessary and meet criteria as described in the AHCCCS Medical Policy Manual. For persons age twenty-one (21) or older, ADHS/DBHS 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 and include exclusions as stated in AMPM Chapter 300.

 

  4.7.30

Nursing Facility includes services in nursing facilities and religious non-medical health care institutions for members that require short-term convalescent care not to exceed ninety (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 as defined in the Scope of Work, Section 4.7 Physical

 

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  Health Care Covered Services. Nursing facility services must be provided in a dually-certified Medicare State licensed 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 as outlined in AMPM Chapter 300. Additional detail on Nursing Facility Reimbursement is contained in the Scope of Work, Section 16.2 The Contractor shall notify AHCCCS’ Assistant Director of the Division of Member Services, by email, when a member has been residing in a nursing facility for sixty (60) days to allow ADHS/DBHS to follow-up on the status of the member’s ALTCS application and to consider potential fee-for-service coverage, if the stay goes beyond the ninety (90) day per Contract Year maximum. The notice should be sent via e-mail to HealthPlan60DayNotice@azahcccs.gov. and must include the following:

 

  4.7.30.1 Member name,

 

  4.7.30.2 AHCCCS ID,

 

  4.7.30.3 Date of birth,

 

  4.7.30.4 Name of facility,

 

  4.7.30.5 Admission date to the facility,

 

  4.7.30.6 Date sixty (60) day limit is reached, and

 

  4.7.30.7 Name of contractor of enrollment.

 

  4.7.31 Nutrition includes nutritional assessments conducted as a part of the EPSDT screenings for members age eighteen (18) through twenty (20), and to assist members twenty-one (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. Nutritional therapy on an enteral, parenteral or oral basis, when determined medically necessary to provide either complete daily dietary requirements or to supplement a member’s daily nutritional and caloric intake is covered according to criteria specified in the AHCCCS Medical Policy Manual.

 

  4.7.32 Oral Health includes medically necessary dental services to members age eighteen (18) through twenty (20) including emergency dental services, dental screening and preventive services in accordance with the AHCCCS Dental Periodicity Schedule, as well as therapeutic dental services, dentures, and pre-transplantation dental services. The Contractor shall:

 

  4.7.32.1 Monitor compliance with the AHCCCS Dental Periodicity Schedule for dental screening services;

 

  4.7.32.2 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 age eighteen (18) through (20) may request dental services without referral and may choose a dental provider within the Contractor’s provider network;

 

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  4.7.32.3 For members twenty-one (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 in conformance with A.A.C. R9-22-207. These services would be considered physician services if furnished by a physician; and

 

  4.7.32.4 Refer to the AHCCCS Medical Policy Manual for additional detail on oral health dental services that are covered for pre-transplant candidates and for members with cancer of the jaw, neck or head.

 

  4.7.33 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:

 

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

 

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

 

  4.7.33.3 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 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.

 

  4.7.34 Physician includes physician services for medical assessment, treatments and surgical services provided by licensed allopathic or osteopathic physicians.

 

  4.7.35 Post-stabilization Care Services Coverage and Payment includes 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 be safely discharged or transferred to another location 42 CFR 438-114(a). Pursuant to A.A.C. R9-22-210 and 42 CFR 438.114; 42 CFR 422.113(c) and 42 CFR 422.133, the following conditions apply for coverage and payment of post-stabilization care services, except where otherwise stated in this Contract. Cover and pay for post-stabilization care services without authorization, regardless of whether the provider that delivers the service has a subcontract with the Contractor, as follows:

 

  4.7.35.1 Post-stabilization care services were pre-approved by the Contractor; or

 

  4.7.35.2 Post-stabilization 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 (1) hour after the treating provider’s request or could not be contacted for pre-approval.

 

  4.7.36 In situations when the Contractor representative and the treating physician cannot reach agreement concerning the member’s care and a Contractor physician is not available for consultation, 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.

 

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

 

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

 

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

 

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

 

  4.7.37.4 The member is discharged.

 

  4.7.38 Pregnancy Termination includes pregnancy termination coverage 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. The Certificate must certify that, in the physician’s professional judgment, the criteria have been met.

 

  4.7.39 Prescription Medications includes medications ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the direction of a licensed pharmacist 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 AHCCCS Medical Policy Manual when it is determined to be a lower-cost alternative to a prescription medication. Additional detail is contained in Scope of Work, Medications, Section 4.11. Additional detail for coverage of Medicare Part D prescription medications is contained in Scope of Work, Medicare Services and Cost Sharing, Section 15.17.

 

  4.7.40 Primary Care Provider (PCP) includes those medically necessary covered services 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.

 

  4.7.41 Radiology and Medical Imaging includes medically necessary services ordered by the member’s PCP, attending physician or dentist for diagnosis, prevention, treatment, or assessment of a medical condition.

 

  4.7.42

Rehabilitation Therapy includes occupational, physical and speech therapies prescribed by the member’s PCP or attending physician for acute health 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 age eighteen

 

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  (18) through 20. Physical Therapy is covered for all members in both inpatient and outpatient settings. Outpatient physical therapy under the age of twenty-one (21), is subject to visit limits per contract year as described in the AMPM.

 

  4.7.43 Respiratory Therapy includes respiratory therapy services covered in inpatient and outpatient settings when prescribed by the member’s PCP or attending physician, and is necessary to restore, maintain or improve respiratory functioning.

 

  4.7.44 Transplantation of Organs and Tissue, and Related Immunosuppressant Drugs includes services covered subject to the limitations in the AHCCCS Medical Policy Manual 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 physical health 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.

 

  4.7.45 Transportation includes 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 a member’s emergency medical condition at an emergency scene and to transport the member to the nearest appropriate medical facility. Non-emergency transportation shall be provided for members who are unable to provide their own transportation for covered services. 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.

 

  4.7.46 Triage/Screening and Evaluation includes services provided by physical health care hospitals, IHS facilities, tribally owned and/or operated 638 facility and after-hours settings to determine whether or not an emergency exists, to 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.

 

  4.7.47 Vision Services/Ophthalmology/Optometry includes all medically necessary emergency eye care, vision examinations, prescriptive lenses and frames, and treatments for conditions of the eye for all members age eighteen (18) to through twenty (20). For members who are twenty-one (21) years of age and older, the Contractor shall provide emergency care for eye conditions which meet the definition of an emergency medical condition, cataract removal, and medically necessary vision examinations and prescriptive lenses and frames, if required following cataract removal and other eye conditions as described in the AHCCCS Medical Policy Manual. 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.

 

4.8 Integrated Health Care Service Delivery for SMI Members

The Contractor shall incorporate the following elements into its integrated health care service delivery system approach:

 

  4.8.1 A treatment team, which includes a psychiatrist or equivalent behavioral health medical professional and an assigned primary care physician with an identified single point of contact;

 

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SOLICITATION NO: ADHS15-00004276

 

  4.8.2 Member and family voice and choice;

 

  4.8.3 Whole-person oriented care;

 

  4.8.4 Quality and safety;

 

  4.8.5 Accessible care;

 

  4.8.6 Effective use of a comprehensive Care Management Program as described in 8.13 Care Management Program Goals, and Care Management Program General Requirements, Sections 8.13 and 8.14;

 

  4.8.7 Coordination of care as described in Section 5.1, Care Coordination;

 

  4.8.8 Health education and health promotion services described in Section 4.9, Health Education and Health Promotion Services;

 

  4.8.9 Improved whole health outcomes of members;

 

  4.8.10 Utilize peer and family delivered support services;

 

  4.8.11 Make referrals to appropriate community and social support services; and

 

  4.8.12 Utilize health information technology to link services.

 

  4.8.13 Maximize the use of existing behavioral and physical health infrastructure including:

 

  4.8.13.1 SMI clinics,

 

  4.8.13.2 Primary care physicians currently serving SMI members,

 

  4.8.13.3 Community Health Centers, and

 

  4.8.13.4 Peer and family run organizations.

 

4.9 Health Education and Health Promotion Services

The Contractor shall provide:

 

  4.9.1 Assistance and education for appropriate use of health care services;

 

  4.9.2 Assistance and education about health risk-reduction and healthy lifestyle choices including tobacco cessation;

 

  4.9.3 Screening for tobacco use with the Ask, Advise, and Refer model and refer to the Arizona Smokers Helpline utilizing the proactive referral process;

 

  4.9.4 Education to SMI members to access Contractor’s Nurse call service;

 

  4.9.5 Assistance and education for self-care and management of health conditions, including wellness coaching;

 

  4.9.6 Assistance and education for EPSDT services for members including education and health promotion for dental/oral health services;

 

  4.9.7 Assistance and education about maternity care programs and services for pregnant women including family planning; and

 

  4.9.8 Assistance and education about self-help programs or other community resources that are designed to improve health and wellness.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

4.10 American Indian Member Services

The Contractor shall:

 

  4.10.1 Provide access to all applicable covered services to Medicaid eligible American Indians within the assigned Geographic Service Area of Greater Arizona, whether they live on or off the reservation.

 

  4.10.2 Cover costs of emergency services and medically necessary services for eligible American Indian members when members are referred off reservation and/or services are rendered at non-IHS or tribally owned or operated facilities.

 

  4.10.3 Not be responsible for payment for medically necessary services provided to Medicaid eligible members at IHS or a tribally owned and operated facility; AHCCCS is responsible for these payments.

 

  4.10.4 Provide medically necessary covered services to eligible American Indians through agreements with tribes, IHS facilities, and other providers of services. Contractor may serve eligible American Indians on reservation with agreement from the tribe.

 

  4.10.5 Develop and maintain a network of providers that can deliver culturally and linguistically appropriate services to American Indian members.

 

  4.10.6 Recognize that in addition to services provided through the Contractor, American Indian members through their enrollment choice can always receive services from an IHS or a 638 tribal facility.

 

4.11 Medications

The Contractor shall:

 

  4.11.1 Develop and maintain a medication list in conformance with the AHCCCS Policy 310-V- Prescription Medications/Pharmacy Services and the ADHS/DBHS Medication List and the ADHS/DBHS Policy on the Medication List.

 

  4.11.2 At a minimum, include the following on the medication list:

 

  4.11.2.1 The available medications on the AHCCCS Minimum Required Prescription Drug List (MRPDL) for SMI members eligible to receive physical health services under this Contract;

 

  4.11.2.2 The available medications on the ADHS/DBHS Medication List for members eligible to receive behavioral health services under this Contract; and

 

  4.11.2.3 Medications to treat anxiety, depression and attention deficit hyperactivity disorder (ADHD).

 

  4.11.3 Provide generic and branded reimbursement guarantees, an aggressive Maximum Allowable Cost (MAC) pricing program, generic dispensing rate guarantee, and utilization methodologies to dispense the least costly, clinically appropriate medication and report the rebates in conformance with requirements in the ADHS/DBHS Financial Reporting Guide for Greater Arizona.

 

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  4.11.4 Recognize that for SMI members, PCP’s may treat members with anxiety, depression and ADHD and may provide medication management services including prescriptions, laboratory, and other diagnostic tests necessary for diagnosis, and treatment. Clinical tool kits for the treatment of anxiety, depression, and ADHD are available in the AMPM. 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.

 

  4.11.5 Recognize that for SMI members Prescription 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.

 

  4.11.6 Recognize that for SMI members, drugs ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the direction of a licensed pharmacist are covered; however, they are 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 will not be covered. This applies to members that are enrolled in Medicare Part D or are eligible for Medicare Part D.

 

4.12 Laboratory Testing Services

The Contractor shall:

 

  4.12.1 Use laboratory testing sites that have either a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver or a Certificate of Registration along with a CLIA identification number.

 

  4.12.2 Verify that laboratories satisfy all requirements in 42 CFR 493, Subpart A, General Provisions.

 

  4.12.3 Cover laboratory services for diagnostic, screening and monitoring purposes when ordered by the member’s PCP, other attending physician or dentist, and provided by a CLIA approved free-standing laboratory or hospital laboratory, clinic, physician office or other health care facility laboratory.

 

  4.12.4 Require all clinical laboratories to provide verification of CLIA Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in either a termination of an active provider ID number or denial of initial registration.

 

  4.12.5 Apply the following requirements to all clinical laboratories:

 

  4.12.5.1 Pass-through billing or other similar activities with the intent to avoid the requirements in the Scope of Work, Laboratory Testing Services, Sections 4.12.1 and 4.12.2 is prohibited;

 

  4.12.5.2 Clinical laboratory providers who do not comply with the requirements in the Scope of Work, Laboratory Testing Services, Sections 4.12.1 and 4.12.2 may not be reimbursed;

 

  4.12.5.3 Laboratories with a Certificate of Waiver are limited to providing only the types of tests permitted under the terms of their waiver; and

 

  4.12.5.4 Laboratories with a Certificate of Registration are allowed to perform a full range of laboratory tests.

 

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  4.12.6 Manage and oversee the administration of laboratory services through subcontracts with qualified services providers to deliver laboratory services.

 

  4.12.7 Obtain laboratory test data on Title XIX/XXI eligible members from a laboratory or hospital based laboratory subject to the requirements in A.R.S. § 36-2903(Q) (1-6) and (R), upon written request.

 

  4.12.8 Use the data in Section 4.12.7 exclusively for quality improvement activities and health care outcome studies required and approved by ADHS/DBHS.

 

4.13 Crisis Services Overview

ADHS/DBHS supports a coordinated system of entry into crisis services that are community based, recovery-oriented, and member focused. The improvement of collaboration, data collection standards, and communication will enhance quality of care which leads to better health care outcomes while containing cost. Expanding provider networks that are capable of providing a full array of crisis services that are geared toward the members is expected to maintain health and enhance member quality of life. The use of crisis service data for crisis service delivery and coordination of care is critical to the effectiveness of the overall crisis delivery system.

 

4.14 Crisis Services-General Requirements

The Contractor shall:

 

  4.14.1 Stabilize individuals as quickly as possible and assist them in returning to their baseline of functioning;

 

  4.14.2 Assess the individual’s needs, identify the supports and services that are necessary to meet those needs, and connect the individual to appropriate services;

 

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

 

  4.14.4 Utilize the engagement of peer and family support services in providing crisis services;

 

  4.14.5 Meet or exceed the immediate and urgent response requirements in conformance with the ADHS/DBHS Policy on Appointment Standards and Timeliness of Service and record referrals, dispositions, and overall response time;

 

  4.14.6 Not require prior authorization for crisis services;

 

  4.14.7 Have the discretion to require subcontracted providers that are not part of Contractor’s crisis network to deliver crisis services or be involved in crisis response activities during regular business operating hours;

 

  4.14.8 Coordinate with all clinics and case management agencies to resolve crisis situations for assigned members;

 

  4.14.9 Develop local county based stabilization services to prevent unnecessary transport outside of the community where the crisis is occurring;

 

  4.14.10 Develop a process where tribal liaisons and appropriate clinical staff coordinate crisis services on tribal lands with the crisis providers;

 

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SOLICITATION NO: ADHS15-00004276

 

  4.14.11 Participate in a data and information sharing system, connecting crisis providers and member physicians through a health information exchange;

 

  4.14.12 Analyze, track, and trend crisis service utilization data in order to improve crisis services;

 

  4.14.13 In conformance with the Scope of Work, Care Coordination and Collaboration Section 5, provide information about crisis services and develop and maintain collaborative relationships with community partners including:

 

  4.14.13.1 Fire,

 

  4.14.13.2 Police,

 

  4.14.13.3 Emergency medical services,

 

  4.14.13.4 Hospital emergency departments,

 

  4.14.13.5 AHCCCS Acute Care Health Plans, and

 

  4.14.13.6 Providers of public health and safety services.

 

  4.14.14 Have active involvement with local police, fire departments, and first responders in the development of strategies for crisis service care coordination and strategies to assess and improve crisis response services;

 

  4.14.15 Provide annual trainings to support and develop law enforcement agencies understanding of behavioral health emergencies and crises;

 

  4.14.16 Utilize and train tribal police to be able to assist in behavioral health crises responses on tribal land;

 

  4.14.17 Develop a collaborative process to ensure information sharing for timely access to Court Ordered Evaluation (COE) services; and

 

  4.14.18 Submit the deliverables related to Crisis Services reporting in accordance with Exhibit 9.

 

  4.14.19 The Contractor is responsible for notifying the responsible health plan within twenty-four (24) hours of an acute dual eligible member engaging in crisis services so subsequent services can be initiated by the member’s health plan. The member’s health plan is responsible for all other medically necessary services related to a crisis episode. The Contractor shall develop policies and procedures to ensure timely notification and communication with health plans for acute dual eligible members who have engaged crisis services.

 

  4.14.20 The Contractor shall be responsible for the full continuum of crisis services, including but not limited to, timely access to crisis services telephone response, mobile crisis teams and stabilization services. Crisis services shall be community based, recovery-oriented, and member focused and shall work to stabilize individuals as quickly as possible and assist them in returning to their baseline of functioning.

 

  4.14.21 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. The policy must address:

 

  4.14.21.1 Involuntary evaluation/petitioning;

 

  4.14.21.2 Court ordered process, including tracking the status of court orders;

 

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SOLICITATION NO: ADHS15-00004276

 

  4.14.21.3 Execution of court order, and;

 

  4.14.21.4 Judicial review.

 

4.15 Crisis Services-Telephone Response

The Contractor shall:

 

  4.15.1 Establish and maintain a twenty-four (24) hours per day, seven (7) days per week crisis response system.

 

  4.15.2 Establish and maintain a single toll-free crisis telephone number.

 

  4.15.3 Publicize its single toll-free crisis telephone number throughout Greater Arizona and include it prominently on Contractor’s web site, the Member Handbook, member newsletters and as a listing in the resource directory of local telephone books.

 

  4.15.4 Have a sufficient number of staff to manage the telephone crisis response line.

 

  4.15.5 Answer calls to the crisis response line within three (3) telephone rings, with a call abandonment rate of less than three per cent (3%).

 

  4.15.6 Include triage, referral and dispatch of service providers and patch capabilities to and from 911 and other crisis providers or crisis systems as applicable.

 

  4.15.7 Conduct a follow-up call within seventy-two (72) hours to make sure the caller has received the necessary services.

 

  4.15.8 Offer interpretation or language translation services to persons who do not speak or understand English and for the deaf and hard of hearing.

 

  4.15.9 Provide Nurse On-Call services twenty-four (24) hours per day, seven (7) days per week to answer general healthcare questions from SMI members receiving physical health care services under this Contract and to provide them with general health information and self-care instructions.

 

4.16 Crisis Services-Mobile Crisis Teams

The Contractor shall establish and maintain mobile crisis teams with the following capabilities:

 

  4.16.1 Ability to travel to the place where the individual is experiencing the crisis.

 

  4.16.2 Ability to assess and provide immediate crisis intervention.

 

  4.16.3 Develop mobile teams that have the capacity to serve specialty needs of population served including youth and children, hospital rapid response, and developmentally disabled.

 

  4.16.4 Reasonable efforts to stabilize acute psychiatric or behavioral symptoms, evaluate treatment needs, and develop plans to meet the individual’s needs.

 

  4.16.5 When clinically indicated, transport the individual to a more appropriate facility for further care.

 

  4.16.6 Require mobile crisis teams to respond on site within the average of ninety (90) minutes of receipt of the crisis call. Average of ninety minutes is calculated by utilizing the monthly average of all crisis call response times.

 

  4.16.7 Develop incentives for those mobile team providers who respond to crisis calls within forty-five (45) minutes of the initial call.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

4.17 Crisis Services- Crisis Stabilization Settings

The Contractor shall establish and maintain crisis stabilization settings with the following capabilities:

 

  4.17.1 Offer twenty-four (24) hour substance use disorder/psychiatric crisis stabilization services including twenty-three (23) hour crisis stabilization/observation capacity.

 

  4.17.2 Provide short-term crisis stabilization services (up to seventy-two (72) hours) in an effort to successfully resolve the crisis and returning the individual to the community instead of transitioning to a higher level of care.

 

  4.17.3 Provide a crisis assessment and stabilization service in settings consistent with requirements to have an adequate and sufficient provider network that includes any combination of the following:

 

  4.17.3.1 Licensed Level I acute and sub-acute facilities; and

 

  4.17.3.2 Outpatient clinics offering twenty-four (24) hours per day, seven (7) days per week access.

 

  4.17.3.3 Have the discretion to include home-like settings such as apartments and single family homes where individuals experiencing a psychiatric crisis can stay to receive support and crisis respite services in the community before returning home.

 

4.18 Prevention Services

The Contractor shall:

 

  4.18.1 Administer a prevention system in conformance with the Strategic Prevention Framework (SPF) Model established by the Substance Abuse and Mental Health Services Administration (SAMHSA);

 

  4.18.2 Submit an Annual Prevention budget for review and approval;

 

  4.18.3 Track spending of Prevention (SABG ) monies annually to ensure prevention funds are expended according to funding guidelines which include but are not limited to the following: completing site visits, providing training and technical assistance to any subcontractors;

 

  4.18.4 Provide prevention services in accordance with completed, formal, comprehensive regional needs assessment;

 

  4.18.5 Subcontract with Community Based Organizations for provision of prevention services;

 

  4.18.6 Designate one full time lead prevention administrator;

 

  4.18.7 Develop a regional strategic plan which conforms to prevention (SABG) funding guidelines;

 

  4.18.8 Report evaluation outcomes annually using the ADHS evaluation tools/surveys to measure outcomes;

 

  4.18.9 Comply with all funding requirements for prevention;

 

  4.18.10 Participate in annual review to evaluate prevention programs; and

 

  4.18.11 Submit deliverables related to Prevention Services reporting in accordance with Exhibit 9.

 

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SOLICITATION NO: ADHS15-00004276

 

4.19 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 Medicaid eligible members under age nineteen (19). Any provider, licensed by the state to administer immunizations, may register with ADHS as a “VFC provider” and receive free vaccines.

For SMI members receiving physical health care services, age eighteen (18) only, the Contractor shall:

 

  4.19.1 Not reimburse providers for the administration of the vaccines in excess of the maximum allowable amount set by the Centers for Medicare and Medicaid (CMS), found in the AHCCCS fee schedule.

 

  4.19.2 Not utilize Medicaid funding to purchase vaccines for SMI members, age eighteen (18).

 

  4.19.3 Contact ADHS/DBHS and the AHCCCS Division of Health Care Management, Clinical Quality Management Unit if vaccines are not available through the VFC Program.

 

  4.19.4 Comply with all VFC requirements and monitor its providers to ensure that, a PCP for an SMI member, age eighteen (18) only, is registered with ADHS as a VFC provider.

 

  4.19.5 Develop and implement processes to ensure that vaccinations are available through a VFC enrolled provider or through the county Health Department when a provider chooses not to provide vaccinations. In all instances, the antigens are to be provided through the VFC program.

 

  4.19.6 Develop and implement processes to pay the administration fee to the VFC provider who administers the vaccine regardless of the provider’s contract status with the Contractor.

 

  4.19.7 Educate its provider network about immunization reporting requirements, the ASIIS Immunization registry, the use of the VFC program and the availability of ASIIS software for providers to assist in meeting reporting requirements.

 

  4.19.8 Monitor compliance with the following reporting requirements:

 

  4.19.8.1 Report all immunizations given to only SMI members that are age eighteen (18); and

 

  4.19.8.2 Report immunizations at least monthly to the ADHS, ASIIS Immunization registry which can be accessed by providers to obtain complete, accurate immunization records.

 

4.20 Medicaid School Based Claiming Program (MSBC)

Pursuant to an Intergovernmental Agreement with the Department of Education, and a contract with a Third Party Administrator, AHCCCS reimburses 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.

Medicaid School Based Claiming (MSBC) 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 MSBC services approved at an alternative setting. Currently, services include audiology, therapies (occupational, physical 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 MSBC service. The Contractor’s evaluations and determinations of medical necessity shall be made independent of the fact that the child is receiving MSBC services.

 

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SOLICITATION NO: ADHS15-00004276

 

For Medicaid eligible SMI members, ages eighteen (18) through twenty (20), receiving physical health care services, the Contractor shall:

 

  4.20.1 Coordinate with schools and school districts that provide MSBC services to members;

 

  4.20.2 Not duplicate services;

 

  4.20.3 Require persons who coordinate care for members to coordinate with the appropriate school staff working with these members;

 

  4.20.4 Transfer member medical information and progress toward treatment goals between the Contractor and the SMI member’s school or school district as appropriate;

 

  4.20.5 Designate a single point of contact to coordinate care and communicate with public school Transition Coordinators; and

 

  4.20.6 Evaluate all requests made for services covered under the MSBC program on the same basis as any request for a covered service.

 

4.21 Special Health Care Needs

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:

 

  4.21.1 Lasts or is expected to last one year or longer, and

 

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

AHCCCS has determined that the following populations meet this definition:

 

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

 

  4.21.4 Members who are recipients of services provided through the Arizona Department of Health Services Division of Behavioral Health contracted Regional Behavioral Health Authorities (RBHAs), and

 

  4.21.5 Members diagnosed with HIV/AIDS

 

  4.21.6 Arizona Long Term Care System:

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

4.21.6.2 Members enrolled in the ALTCS program who have a developmentally disability.

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

For all Medicaid eligible populations receiving services under this Contract, the Contractor shall:

 

  4.21.7 Have mechanisms in place to assess the quality and appropriateness of care furnished to members with special health care needs as defined by the State (42 CFR 438.208(c)(1)).

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  4.21.8 Have mechanisms in place to assess each member in order to identify any ongoing special conditions of the member which require a course of treatment or regular care monitoring (42 CFR 438.208(c)(2)).

 

  4.21.9 Utilize appropriate health care professionals in the assessment process.

 

  4.21.10 Share with other entities providing services to that member any results of its identification and assessment of that member’s needs to prevent duplication of those activities. (42 CFR 438.208(b)(3)).

 

  4.21.11 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)).

 

4.22 Special Assistance for SMI Members

The Contractor shall:

 

  4.22.1 Require its staff, subcontractors, and service providers to identify all persons in need of special assistance to the ADHS/DBHS Office of Human Rights, and ensure those persons are provided the special assistance they require, consistent with the requirements in the ADHS/DBHS Policy and Procedure Manual Section on Special Assistance for Persons Determined to have a Serious Mental Illness.

 

  4.22.2 Cooperate with the Human Rights Committee in meeting its obligations in the ADHS/DBHS Policy and Procedure Manual Section on Special Assistance for Persons Determined to have a Serious Mental Illness.

 

  4.22.3 Submit the deliverables related to Special Assistance Services reporting in accordance with Exhibit 9.

 

4.23 Psychiatric Rehabilitative Services-Housing

The Contractor shall:

 

  4.23.1 Develop and maintain a housing continuum for members with SMI in conformance with the ADHS/DBHS Housing Desktop Manual.

 

  4.23.2 Collaborate with community stakeholders, state agency partners, federal agencies and other entities to identify, apply for or leverage alternative funding sources for housing programs.

 

  4.23.3 Develop and manage state and federal housing programs and deliver housing related services.

 

  4.23.4 Utilize all housing units previously purchased in the GSA for purposes of providing housing for SMI members.

 

  4.23.5 Evaluate and report annually the fidelity of the Housing program through utilizing SAMHSA’s Permanent Supportive Housing toolkit.

 

  4.23.6 Comply with all federally funded and state funded housing requirements as directed by ADHS/DBHS.

 

  4.23.7 Submit the deliverables related to the Housing Program in accordance with Exhibit 9.

 

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SOLICITATION NO: ADHS15-00004276

 

The Contractor shall not:

 

  4.23.8 Utilize state funds in any capacity for unlicensed boarding homes, or other similar unlicensed facilities.

 

4.24 Psychiatric Rehabilitative Services-Employment

The Contractor shall:

 

  4.24.1 Develop and manage a continuum of vocational employment and business development services to assist SMI members, including transition age youth to achieve their employment goals.

 

  4.24.2 Provide priority to those providers under contract with ADES/RSA when entering into subcontracts for vocational/employment services.

 

  4.24.3 Make all reasonable efforts to increase the number of providers who are mutually contracted with ADES/RSA.

 

  4.24.4 Evaluate and report annually the fidelity of Supported Employment services utilizing SAMHSA’s Supported Employment toolkit.

 

4.25 Psychiatric Rehabilitative Services-Peer Support

The Contractor shall:

 

  4.25.1 Require subcontractors and providers to assign at least one (1) Peer Support Specialist/Recovery Support Specialist on each adult recovery team to provide covered services, when appropriate.

 

  4.25.2 Evaluate and report annually the fidelity of peer support programs utilizing SAMHSA’s Consumer Operated Services Program toolkit.

 

4.26 Centers of Excellence

 

  4.26.1 Centers of Excellence are facilities that are recognized as providing the highest levels of leadership, quality, and service. Centers of Excellence align physicians and other providers to achieve higher value through greater focus on appropriateness of care, clinical excellence, and patient satisfaction. Designation as a Center of Excellence is based on criteria such as procedure volumes, clinical outcomes, and treatment planning and coordination. To encourage Contractor activity which incentivizes utilization of the best value providers for select, evidenced based, high volume procedures or conditions, the Contractor shall ensure that its subcontractors submit a Centers of Excellence Report to AHCCCS, DHCM by April 1, 2016, as specified in Exhibit 9, outlining the Contractor’s approach to developing at least two Centers of Excellence for at least two different procedures or conditions. The Centers of Excellence Report must:

 

  4.26.1.1 Identify why the selected procedures or conditions were chosen,

 

  4.26.1.2 Outline how the Contractor will identify and select providers with the highest quality outcomes,

 

  4.26.1.3 Provide a high-level summary of potential contracting approaches,

 

  4.26.1.4 Identify how the Contractor plans to drive utilization to the Centers of Excellence, and

 

  4.26.1.5 Identify any barriers or challenges with the development of such Centers of Excellence.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

5 CARE COORDINATION AND COLLABORATION

 

5.1 Care Coordination

Care Coordination encompasses a variety of activities for coordinating services and providers to assist a member in achieving his or her Recovery goals described in the Individual Recovery Plan. These activities, which can occur both at a clinical and system level, are performed by Treatment Team members depending on a member’s needs, goals, and functional status. Regardless of who performs care coordination, the care coordinator should have expertise in member self-management approaches, member advocacy and be capable of navigating complex systems and communicating with a wide spectrum of professional and lay persons including family members, physicians, specialists and other health care professionals.

The Contractor shall conduct care coordination activities which at a minimum shall include, when appropriate, the following activities:

 

  5.1.1 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, Arizona statutes and regulations, and to the extent that they are applicable [42 CFR 438.208 (b)(2) and (b)(4) and 438.224] and the Scope of Work, Medical Records Section 18.10.12 and 18.10.13.

 

  5.1.2 Engage the member to participate in service planning.

 

  5.1.3 Monitor adherence to treatment goals including medication adherence.

 

  5.1.4 Authorize the initial service package, continuing or additional services and suggest or create service alternatives when appropriate.

 

  5.1.5 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.

 

  5.1.6 Monitor individual health status and service utilization to determine use of evidence-based care and adherence to or variance from the Individual Recovery Plan.

 

  5.1.7 Monitor member services and placements to assess the continued appropriateness, medical necessity and cost effectiveness of the services.

 

  5.1.8 Identify and document the member’s primary care and specialty care providers to make sure the information is current and accurate.

 

  5.1.9 Communicate among behavioral and physical health service providers regarding member progress and health status, test results, lab reports, medications and other health care information when necessary to promote optimal outcomes and reduce risks, duplication of services or errors;

 

  5.1.10 Track the member’s eligibility status for covered benefits and assist with eligibility applications or renewals.

 

  5.1.11 Communicate with the member’s assigned Care Manager, treatment team or other service providers to ensure management of care and services including addressing and resolving complex, difficult care situations.

 

  5.1.12 Participate in discharge planning from hospitals, jail or other institutions and follow up with members after discharge.

 

  5.1.13 Ensure applicable services continue after discharge.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.1.14 Comply with the AMPM and the ACOM Policy 402 standards for member transitions between Contractors or GSAs, participation in or discharge from CRS or CMDP, to or from an ALTCS and Acute Care Contractor and upon termination or expiration of a contract.

 

  5.1.15 Recognize that the exiting Contractor shall be responsible for performing all transition activities at no cost.

 

  5.1.16 Track member transitions from one (1) level of care to another, streamline care plans, and mitigate any disruption in care.

 

  5.1.17 Make referrals to providers, services or community resources.

 

  5.1.18 Verify that periodic re-assessment occurs at least annually or more frequently when the member’s psychiatric and/or medical status changes.

 

  5.1.19 Communicate with family members and other system stakeholders that have contact with the member including, state agencies, other governmental agencies, tribal nations, schools, courts, law enforcement, and correctional facilities.

 

  5.1.20 Identify gaps in services and report gaps to Contractor’s network development manager.

 

  5.1.21 Verify that members discharged from Arizona State Hospital with diabetes are issued appropriate equipment and supplies they were trained to use while in the facility.

 

  5.1.22 Coordinate medical care for members who are inpatient at the Arizona State Hospital (AzSH) in accordance with ACOM 432 and AMPM Policy 1020.

 

  5.1.23 Coordinate outreach activities to members not engaged, but who would benefit from services.

 

  5.1.24 When a Contractor receives members from another Contractor the Contractor shall:

 

  5.1.24.1 Ensure a smooth transition for members by continuing previously approved prior authorizations for thirty (30) days after the member transition unless mutually agreed to by the member or member’s representative; and

 

  5.1.24.2 When relinquishing members, timely notify the receiving Contractor regarding pertinent information related to any special needs of transitioning members.

 

  5.1.24.3 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 thirty (30) days after the member transition unless mutually agreed to by the member or member’s representative.

 

  5.1.25 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 RBHA or T/RBHA prescriber for evaluation and/or continued medication management services, the Contractor shall:

 

  5.1.25.1 Require and ensure that the PCP coordinates the transfer of care.

 

  5.1.25.2 Include this provision in all affected subcontracts; and

 

  5.1.25.3 Ensure that PCPs maintain continuity of care for these members.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.1.26 Establish policies and procedures for the transition of members to the RBHA or T/RBHA for ongoing treatment. The policies and procedures must address, at a minimum, the following:

 

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

 

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

 

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

 

  5.1.26.4 Protocols for transition of prescription services, including but not limited to notification to the RBHA or 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 RBHA or T/RBHA prescriber and that all relevant member medical information including the reason for transfer is forwarded to the receiving RBHA or T/RBHA prescriber prior to the member’s first scheduled appointment with the RBHA or T/RBHA prescriber; and

 

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

 

5.2 Care Coordination for Dual Eligible SMI Members

Medicaid members who are also enrolled in Medicare are considered dually eligible or ‘dual eligible’. In an effort to improve care coordination and control costs for dual eligible members with Serious Mental Illness (SMI), the contractor shall offer Medicaid services to eligible members with SMI as a Dual Eligible Special Needs Plan (D-SNP) as required in Exhibit 3. The Contractor shall comply with the Care Coordination requirements in the Scope of Work Care Coordination Section 5 and:

 

  5.2.1 Create a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP) and if the member enrolls with the Contractor’s D-SNP, be the sole organization that manages the provision of Medicare benefits to SMI dual eligible members enrolled with the Integrated RBHA and may not delegate or subcontract with another entity except as specified below, in Exhibit 3 and the scope of work Section 18.3.3 and 20.3.2.

 

  5.2.2 Meet all Medicare Advantage requirements to remain in compliance and continue operating as a D-SNP in order to provide Medicare services to eligible individuals in accordance with ACOM Policy 107 for Contractors that currently have contracts, or will be pursuing contracts, with the CMS to operate as a Medicare Advantage Dual Eligible Special Needs Plan (D-SNP).

 

  5.2.3 May delegate or subcontract the managed care functions with another entity for the provision of Medicare benefits when that entity is also responsible for performing those functions for the Contractor’s Medicaid line of business.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.2.4 Establish an easily identifiable brand that is recognized by SMI dual eligible members and providers as an integrated service delivery health plan for both Medicare and Medicaid services.

 

  5.2.5 Sign a Medicare Advantage D SNP Health Plan Agreement with AHCCCS to fulfill the requirement per CMS guidelines, that all D-SNPs are required to have an agreement with the State Medicaid Agency to operate as a D-SNP. This agreement will outline specific D-SNP responsibilities related to care coordination, data sharing, and eligibility verification.

 

  5.2.6 Work with ADHS and AHCCCS to improve the system for dual eligible which may include, but is not limited to:

 

  5.2.6.1 Participating in work groups,

 

  5.2.6.2 Department sponsored marketing, outreach, and education, and

 

  5.2.6.3 Communication with CMS.

 

  5.2.7 Provide choice of providers to Dual eligible members in the network and shall not be restricted to those that accept Medicare.

 

  5.2.8 Use all data, including Medicare A, B, and D data, in developing and implementing care coordination models. See Section 8, Medical Management, for care coordination requirements.

 

  5.2.9 The Contractor shall ensure the coordination of care for dual eligible members turning eighteen (18) years of age and for newly eligible dual members transitioning to an Acute Care Contractor for their behavioral health services.

 

5.3 Coordination with AHCCCS Contractors and Primary Care Physicians

For members not eligible to receive physical health care services under this Contract, the Contractor shall:

 

  5.3.1 Coordinate care with AHCCCS contractors and PCPs that deliver services to Title XIX/XXI members 42 CFR 438.208(b)(3-4).

 

  5.3.2 Develop and implement policies and procedures that govern confidentiality, implementation and monitoring of coordination between subcontractors, AHCCCS physical health care contractors, behavioral health providers, and other governmental agencies.

 

  5.3.3 Forward behavioral health records including copies or summaries of relevant information of each Title XIX/XXI member to the member’s PCP as needed to support quality medical management and prevent duplication of services.

 

  5.3.4 For all members referred by the PCP, provide the following member information to the PCP upon request no later than ten (10) days from the request (42 CFR 438.208(b)(3)):

 

  5.3.4.1 The member’s diagnosis,

 

  5.3.4.2 Critical lab results as defined by the laboratory and prescribed medications, and

 

  5.3.4.3 Changes in class of medications.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.3.5 Use the ADHS/DBHS required, standardized forms to transmit the information required in Sections 5.2.3 and 5.2.4.

 

  5.3.6 Obtain proper consent and authorization in conformance with Section 18.11, Consent and Authorization.

 

  5.3.7 Have consultation services and materials available as follows:

 

  5.3.7.1 The Contractor will ensure consultation services are available to health plan PCPs and have materials available for the Acute Care Contractors and primary care providers describing how to access consultation services and how to initiate a referral for ongoing behavioral health services.

 

  5.3.7.2 Behavioral health recipients currently being treated by the Contractor for depression, anxiety or attention deficit hyperactivity disorders may be referred to a PCP (which is not required to be the member’s assigned PCP) for ongoing care only after consultation with and acceptance by the member and the PCP.

 

  5.3.7.3 The Contractor must ensure the systematic review of the appropriateness of decisions to refer members to PCPs for ongoing care for depression, anxiety or attention deficit hyperactivity disorders. Upon request, the Contractor shall ensure that PCPs are informed about the availability of resource information regarding the diagnosis and treatment of behavioral health disorders.

 

  5.3.8 Develop protocols for transition of the member back to the PCP. This coordination must ensure at a minimum, that the member does not run out of prescribed medications prior to the first appointment with the PCP and that all relevant member medical information including the reason for transfer is forwarded to the PCP prior to the member’s first scheduled appointment with the PCP.

 

  5.3.9 Ensure that information and training is available to PCPs regarding behavioral health coordination of care processes.

 

  5.3.10 Meet, at least quarterly, with the AHCCCS Health Plans operating in Greater Arizona and AIHP to address systemic coordination of care issues including at a minimum, sharing information with Health Plans regarding referral and consultation services and solving identified problems.

 

  5.3.11 Assign staff to facilitate the meetings described in Section 5.2.12 who have sufficient program and administrative knowledge and authority to identify and resolve issues in a timely manner.

 

  5.3.12 Have a Physical Health Plan and Provider Coordinator to address and resolve coordination of care issues at the lowest level.

 

  5.3.13 Forward the following information in writing to ADHS/DBHS if the Contractor is unable to resolve issues with AHCCCS Health Plans:

 

  5.3.13.1 The unresolved issue;

 

  5.3.13.2 The actions taken to resolve the issue; and

 

  5.3.13.3 Recommendations for resolution of the issue.

 

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SCOPE OF WORK

ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

5.4 Collaboration with System Stakeholders

The Contractor shall:

 

  5.4.1 Meet, agree upon and reduce to writing collaborative protocols with each of:

 

  5.4.1.1 Arizona Department of Child Safety;

 

  5.4.1.2 Arizona Department of Economic Security/Division of Developmental Disabilities;

 

  5.4.1.3 Arizona Department of Economic Security/Rehabilitative Services Administration;

 

  5.4.1.4 The Veteran’s Administration; and

 

  5.4.1.5 Children’s Rehabilitative Services.

 

  5.4.2 Address in each collaborative protocol, at a minimum, the following:

 

  5.4.2.1 Procedures for each entity to coordinate the delivery of covered services to members served by both entities;

 

  5.4.2.2 Mechanisms for resolving problems;

 

  5.4.2.3 Information sharing;

 

  5.4.2.4 Resources each entity commits for the care and support of members mutually served;

 

  5.4.2.5 Procedures to identify and address joint training needs; and

 

  5.4.2.6 Where applicable, procedures to have providers co-located at Department of Child Safety (DCS) offices, juvenile detention centers or other agency locations as directed by ADHS/DBHS.

 

  5.4.3 Meet, agree upon and reduce to writing collaborative protocols with local law enforcement and first responders, which, at a minimum, shall address:

 

  5.4.3.1 Continuity of covered services during a crisis;

 

  5.4.3.2 Information about the use and availability of Contractor’s crisis response services;

 

  5.4.3.3 Jail diversion and safety;

 

  5.4.3.4 Strengthening relationships between first (1st) responders and providers when support or assistance is needed in working with or engaging members; and

 

  5.4.3.5 Procedures to identify and address joint training needs.

 

  5.4.4 Complete all written protocols and agreements within one hundred and twenty (120) days of Contract Award Date.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.4.5 Review the written protocols on an annual basis with system partners and update as needed.

 

  5.4.6 Submit written protocols to ADHS/DBHS upon request.

 

  5.4.7 Comply with the requirements of the Arizona Early Intervention Program (AzEIP). The AzEIP is implemented through the coordinated activities of the ADES, ADHS, Arizona State Schools for the Deaf and Blind (ASDB), AHCCCS, and ADE. The AzEIP Program is governed by the Individuals with Disabilities Act (IDEA), Part C (P.L.105-17). AzEIP, through federal regulation, is stipulated as the payor of last resort to Medicaid, and is prohibited from supplanting another entitlement program, including Medicaid.

 

  5.4.8 Meet, agree upon and reduce to writing Memorandums of Understanding (MOUs) specific to the following correctional entities:

 

  5.4.8.1 Arizona Administrative Office of the Courts for Juvenile and Adult Probation;

 

  5.4.8.2 The Arizona Department of Corrections for Juvenile and Adults; and

 

  5.4.8.3 The county jails.

 

  5.4.9 At a minimum, shall include the following care coordination requirements. The Contractor shall:

 

  5.4.9.1 Partner with the justice system to communicate timely data necessary for coordination of care in conformance with all applicable administrative orders and Health Insurance Portability and Accountability Act (HIPPA) requirements that permit the sharing of written, verbal and electronic information; and

 

  5.4.9.2 Utilize data sharing agreements and administrative orders that permit the sharing of written, verbal and electronic information at the time of admission into the facility and at the time of discharge. At a minimum, data communicated shall comply with HIPAA requirements and consist of:

 

  5.4.9.2.1 Individual’s Name (FN, MI, LN),

 

  5.4.9.2.2 DOB,

 

  5.4.9.2.3 AHCCCS ID,

 

  5.4.9.2.4 Social Security Number,

 

  5.4.9.2.5 Gender,

 

  5.4.9.2.6 COT Status,

 

  5.4.9.2.7 Public Fiduciary/ Guardianship status,

 

  5.4.9.2.8 Assigned Behavioral Health Provider Agency,

 

  5.4.9.2.9 Assigned Behavioral Health Provider’s Phone Number,

 

  5.4.9.2.10 RBHA Identified Program (SMI, GMH),

 

  5.4.9.2.11 Acute Health Plan/ American Indian Health Plan,

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.4.9.2.12 Primary Care Physician’s Name,

 

  5.4.9.2.13 Primary Care Physician’s Phone Number,

 

  5.4.9.2.14 Diagnoses (Medical and Psychiatric), and

 

  5.4.9.2.15 Medications.

 

  5.4.10 Offer customized training that is designed to strengthen staff’s ability to effectively work with individuals in the correctional facility.

 

  5.4.11 Share information that assists the clinical team in developing treatment plans that incorporate community release conditions, as appropriate.

 

  5.4.12 Policies and procedures that identify specific time frames to have the team (i.e. Correctional Facility, RBHA, Provider and Jail Coordinator) convene to discuss services and resources needed for the individual to safely transition into the community upon release for persons with an SMI diagnosis and those persons categorized as GMH and/or Substance Abuse who have the following complicated/high cost medical needs:

 

  5.4.12.1 Skilled Nursing Facility (SNF) level of care,

 

  5.4.12.2 Continuous oxygen,

 

  5.4.12.3 Invasive treatment for Cancer,

 

  5.4.12.4 Kidney Dialysis,

 

  5.4.12.5 Home Health Services (example- Infusions, Wound Vacs),

 

  5.4.12.6 Terminal Hospice Care,

 

  5.4.12.7 HIV Positive,

 

  5.4.12.8 Pregnant,

 

  5.4.12.9 Insulin Dependent Diabetic, and

 

  5.4.12.10 Seizure Disorder.

 

  5.4.13 Utilize strategies to optimize the use of services in connection with Mental Health Courts and Drug Courts.

 

5.5 Collaboration to Improve Health Care Service Delivery

The Contractor shall:

 

  5.5.1 At least every six (6) months, meet with a broad spectrum of behavioral and physical health providers to gather input; discuss issues; identify challenges and barriers; problem-solve; share information and strategize ways to improve or strengthen the health care service delivery.

 

  5.5.2 Invite ADHS/DBHS and AHCCCS to participate at these meetings.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

5.6 Collaboration with Peers and Family Members

The Contractor shall:

 

  5.6.1 At least every six (6) months, meet with a broad spectrum of peers, family members, peer and family run organizations, advocacy organizations or any other persons that have an interest in participating in improving the system. The purpose of these meetings is to gather input; discuss issues; identify challenges and barriers; problem-solve; share information and strategize ways to improve or strengthen the service delivery system.

 

  5.6.2 Invite ADHS/DBHS and AHCCCS to participate at these meetings.

 

5.7 Collaboration with Tribal Nations

The Contractor shall:

 

  5.7.1 Consult with each Tribal Nation within the assigned Geographic Service Area in Greater Arizona to ensure availability of appropriate and accessible services.

 

  5.7.2 Coordinate eligibility and service delivery between the RBHA, IHS, and tribally owned and operated facilities authorized to provide services pursuant to P.L. 93-638, as amended.

 

  5.7.3 Participate at least annually in meetings or forums with the IHS and tribally owned and operated facilities and providers that serve American Indian members.

 

  5.7.4 Communicate and collaborate with the tribal, county and state service delivery and legal systems and with the Tribal and IHS Providers to coordinate the involuntary commitment process for American Indian members.

 

  5.7.5 Collaborate with ADHS/DBHS and AHCCCS to reach an agreement with Indian Health Services and Phoenix Indian Medical Center to exchange health information, coordinate care and improve health care outcomes for American Indian members.

 

  5.7.6 Develop collaborative relationships with IHS, Tribes, Tribal Organizations, Urban Indian Organizations (I/T/U) serving tribes in the geographical service areas assigned to the RBHA for the purposes of care coordination which may include member data sharing.

 

  5.7.7 Collaborate with ADHS, AHCCCS, IHS in order to improve communication through the utilization of health information exchange in order to improve coordination of care and health outcomes for American Indian members.

 

  5.7.8 Facilitate coordination of care to include face to face meeting with children in residential facilities located off tribal lands, ensuring the child has communication with the tribal community.

 

  5.7.9 Provide continuing education on a quarterly basis, training for para-professionals and behavioral health professionals working on tribal lands. RBHAs shall offer the courses through face to face or telemedicine and provide Continuing Education Units (CEUs) for the completion of the courses electronically.

 

  5.7.10 Develop and provide in-service trainings for I/T/U on utilization of services and behavioral health resources available to American Indian Communities located within the Geographic Service Areas in Greater Arizona.

 

  5.7.11 Develop agreements with the tribes located within the assigned Geographic Service Area in Greater Arizona to provide, on a monthly basis, provision of mobile behavioral health and physical health services.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.7.12 Collaborate with ADHS to implement changes provided from the quarterly Formal Tribal Consultation.

 

  5.7.13 Collaborate with tribes to build technological infrastructure, so that both telemedicine and telepsychiatry can occur on tribal lands which may include partnership with University of Arizona, Northern Arizona University, Arizona State University or other educational entities with community investment dollars that provide telemedicine.

 

  5.7.14 Hold care coordination meetings on a monthly basis between the RBHA, IHS facilities, and tribally owned and operated facilities and the tribes located within their geographic services area to address issues related to crisis and other service delivery issues.

 

5.8 Coordination for Transitioning Members

 

  5.8.1 The Contractor shall comply with the AMPM and the ACOM Policy 402 standards for member transitions between Contractors or GSAs, participation in or discharge from CRS or CMDP, to or from an ALTCS and Acute Care Contractor and upon termination or expiration of a contract.

 

  5.8.2 When a Contractor receives members from another Contractor the Contractor shall:

 

  5.8.2.1 Ensure a smooth transition for members by continuing previously approved prior authorizations for thirty (30) days after the member transition unless mutually agreed to by the member or member’s representative; and

 

  5.8.2.2 When relinquishing members, timely notify the receiving Contractor regarding pertinent information related to any special needs of transitioning members.

 

  5.8.2.3 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 thirty (30) days after the member transition unless mutually agreed to by the member or member’s representative.

 

  5.8.3 For individuals determined to have a Serious Mental Illness (SMI) who are transitioning from a health plan to an Integrated RBHA, there shall be a fourteen (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.

 

  5.8.4 For individuals in Maricopa County who transition to the Contractor for their physical health from a health plan and who have an established relationship with a PCP that does not participate in the Integrated RBHA’s provider network, the Contractor shall ensure that the Integrated RBHA provides, at a minimum, a six 6-month transition period in which the individual may continue to seek care from their established PCP while the individual, the Integrated RBHA and/or case manager finds an alternative PCP within the Integrated RBHA’s provider network.

 

  5.8.5 For individuals outside of Maricopa County (i.e. Greater Arizona) who transition to the Contractor for their physical health from a health plan and who have an established relationship with a PCP that does not participate in an Integrated RBHA’s provider network, the Contractor shall ensure that an Integrated RBHA provides, at a minimum, a twelve 12-month transition period in which the individual may continue to seek care from their established PCP while the individual, an Integrated RBHA and/or case manager finds an alternative PCP within the RBHA’s provider network.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  5.8.6 When individuals transition to an Integrated RBHA for their physical health from a health plan, members in active treatment (including but not limited to chemotherapy, pregnancy, drug regime or a scheduled procedure) with a non-participating/non-contracted provider shall be allowed to continue receiving treatment from the non-participating/non-contracted provider through the duration of their prescribed treatment.

 

  5.8.7 The Contractor shall ensure the coordination of care for dual eligible members turning eighteen (18) years of age and for newly eligible dual members transitioning to an acute Care Contractor for their behavioral health services.

 

6 PROVIDER NETWORK

 

6.1 Network Development

For all populations eligible for services under this Contract, the Contractor shall develop and maintain a network of providers that:

 

  6.1.1 Is sufficient in size, scope and types to deliver all medically necessary covered services and satisfy all service delivery requirements in this Contract (42 CFR 438.206(b)(1)).

 

  6.1.2 Delivers culturally and linguistically appropriate services in home and community-based settings for American Indian members and other culturally and linguistically diverse populations.

 

  6.1.3 Provides timely and accessible services to Medicaid eligible members in the amount, duration and scope as those services are available to Non-Medicaid eligible persons within the same service area (42 CFR 438.210(a)(2)).

 

  6.1.4 Ensures covered services are provided promptly and are reasonably accessible in terms of location and hours of operation.

 

  6.1.5 Places priority on allowing members, when appropriate, to reside or return to their own home and/or reside in the least restrictive environment.

 

  6.1.6 Is designed, established and maintained by utilizing, at a minimum, the following:

 

  6.1.6.1 The number of current and anticipated Title XIX/XXI eligible members;

 

  6.1.6.2 The number of current and anticipated Non-Title XIX SMI eligible members;

 

  6.1.6.3 The number of current and anticipated Non-SMI, Non-Title XIX/XXI members;

 

  6.1.6.4 Current and anticipated utilization of services;

 

  6.1.6.5 Cultural and linguistic needs of members considering the prevalent languages spoken, including sign language, by population (42 CFR 432.10(c));

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  6.1.6.6 The number of providers not accepting new referrals;

 

  6.1.6.7 The geographic location of providers and their proximity to members, considering distance, travel time, the means of available transportation and access for persons with disabilities;

 

  6.1.6.8 Consumer Satisfaction Survey data;

 

  6.1.6.9 Member Grievance, SMI grievance and appeal data;

 

  6.1.6.10 Issues, concerns and requests brought forth by state agencies and other system stakeholders that that have involvement with persons eligible for services under this Contract;

 

  6.1.6.11 Demographic data; and

 

  6.1.6.12 Geo-mapping data.

 

  6.1.7 Responds to referrals twenty-four (24) hours per day, seven (7) days per week (42 CFR 438.206(c)(1)(iii)).

 

  6.1.8 Responds to routine, immediate, and urgent needs within the established timeframes in conformance with the ADHS/DBHS Policy on Appointment Standards and Timeliness of Services (42 CFR 438.206(c)(1)(i)).

 

  6.1.9 For Title XIX/XXI members, provides emergency services on a twenty-four (24) hours a day, seven (7) days a week basis and timely access for routine and emergency services (42 CFR 438.206(c)(1)(i) and(iii)).

 

  6.1.10 Provides evening or weekend access to appointments (42 CFR 438.206(c)(1)(ii)).

 

  6.1.11 Provides all covered services within a continuum of care including crisis services in conformance with the requirements in the Scope of Work Crisis Services Sections 4.13 through 4.17.

 

  6.1.12 Includes peer and family support specialists.

 

  6.1.13 Includes the Arizona State Hospital in accordance with the process described in ADHS/DBHS Policy and Procedure Manual Section on the Arizona State Hospital.

 

  6.1.14 Offers members a choice of providers in conformance with enrollment/disenrollment procedures in the ADHS/DBHS policy on Outreach, Engagement, Re-engagement and Closure.

 

  6.1.15 Includes providers that offer services to both children and adults for members moving from one system of care to another in order to maintain continuity of care without service disruptions or mandatory changes in service providers for those members who wish to keep the same provider.

 

  6.1.16 Includes a sufficient number of locally established, Arizona-based, independent peer/consumer and family operated/run organizations to provide support services, advocacy and training.

 

  6.1.17 Includes specialty service providers to deliver services to children, adolescents and adults with developmental or cognitive disabilities; sexual offenders; sexual abuse victims; individuals with substance use disorders; individuals in need of dialectical behavior therapy; transition aged youth ages eighteen (18) through twenty (20) and infants and toddlers under the age of five (5) years (42 CFR 438.214(c)).

 

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SOLICITATION NO: ADHS15-00004276

 

  6.1.18 Implements E-Prescribing within its provider network.

 

  6.1.19 Develops policies and procedures for telemedicine.

 

  6.1.20 Utilizes telemedicine to support an adequate provider network. Telemedicine shall not replace provider choice and/or member preference for physical delivery.

 

  6.1.21 Develops incentive plans to recruit and retain BHP’s and BHMP’s in the local community.

 

  6.1.22 Does not discriminate regarding participation in the ADHS/DBHS program, reimbursement or indemnification against any provider based solely on the provider’s type of licensure or certification (42 CFR 438.12(a)(1)).

 

  6.1.23 Does not discriminate against particular providers that service high-need 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, provided the needs of Title XIX/XXI members are met. This provision also does not interfere with measures established by the Contractor to control costs consistent with its responsibilities under this Contract (42 CFR 438.12(b)(1)).

 

  6.1.24 Timely notifies providers in writing of the reason for its decision if the Contractor declines to include individual or groups of providers in its network, (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)).

 

  6.1.25 Supports workforce development and medical residency and dental student training programs in the state of Arizona through Graduate Medical Education (GME) Residency Training Programs or other opportunities for resident participation in Contractor medical management and committee activities. In the event of a contract termination between the Contractor and a Graduate Medical Education Residency Training Program or training site, the Contractor may not remove members from that program in such a manner as to harm the stability of the program. ADHS/DBHS reserves the right to determine what constitutes risk to the program. If a Residency Training Program is in need of patients in order to maintain accreditation, ADHS/DBHS may require the Contractor to make members available 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.

 

  6.1.26 Develops a mobile crisis team network where ninety per cent (90%) of all eligible members residing within the GSA will have geographical access to a contracted mobile crisis team within sixty (60) minutes.

 

  6.1.27 Submit an Assurance of Network Adequacy and Sufficiency Report that shall be supported by data to demonstrate the adequacy and sufficiency of its provider network in delivering all medically necessary covered services 42 CFR 438.207(c) Contractor shall include with submission an assurance, signed by its CEO/COO attesting that its network:

 

  6.1.27.1 Offers a full array of service providers to meet the needs of the actual and anticipated number of children, Title XIX/XXI members and Non-Title XIX persons with SMI and the SMI Members receiving physical health care services under this Contract;

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  6.1.27.2 Is sufficient in number, mix, and geographic distribution of providers including crisis providers to meet the accessibility and service needs of the populations under this Contract;

 

  6.1.27.3 Meets all Network Standards set forth in ACOM Policy 415 and ACOM Policy 436, Network Standards; and

 

  6.1.27.4 Is developed, maintained, managed and expanded in conformance with the goals and objectives in the System of Care Plan.

 

  6.1.28 Submit a Provider Network Development and Management Plan in accordance with the AHCCCS Contractor Operations Manual Policy 415 including Network Development and Management Plan Checklist Attachment B, and instructions provided by ADHS/DBHS (42 CFR 438.207(b)). Additional instructions required at a minimum on:

 

  6.1.28.1 Availability of Methadone and Buprenorphine treatment provider sites;

 

  6.1.28.2 Utilization analysis for Developmentally Disabled population; including comprehensive provider network evaluation in totality of DD.

 

  6.1.28.3 Narrative analysis of network adequacy based on ADHS established Minimum Network Standards;

 

  6.1.28.4 Provider network issues that occurred over the prior year that were significant in nature requiring a corrective action plan;

 

  6.1.28.5 Process and procedures relating to wait time monitoring for all required categories; (transportation wait time, office wait time etc.);

 

  6.1.28.6 Description of crisis system, including subcontractors methodology for telephone, mobile, stabilization, walk-in, detoxification, transportation and other service system supports; and

 

  6.1.28.7 Description of network design by GSA for special populations: Developmental Disability, Sex Offender Treatment, Sex Abuse Trauma, Substance Use Disorder Treatment, Infant and Early Childhood Mental Health, Dialectical Behavioral Therapy, Peer Support Services, Family Support Services, AzEIP, Homeless, Border communities, Veterans, and Gender Identity and Sexual Orientation Minorities (GSM).

 

6.2 Network Development for Integrated Health Care Service Delivery

For SMI members eligible to receive physical health care services under this Contract, the Contractor shall develop and maintain a network of providers that comply with ACOM 436 and to maximize member choice; and:

 

  6.2.1 Has accessibility and choice to integrated health care covered services within the following designated distance limits:

 

  6.2.1.1 For urban; Ninety per cent (90%) of SMI members residing within the GSA will be given a choice of at least two appropriate PCP, dentist and pharmacy within the access limit of ten (10) miles or fifteen (15) minutes from residence to the PCP, dentist or pharmacy;

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  6.2.1.2 For rural; Comply with the PCP, dentist and pharmacy requirements as stated in ACOM 436; and

 

  6.2.1.3 Contractor must have subcontracts with a sufficient number of the specified hospitals in the district groupings outlined in AHCCCS Contractor Operations Manual Policy 436-Network Standards.

 

  6.2.2 Maximizes the availability and access to community based primary care and specialty care providers.

 

  6.2.3 Reduces utilization of the following:

 

  6.2.3.1 Non-emergent utilization of emergency room services;

 

  6.2.3.2 Single day hospital admissions;

 

  6.2.3.3 Avoidable hospital re-admissions;

 

  6.2.3.4 Hospital based outpatient surgeries when lower cost surgery centers are available; and

 

  6.2.3.5 Hospitalization for preventable medical conditions.

 

  6.2.4 Has availability of non-emergent after-hours physician services or primary care services.

 

  6.2.5 Complies with the network requirements in Section 7.6, Primary Care Provider Standards.

 

  6.2.6 Complies with the network requirements in Section 7.7, Maternity Care Provider Standards.

 

6.3 Network Management

For all populations eligible for services under this Contract, the Contractor shall:

 

  6.3.1 Monitor providers to demonstrate compliance with all network requirements in this Contract including, at a minimum, the following:

 

  6.3.1.1 Technical assistance and support to consumer-and family-run organizations;

 

  6.3.1.2 Distance traveled; location, time scheduled, and member’s response to an offered appointment for services; and

 

  6.3.1.3 Status of required licenses, registration, certification or accreditation (42 CFR 438.206(1)(iv)).

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  6.3.2 Eliminate barriers that prohibit or restrict advocacy for the following:

 

  6.3.2.1 The member’s health status, medical care or treatment options, including any alternative treatment that may be self-administered (42 CFR 438.102(a)(1)(i));

 

  6.3.2.2 Any information the member needs in order to decide among all relevant treatment options including the risks, benefits, and consequences of treatment or non-treatment (42 CFR 438.102(a)(1)(ii) and(iii)); and

 

  6.3.2.3 The member’s right to participate in health care decisions including the right to refuse treatment, and to express preferences about future treatment decisions (42 CFR 438.102(a)(1)(iv)).

 

  6.3.3 Document in the member’s medical record all communication related to the subject matter in Section 6.3.2.

 

  6.3.4 Continually assess network sufficiency and capacity using multiple data sources to monitor appointment standards, Member Grievances, SMI grievances and appeals, Title XIX/XXI eligibility utilization of services, penetration rates, member satisfaction surveys and demographic data requirements.

 

  6.3.5 Comply with ADHS/DBHS policy on Network Management.

 

  6.3.6 Comply with ADHS/DBHS Behavioral Health Minimum Network Standards, geographic access requirements.

 

  6.3.7 Comply with ADHS/DBHS policy Network Material Changes, for appropriate notification of network material changes.

 

  6.3.8 When feasible, develop non-financial incentive programs to increase participation in its provider network.

 

6.4 Out of Network Providers

For all populations eligible for services under this Contract, the Contractor shall:

 

  6.4.1 Provide adequate, timely and medically necessary covered services through an out-of-network provider if Contractor’s provider network is unable to provide adequate and timely services required under this Contract and continue to provide services by an out of network provider until a network provider is available (42 CFR 438.206(b)(4)).

 

  6.4.2 Coordinate with out-of-network providers for authorization and payment (42 CFR 438.206(b)(4) and (5)).

For SMI members eligible to receive physical health care services under this Contract, the Contractor shall:

 

  6.4.3 Reimburse (non-contracted) providers for non-hospital, non-emergent in State services when directed out of network by the Contractor 1) not less than the AHCCCS capped fee-for-service schedule for physical health services, and 2) at the rate prescribed by ADHS for behavioral health services unless the parties have negotiated different rates.

 

  6.4.4 Permit the provider to become an in network provider at the Contractor’s in network rates.

 

  6.4.5 Offer the provider a single case agreement if the provider is unwilling to become a network provider but is willing to continue providing physical health care services to the SMI member at the Contractor’s in network rates.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

6.5 Notification of Changes to the Network-Request for Approval

 

  6.5.1 For all populations eligible for services under this Contract, the Contractor shall:Be 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)]. Notify and obtain written approval from ADHS/AHCCCS before making any Contractor initiated material changes in the size, scope or configuration of the Contractor’s provider network. 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 five (5%) of members in the GSA to change the location where services are received or rendered.

 

  6.5.2 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. ADHS/DBHS will review and respond to the Contractor within thirty (30) days of the submission. A material change in the Contractor’s provider network requires sixty (60) days advance written notice from the Contractor to members and providers.

 

  6.5.3 Include in its request a description of any short-term gaps identified as a result of the change and the alternatives to address them.

 

  6.5.4 In the event unforeseen circumstances prevent the Contractor from providing sixty (60) days advance written notice to members and providers, the Contractor shall notify ADHS/DBHS within one (1) business day of identifying the material change to the provider network for ADHS/DBHS determination of notification requirements.

 

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

 

  6.5.6 Issue notice in writing to providers denied from participating in the Contractor’s network, including a reason for the Contractor’s decision [42 CFR 438.12].

 

6.6 Notification of Changes to the Network

 

  6.6.1 Submit notification to ADHS/DBHS for network changes that impact crisis services, residential and/or other services that relate to where a members resides in the provider network, within three (3) days of provider initiated changes, forty five (45) days prior to the expected implementation of the change.

 

6.7 Network Reporting Requirements

 

  6.7.1 For all populations eligible for services under this Contract, the Contractor shall submit the deliverables related to its Provider Network in accordance with Exhibit 9.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

7 PROVIDER REQUIREMENTS

 

7.1 Provider General Requirements

The Contractor shall:

 

  7.1.1 Hold a Provider Forum no less than quarterly. 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 ADHS/DBHS upon request.

 

  7.1.2 Report information discussed during these Forums to Executive Management within the organization.

 

  7.1.3 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 ADHS/DBHS.

 

7.2 Provider Registration Requirements

The Contractor shall:

 

  7.2.1 Require subcontracted providers to have a license, registration, certification or accreditation in conformance with the ADHS/DBHS Covered Behavioral Health Services Guide, or other state or federal law and regulations.

 

  7.2.2 Require through verification and monitoring that subcontracted providers:

 

  7.2.3 Register with AHCCCS as applicable or in conformance with the ADHS/DBHS Covered Behavioral Health Services Guide;

 

  7.2.4 Sign the Provider Participation Agreement;

 

  7.2.5 Obtain a unique National Provider Identifier (NPI); and

 

  7.2.6 For specific requirements on Provider Registration, refer to the AHCCCS website at: http://www.azahcccs.gov/commercial/ProviderRegistration/registration.aspx.

 

7.3 Provider Manual Policy Requirements

The Contractor shall:

 

  7.3.1 Develop, distribute and maintain a Provider Manual consistent with the requirements in the ADHS/DBHS Policy and Procedures Manual.

 

  7.3.2 Add the Contractor’s specific provider operational requirements and information into an electronic version of the Provider Manual.

 

  7.3.3 Transmit copies to ADHS/DBHS on all communication regarding updates to Contractor’s Provider Manual.

 

  7.3.4 Obtain ADHS/DBHS prior approval for any Provider Manual content created or deleted by the Contractor that result in material changes to operations or directly impacts members.

 

  7.3.5 Add Contractor-specific policies that the Contractor requires in the Provider Manual.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  7.3.6 Complete and disseminate Provider Manual changes to all subcontracted providers no later than the effective date indicated.

 

  7.3.7 Modify practice in accordance with the new or revised Provider Manual policies by the effective date.

 

  7.3.8 Post an electronic version of the Provider Manual policies to the Contractor’s web site and make hard copies available upon request.

 

  7.3.9 Require subcontracted providers to utilize the Contractor-specific version of the Provider Manual for the provision of covered behavioral health services.

 

  7.3.10 Permit subcontracted providers to add detail to the specific requirements established by the Contractor; but shall prohibit provider policies that are contrary or redundant to content already established in the Contractor Provider Manual.

 

  7.3.11 Maintain the Contractor Provider Manual to be consistent with federal and state laws that govern member rights when delivering services, including the protection and enforcement, at a minimum, of a person’s right to the following:

 

  7.3.11.1 Be treated with respect and due consideration for his or her dignity and privacy (42 CFR 100.(b)(2)(ii));

 

  7.3.11.2 Receive information on available treatment options and alternatives, presented in a manner appropriate to the member’s condition and ability to understand (42 CFR 100(b)(2)(iii));

 

  7.3.11.3 Participate in decisions regarding his or her health care, including the right to refuse treatment (42 CFR 100(b)(2)(iv));

 

  7.3.11.4 Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation (42 CFR 100(b)(2)(v));

 

  7.3.11.5 Request and receive a copy of his or her medical records, and to request that they be amended or corrected, as specified in 45 CFR part 164 and applicable state law (42 CFR 100(b)(2)(vi)); and

 

  7.3.11.6 Exercise his or her rights and that the exercise of those rights shall not adversely affect service delivery to the member (42 CFR 438.100(c)).

 

  7.3.12 Consistent with the above Section 7.3.5 include the following policies:

 

  7.3.12.1 A description of sanctions for noncompliance with provider subcontract requirements;

 

  7.3.12.2 Financial management, audit and reporting, and disclosure;

 

  7.3.12.3 Fraud, waste, and abuse and Corporate Compliance;

 

  7.3.12.4 Quality Management, including annual Quality Management Plan, Quality Management work plan and evaluation of outcomes;

 

  7.3.12.5 Medical Management/Utilization Management, including annual Medical Management Plan, Medical Management work plan and evaluation of outcomes;

 

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SOLICITATION NO: ADHS15-00004276

 

  7.3.12.6 Special service delivery systems;

 

  7.3.12.7 Responsibility for clinical oversight and point of contact;

 

  7.3.12.8 Inter-rater reliability to assure the consistent application of coverage criteria;

 

  7.3.12.9 Overview of the Contractor’s Provider Service department and function;

 

  7.3.12.10 Emergency room utilization guidelines, including appropriate and inappropriate use of the emergency room;

 

  7.3.12.11 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services in conformance with the scope of work Section 4.7.6, including a description of dental services coverage and limitations and the other EPSDT requirements in the scope of work;

 

  7.3.12.12 Maternity services in conformance with Physical Health scope of work Section 4.7 Maternity and Section 7.7 Maternity Care Provider Standards;

 

  7.3.12.13 Family Planning services in conformance with scope of work Section 7.7.21, Family Planning;

 

  7.3.12.14 PCP assignments;

 

  7.3.12.15 Physical and behavioral health coordination of care;

 

  7.3.12.16 Referrals to specialists and other providers that include, criteria, processes, responsible parties and meets the minimum requirements for the forwarding of member medical information;

 

  7.3.12.17 Claims medical review;

 

  7.3.12.18 Medication management services; and

 

  7.3.12.19 Appointment standards; and wait times for transportation for medical and behavioral health services.

 

  7.3.13 TXIX/XXI SMI Member Transition policies on:

 

  7.3.13.1 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.;

 

  7.3.13.2 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;

 

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

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  7.3.13.4 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;

 

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

 

  7.3.13.6 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); and

 

  7.3.13.7 Any members transitioning to CMDP.

 

7.4 Provider Manual Policy Network Requirements

The Contractor shall, consistent with the Scope of Work Provider Manual Policy Requirements Section 7.3, include the following Provider Network Policies and Procedures (42 CFR 438.214):

 

  7.4.1 Provider selection and retention criteria (42 CFR 438.214(a));

 

  7.4.2 Communication with providers regarding contractual and program changes and requirements;

 

  7.4.3 Monitoring and maintaining providers’ compliance with AHCCCS and ADHS/DBHS policies and rules, including grievance system requirements and ensuring member care is not compromised during the grievance/appeal process;

 

  7.4.4 Evaluating the network for delivery of quality of covered services;

 

  7.4.5 Providing or arranging for medically necessary covered services should the network become temporarily insufficient;

 

  7.4.6 Monitoring the adequacy, accessibility and availability of the Provider Network to meet the needs of the members, including the provision of culturally and linguistically competent care to members with limited proficiency in English;

 

  7.4.7 Monitoring network capacity to have sufficient qualified providers to serve all members and meet their specialized needs;

 

  7.4.8 Processing expedited and temporary credentials;

 

  7.4.9 Recruiting, selecting, credentialing, re-credentialing and contracting with providers in a manner that incorporates quality management, utilization, office audits and provider profiling;

 

  7.4.10 Ensure a process is in place to monitor provider credentialing issues during non-re-credentialing years;

 

  7.4.11 Providing training for its providers and maintaining records of such training;

 

  7.4.12 Tracking and trending provider inquiries/complaints/requests for information and taking systemic action as necessary and appropriate;

 

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SOLICITATION NO: ADHS15-00004276

 

  7.4.13 Ensuring that provider calls are acknowledged within three (3) business days of receipt, are resolved and the result communicated to the provider within thirty (30) business days of receipt (includes referrals from ADHS/DBHS or AHCCCS);

 

  7.4.14 Service accessibility, including monitoring appointment standards, appointment waiting times and service provision standards;

 

  7.4.15 Guidelines to establish reasonable geographic access to service for members;

 

  7.4.16 Collecting information on the cultural and linguistic needs of communities and that the Provider Network adequately addresses identified cultural and linguistic needs; and

 

  7.4.17 Provider capacity by provider type needed to deliver covered services.

 

7.5 Specialty Service Providers

The Contractor shall:

 

  7.5.1 Cooperate with AHCCCS, which may at any time negotiate or contract on behalf of the Contractor and ADHS/DBHS for specialized hospital and medical services such as transplant services, anti-hemophilic agents and pharmaceutical related services. Existing Contractor resources will be considered in the development and execution of specialty contracts.

 

  7.5.2 Modify its service delivery network to accommodate the provisions of specialty contracts when required by ADHS/DBHS. ADHS/DBHS may waive this requirement in particular situations if such action is determined to be in the best interest of the state.

 

  7.5.3 Not include in capitation rates development or risk sharing arrangement of any reimbursement exceeding that payable under the relevant AHCCCS specialty contract.

 

  7.5.4 Cooperate with ADHS/DBHS and AHCCCS during the term of specialty contracts if ADHS/DBHS or AHCCCS acts as an intermediary between the Contractor and specialty Contractors to enhance the cost effectiveness of service delivery and medical management.

 

  7.5.5 Be responsible for adjudication of claims related to payments provided under specialty contracts. AHCCCS may provide technical assistance prior to the implementation of any specialty contracts.

 

  7.5.6 Be given at least sixty (60) days advance written notice prior to the implementation of any specialty contract.

 

7.6 Primary Care Provider Standards

For SMI members eligible to receive physical health care services, the Contractor shall:

 

  7.6.1 Have a sufficient number of PCPs in its Provider Network to meet the requirements of this Contract.

 

  7.6.2 Have Arizona licensed PCPs as allopathic or osteopathic physicians in its Provider Network that 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)).

 

  7.6.3 When determining assignments to a PCP:

 

  7.6.3.1 Assess the PCP’s ability to meet ADHS/DBHS appointment availability and other standards;

 

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SOLICITATION NO: ADHS15-00004276

 

  7.6.3.2 Consider the PCP’s total panel size;

 

  7.6.3.3 Adjust the size of a PCP’s panel, as needed, for the PCP to meet ADHS/DBHS appointment and clinical performance standards; and

 

  7.6.3.4 Be informed by ADHS/DBHS when a PCP has a panel of more than 1,800 AHCCCS members to assist in the assessment of the size of its panel.

 

  7.6.4 Monitor PCP assignments so that each member is assigned to an individual PCP and that the Contractor’s data regarding PCP assignments is current.

 

  7.6.5 Assign members diagnosed with AIDS or as HIV positive to PCPs that comply with criteria and standards set forth in the AHCCCS Medical Policy Manual.

 

  7.6.6 Educate and train providers serving EPSDT members to utilize AHCCCS-approved EPSDT Tracking Forms.

 

  7.6.7 Offer members freedom of choice in selecting a PCP within the network (42 CFR 438.6(m)) and 438.52(d). 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).

 

  7.6.8 Members will have a choice of at least two primary care providers, and may request change of primary care provider at least at the times described in (42 CFR 438.56(c). In addition, the Contractor shall offer contracts to primary and specialist physicians who have established relationships with beneficiaries including specialists who may also serve as PCPs to encourage continuity of provider. For individuals who have an established relationship with a PCP that does not participate in the Contractor’s provider network, the Contractor will provide, at a minimum, a 12-month transition period in which the individual may continue to seek care from their established PCP while the individual, the Contractor and/or case manager finds an alternative PCP within the Contractor’s provider network.

 

  7.6.9 Not restrict PCP choice unless the 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.

 

  7.6.10 Inform the member in writing of his or her enrollment and PCP assignment within ten (10) days of the Contractor’s receipt of notification of a new member assignment by ADHS/DBHS.

 

  7.6.10.1 Include with the notification required in Section 7.6.9;

 

  7.6.10.2 A list of all the Contractor’s available PCPs;

 

  7.6.10.3 The process for changing the PCP assignment; and

 

  7.6.10.4 Information required in the AHCCCS Contractor Operations Manual Member Information Policy.

 

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SOLICITATION NO: ADHS15-00004276

 

  7.6.11 Inform the member in writing of any PCP change.

 

  7.6.12 Allow members to make the initial PCP selection and any subsequent PCP changes verbally or in writing.

 

  7.6.13 Hold the PCP responsible, at a minimum, for the following activities (42 CFR 438.208(b)(1)):

 

  7.6.13.1 Supervision, coordination and provision of care to each assigned member; except for dental services provided to EPSDT members without a PCP referral;

 

  7.6.13.2 Initiation of referrals for medically necessary specialty care;

 

  7.6.13.3 Maintaining continuity of care for each assigned member;

 

  7.6.13.4 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;

 

  7.6.13.5 Utilizing the AHCCCS approved EPSDT Tracking Forms;

 

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

 

  7.6.13.7 In lieu of developing a medical record when behavioral health information is received on a member not yet seen by the PCP, a separate file may be established to hold behavioral health information. The behavioral health information must be added to the member medical record when the member becomes an established patient; and

 

  7.6.13.8 Enrolling as a Vaccines for Children (VFC) provider for members, age eighteen (18) only.

 

  7.6.14 Develop and implement policies and procedures to monitor PCP activities.

 

  7.6.15 Develop and implement policies and procedures to notify and provide documentation to PCPs for specialty and referral services available to members by specialty physicians, and other health care professionals.

 

7.7 Maternity Care Provider Standards

For SMI members receiving physical health care services under this Contract that are pregnant, the Contractor shall:

 

  7.7.1 Designate a maternity care provider for each pregnant member for the duration of her pregnancy and postpartum care to deliver maternity services in conformance with the AHCCCS Medical Policy Manual.

 

  7.7.2 Arizona licensed allopathic and/or osteopathic physicians that are Obstetricians or general practice/family practice providers to provide maternity care services in the provider network:

 

  7.7.2.1 Physician Assistants,

 

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  7.7.2.2 Nurse Practitioners,

 

  7.7.2.3 Certified Nurse Midwives, and

 

  7.7.2.4 Licensed Midwives.

 

  7.7.3 Offer pregnant members a choice or be assigned, a PCP that provides obstetrical care consistent with the freedom of choice requirements for selecting health care professionals so as not to compromise the member’s continuity of care.

 

  7.7.4 Allow members anticipated to have a low-risk delivery, the option to 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.

 

  7.7.5 Allow members anticipated to have a low-risk prenatal course and delivery the option to elect to receive prenatal care, labor and delivery and postpartum care by certified nurse midwives or licensed midwives.

 

  7.7.6 For members receiving maternity services from a certified nurse midwife or a licensed midwife, assign a PCP to provide other health care and medical services. A certified nurse midwife may provide those 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 also elect to receive some or all her primary care from the assigned PCP. Licensed midwives may not provide any additional medical services as primary care that is not within their scope of practice.

 

  7.7.7 Require all physicians and certified nurse midwives who perform deliveries to have OB hospital privileges or a documented hospital coverage agreement for those practitioners performing deliveries in alternate settings. Licensed midwives perform deliveries only in the member’s home. Physicians, certified nurse practitioners and certified nurse midwives within the scope of their practice, may provide labor and delivery services in the member’s home.

 

  7.7.8 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. However, for payment purposes, inpatient limits will apply to the extent consistent with EPSDT.

 

  7.7.9 Submit Maternity Care Deliverables in accordance with Exhibit 9.

 

7.8 Federally Qualified Health Centers and Rural Health Clinics

The Contractor shall:

 

  7.8.1 Use Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) and FQHC look-alikes in Arizona to provide covered services. The PPS rate is an all-inclusive per visit rate.

 

  7.8.2 Ensure compliance with the requirement of 42 USC 1396 b (m)(2)(A)(ix) which requires 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:

 

  7.8.3 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 for dates of service from October 1, 2014 through March 31, 2015.

 

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  7.8.4 Negotiate sub-capitated agreements comparable to the unique PPS rates, to FQHCs/RHCs and FQHC Look-Alikes for dates of service on and after April 1, 2015.

 

  7.8.5 Be aware that ADHS/DBHS reserves the right to require the Contractor to pay FQHCs/RHCs and FQHC Look-Alikes unique, cost based Prospective Payment System (PPS) rates for the majority, but not all, of non-pharmacy Medicaid covered services or negotiate sub- capitated agreements comparable to the unique PPS rates for PPS eligible services.

 

  7.8.6 For services not eligible for PPS reimbursement, ADHS/DBHS reserves the right to require the Contractor to negotiate rates of payment with FQHCs/RHCs and FQHC look-alikes for non-pharmacy services that are comparable to the rates paid to providers that provide similar services.

 

  7.8.7 Be aware that ADHS/DBHS reserves the right to review a Contractor’s negotiated rates with an FQHC/RHC or FQHC look-alike for reasonableness and to require adjustments when negotiated rates are found to be substantially less than those being paid to other, non-FQHC/RHC or FQHC look-alike providers for comparable services or not equal to or substantially less than the PPS rates.

 

  7.8.8 For FQHC and FQHC Look-Alike pharmacies, all 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. These drugs shall be reimbursed at the lesser of the two amounts above plus a dispensing fee. See AHCCCS rule R9-22-710 (C) for further details.

 

  7.8.9 Submit member information, if required, for each FQHC/RHC and FQHC look-alike on a quarterly basis as a part of the financial statement reporting package due to ADHS/DBHS thirty (30) days after the quarter or forty (40) days after September 30th. ADHS/DBHS will perform periodic audits of the member information submitted.

 

7.9 Homeless Clinics:

The Contractor shall:

 

  7.9.1 Utilize the AHCCCS Fee-for-Service rate for Primary Care Services when contracting with the homeless clinics within the Geographic Service Area in Greater Arizona. Contracts must stipulate that:

 

  7.9.1.1 Only those members that request a homeless clinic as a PCP may be assigned to them; and

 

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

 

  7.9.2 Make resources available to assist homeless clinics with administrative issues such as obtaining Prior Authorization, and resolving claims issues.

 

  7.9.3 Recognize that ADHS will convene meetings, as necessary, with the Contractor and the homeless clinics to resolve administrative issues and perceived barriers to the homeless members receiving care. Representatives from the Contractor must attend these meetings.

 

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8 MEDICAL MANAGEMENT

 

8.1 General Requirements

For all populations eligible to receive services under this Contract, the Contractor shall:

 

  8.1.1 Implement, monitor, evaluate and comply with applicable requirements in the ADHS/DBHS Policy and Procedure Manual, Exhibit 7, ADHS/DBHS Bureau of Quality and Integration (BQ&I) Specifications Manual, and Exhibit 7, AHCCCS Medical Policy Manual, Chapter 1000.

 

  8.1.2 Develop an annual Medical Management (MM) Plan, evaluation, and work plan that includes:

 

  8.1.2.1 Short- and long-term strategies for improving care coordination using the physical and behavioral health care data available for members with behavioral health needs;

 

  8.1.2.2 Criteria to stratify data to identify high need/high cost members within six months of contract implementation;

 

  8.1.2.3 Strategies on how the Contractor will collaborate with AHCCCS Health Plans and AIHP in their assigned GSA with at-least semi-monthly meeting to identify and jointly manage shared members that would benefit from intervention and care coordination to improve health outcomes. Contractor shall report every six (6) months to ADHS and AHCCCS regarding criteria to identify members, count of members and outcomes;

 

  8.1.2.4 Proposed interventions to improve health care outcomes, such as developing care management strategies to work with acute care providers to coordinate care;

 

  8.1.2.5 A minimum of one measurable short and long term goal, such as performance indicators, designed to determine the impact of applied interventions such as reduced emergency room visits (all cause, inpatient admissions (all cause), and readmission rates (all cause);

 

  8.1.2.6 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 Medical Management/Utilization Management (MM/UM) Plan and Evaluation submitted to ADHS as specified in Exhibit 9; and

 

  8.1.2.7 A summary of the prior authorization requirement changes and the rationale for those changes must be included in the annual MM/UM Plan and Evaluation submission.

 

  8.1.3 Monitor subcontractors’ medical management activities for compliance with federal regulations, AHCCCS and ADHS/DBHS requirements, and adherence to Contractor’s Medical Management (MM) Plan, evaluation and work plan.

 

  8.1.4 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.

 

  8.1.5

Establish a Medical and Utilization Management (MM/UM) unit within its organizational structure that is separate and distinct from any other units or departments such as

 

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  Quality Management and shall 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)].

 

  8.1.6 Establish a MM/UM Committee, Pharmacy and Therapeutics (P&T) subcommittee and other subcommittees under the MM/UM Committee.

 

  8.1.7 Require the MM/UM Committee and P&T subcommittee to meet at least quarterly and be chaired by the Chief Medical Officer.

 

  8.1.8 Report Medical Management data and management activities through the MM/UM Committee to analyze the data, make recommendations for action, monitor the effectiveness of actions and report these findings to the Committee.

 

  8.1.9 Provide subcontractors and providers with technical assistance regarding medical management as needed and consider corrective action and sanctions, for subcontractors who consistently fail to meet medical management objectives, including, at a minimum, compliance with medical management requirements and the submission of complete, timely and accurate utilization or medical management reports and data.

 

  8.1.10 Coordinate and implement any necessary clinical interventions or service plan revisions in the event a particular member is identified as an outlier.

 

  8.1.11 Utilize an Arizona licensed dentist to review complex cases involving dental services or when reviewing or denying dental services.

 

  8.1.12 Have the discretion to utilize a person with expertise in dental claims management for matters related to dental services not covered in Section 8.1.11.

 

  8.1.13 Must proactively provide care coordination for members who have both behavioral health and physical health needs. The Contractor must meet regularly with the Acute Care, DES/DDD and CMDP Contractors to improve and address coordination of care issues. Meetings shall occur at least every other month or more frequently if needed to develop process, implement interventions, and discuss outcomes. Care coordination meetings and staffings shall occur at least monthly or more often as necessary to affect change.

The Contractor shall implement and report the following:

 

  8.1.14 Identify High Need/High Cost members for each Acute Care contractor in each RBHA Geographic Service Area, in accordance with the standardized criteria developed by the AHCCCS/Contractor workgroup;

 

  8.1.14.1 Members included in the High Need/High Cost Program prior to October 1, 2015 must be included in the ongoing High Need/High Cost Program.

 

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

 

  8.1.16 Report outcome summaries utilizing the standardized template developed by the AHCCCS/Contractor workgroup as specified in Exhibit-9.

 

  8.1.17 High Need/High Cost Program: From October 1, 2015 through December 31, 2015, the Contractor shall collaborate with the Acute Care Contractors to select members for the High Need/High Cost Program and plan interventions to be effective January 1, 2016. The Contractor is required to include the number of members indicated below, by RBHA Geographic Service Area.

 

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# of High Need/High Cost Members

RBHA

Geographic

Service Area

 

Health Choice Integrated Care

(HCIC)

 

Cenpatico Integrated Care

(C-IC)

 

Mercy Maricopa Integrated Care

(MMIC)

Maricopa      

Care1st – 30

Health Choice – 30

Health Net Access – 30

Maricopa Health Plan – 30

Phoenix Health Plan – 30

UnitedHealthcare Comm. Plan – 50

Mercy Care Plan – 70

*Northern  

University Family Care – 20

Health Choice – 40

UnitedHealthcare Comm. Plan-40

   
**Southern    

Care1st – 25

Mercy Care Plan – 25

Health Choice – 30

University Family Care – 50

UnitedHealthcare Comm. Plan – 50

 
AIHP - Statewide   20   40   20
CMDP - Statewide   5   5   10
 

 

 

 

 

 

Total   125   225   300
 

 

 

 

 

 

 

* 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

 

  8.1.18 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 Manual.

 

  8.1.19 Hospital Holds (Behavioral Health Crisis Facilities):

 

  8.1.19.1 Less than 10% hospital hold monthly for each facility. (UPC and RRC)

 

  8.1.19.2 Less than 5% concurrent hospital hold monthly.

 

  8.1.20 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/UM Plan submission. An attestation that the annual review has been completed must be submitted in accordance with Exhibit 9 of this contract.

 

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8.2 Utilization Data Analysis and Data Management

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.2.1 Develop a process to collect, monitor, analyze, evaluate and report utilization data consistent with the ADHS/DBHS BQ&I Specifications Manual.

 

  8.2.2 ADHS and AHCCCS will provide the Contractor:

 

  8.2.2.1 Three (3) years of historical Acute Care Program encounter data for members enrolled with the Contractor as of December 1, 2015; and

 

  8.2.2.2 A claims data file of physical health encounters for all General Mental Health, Children’s and non-integrated members with serious mental illness enrolled with the Contractor, for purposes of care coordination, on a recurring basis.

 

  8.2.3 At a minimum, review and analyze the following data elements, interpret the variances, review outcomes and develop and/or approve interventions based on the findings:

 

  8.2.3.1 Under and over utilization of service and cost data;

 

  8.2.3.2 Avoidable hospital admissions and readmission rates and the Average Length of Stay (ALOS) for all psychiatric inpatient facilities for all members receiving behavioral health services;

 

  8.2.3.3 Medical facilities for Medicaid eligible SMI members receiving physical health care services;

 

  8.2.3.4 Follow up after discharge;

 

  8.2.3.5 Outpatient civil commitments;

 

  8.2.3.6 Emergency Department (ED) utilization and crisis services use;

 

  8.2.3.7 Prior authorization/denial and notices of action;

 

  8.2.3.8 Pharmacy utilization;

 

  8.2.3.9 Laboratory and diagnostic utilization; and

 

  8.2.3.10 Medicare utilization.

 

  8.2.4 Utilize data to assist with identifying members in need of medical management.

 

  8.2.5 Ensure intervention strategies have measurable outcomes and are recorded in the UM/MM Committee meeting minutes.

 

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8.3 Prior Authorization

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.3.1 Identify and communicate to providers and members those services that require authorization and the relevant clinical criteria required for authorization decisions.

 

  8.3.2 Authorize services in conformance with Section 4.2.2.

 

  8.3.3 Consult with the provider requesting authorization when appropriate.

 

  8.3.4 Specify timeframes for responding to requests for initial and continuous determinations for standard and expedited authorization requests (42 CFR.438.210).

 

  8.3.5 Make decisions based on adopted national standards or a consensus of relevant healthcare professionals.

 

  8.3.6 Monitor members with special health care needs for direct access to care.

 

  8.3.7 Have a process in place for authorization determinations when Contractor is not the primary payor.

 

  8.3.8 Assess, monitor and report quarterly through the MM/UM Committee medical decisions to assure compliance with timeliness and Notice of Action (NOA) intent, and that the decisions comply with all Contractor coverage criteria. This includes quarterly evaluation of all NOA decisions that are made by a subcontractor.

 

  8.3.9 Ensure medically necessary services are provided in a timely manner through the review of prior authorization requests received for benefit coverage and clinical appropriateness while confirming potential for third-part coverage.

 

  8.3.10 Comply with Chapter 1000 of the AHCCCS Medical Policy Manual (AMPM), http://www.ahcccs.state.az.us, the ADHS/DBHS MM/UM Plan, and QM/MM/UM Performance Improvement Specifications Manual.

 

8.4 Concurrent Review

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.4.1 Develop and implement procedures for review of medical necessity prior to a planned institutional admission.

 

  8.4.2 Develop and implement procedures for determining medical necessity for ongoing institutional care (42 CFR 438.210(b)(1)).

 

  8.4.3 Specify timeframes and frequency for conducting concurrent review.

 

  8.4.4 Make decisions on coverage based on adopted national standards or a consensus of relevant healthcare professionals.

 

8.5 Additional Authorization Requirements

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.5.1 Require admission and continued stay authorizations for members in Level I inpatient facilities including Residential Treatment Centers (RTC), Level I sub-acute facilities, Behavioral Health Residential Facilities and Home Care Training to Home Care Client (HCTC) facilities are conducted by a physician or other qualified health care professional.

 

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SOLICITATION NO: ADHS15-00004276

 

  8.5.2 Require a health care professional who has appropriate expertise in treating the condition to review and approve any decision that determines the criteria for admission or continued stay is not met prior to issuing a decision (42 CFR 438.210(b)(3)).

 

  8.5.3 Comply with member notice requirements in the ADHS/DBHS Policy on Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI).

 

  8.5.4 Require consistent application of standardized review criteria in making authorization decisions on requests for initial and continuing authorizations of services and consult with the requesting provider when appropriate (42 CFR 438.210(b)(i) and (ii)).

 

8.6 Discharge Planning

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.6.1 Develop and implement policies and procedures for proactive discharge planning when members have been admitted into inpatient facilities even when the Contractor is not the primary payor.

 

8.7 Inter- rater Reliability

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.7.1 Develop and implement a process to ensure consistent application of review criteria in making medical necessity decisions which include prior authorization, concurrent review, and retrospective review.

 

  8.7.2 Monitor the staff involved in these processes receive inter-rater reliability training and testing within ninety (90) days of hire and annually thereafter.

 

8.8 Retrospective Review

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.8.1 Develop and implement a process or policy describing services requiring retrospective review.

 

8.9 Practice Guidelines

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.9.1 Adopt and disseminate to providers, members and potential members upon request, Clinical Practice Guidelines based on reliable clinical evidence or a consensus of health care professionals in the field that consider member needs; (42 CFR 438.236(c)).

 

  8.9.2 Review Clinical Practice Guidelines annually in the MM/UM Committee and in conjunction with contracted providers to determine if the guidelines remain applicable and reflect the best practice standards. (42 CFR 438.236(b)).

 

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8.10 New Medical Technologies and New Uses of Existing Technologies

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.10.1 Develop and implement policies and procedures for evaluation of new medical technologies and new uses of existing technologies on a case by case basis to allow for individual members’ needs to be met.

 

  8.10.2 Evaluate peer-reviewed medical literature that includes well designed investigations reproduced by non-affiliated authoritative sources with measurable results and with positive endorsements by national medical bodies regarding scientific efficacy and rationale.

 

  8.10.3 Obtain ADHS/DBHS approval prior to implementing new technologies and/or new use of existing technologies Comply with the timelines prescribed if the new medical technology is a Prior Authorization request

 

  8.10.4 Have a website with links to the information as described in ACOM Policy 404 and 416.

 

8.11 Care Coordination

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.11.1 Comply with all requirements in Sections 5, Care Coordination and Collaboration.

 

  8.11.2 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.

 

  8.11.3 Ensure the provision of appropriate services in acute, home, chronic, and alternative care settings that meet the members’ needs in the most cost effective manner available.

 

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

 

  8.11.5 Address, document, refer, and/or follow up on each member’s health status, changes in health status, health care needs, and health care services provided.

 

  8.11.6 Include the health risk assessment tool in the new member welcome packet.

 

  8.11.7 Meet regularly with the Acute Care, DES/DDD and CMDP Contractors to improve and address coordination of care issues. Meetings shall occur at least every other month or more frequently if needed to develop process, implement interventions, and discuss outcomes. Care coordination meetings and staffings shall occur at least monthly or more often as necessary to affect change.

 

8.12 Disease Management

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.12.1 Develop and implement a program that focuses on members with high risk and/or chronic conditions that include a concerted intervention plan, including interventions targeting chronic behavioral and physical health conditions such as, but not limited to, depression, bi-polar disorder, schizophrenia, cardiac disease, chronic heart failure, chronic obstructive pulmonary disease, diabetes mellitus and asthma.

 

  8.12.2 Ensure the goal of the program is to employ strategies such as health coaching and wellness to facilitate behavioral change to address underlying health risks and to increase member self-management as well as improve practice patterns of providers, thereby improving healthcare outcomes for members.

 

  8.12.3 Develop methodologies to evaluate the effectiveness of programs including education specifically related to the identified member’s ability to self-manage disease and measurable outcomes.

 

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8.13 Care Management Program-Goals

Care Management is essential to successfully improving healthcare outcomes for a specifically defined segment of Title XIX eligible SMI members receiving physical health care services under this Contract. Care Management is designed to cover a wide spectrum of episodic and chronic health care conditions for members in the top tier of high need/high cost members with an emphasis on proactive health promotion, health education, disease management, and self-management resulting in improved physical and behavioral health outcomes. Care Management is an administrative function and not a billable service. It is performed by the Contractor’s Care Managers. While Care Managers can provide consultation to a member’s Treatment Team, they should not perform the day-to-day duties of case management or service delivery.

The primary goals of the Contractor’s Care Management program are as follows:

 

  8.13.1 Identify the top tier of high need/high cost members with serious mental illness in a fully integrated health care program (estimated at twenty per cent (20%));

 

  8.13.2 Effectively transition members from one level of care to another;

 

  8.13.3 Streamline, monitor and adjust members’ care plans based on progress and outcomes;

 

  8.13.4 Reduce hospital admissions and unnecessary emergency department and crisis service use; and

 

  8.13.5 Provide members with the proper tools to self-manage care in order to safely live work and integrate into the community.

 

8.14 Care Management Program-General Requirements

For SMI members receiving physical health care services under this Contract, the Contractor shall:

 

  8.14.1 Establish and maintain a Care Management Program (CMP). See Exhibit 1, Definitions for an explanation of “Care Management Program”.

 

  8.14.2 Have the following capability for the top tier of high need/ high cost SMI members:

 

  8.14.2.1 On an ongoing basis, utilize tools and strategies to stratify all SMI members into a case registry, which at a minimum, shall include:

 

  8.14.2.1.1 Diagnostic classification methods that assign primary and secondary chronic co-morbid conditions;

 

  8.14.2.1.2 Predictive models that rely on administrative data to identify those members at a high risk for over utilization of behavioral health and physical health services, adverse events, and high costs;

 

  8.14.2.1.3 Incorporation of health risk assessment into predictive modeling in order to tier members into categories of need to design appropriate levels of clinical intervention, especially for those members with the most potential for improved health-related outcome and more cost effective treatment;

 

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  8.14.2.1.4 Criteria for identifying the top tier of high cost, high need members for enrollment into the Care Management Program; and

 

  8.14.2.1.5 Criteria for disenrolling members from the Care Management Program.

 

  8.14.3 Assign and monitor Care Management caseloads based upon national standards and consistent with a member’s acuity and complexity of need for Care Management.

 

  8.14.4 Allocate Care Management resources to members consistent with acuity, and evidence-based outcome expectations.

 

  8.14.5 Provide technical assistance to Care Managers including case review, continuous education, training and supervision.

 

  8.14.6 Communicate Care Management activities with all of Contractor’s organizational units with emphasis on regular channels of communication with Contractor’s Medical Management, Quality Management and Provider Network departments.

 

  8.14.7 Have Care Managers who, at a minimum, shall be required to complete a comprehensive case analysis review of each member enrolled in Contractor’s Care Management Program on a quarterly basis. The case analysis review shall include, at a minimum:

 

  8.14.7.1 A medical record chart review;

 

  8.14.7.2 Consultation with the member’s treatment team;

 

  8.14.7.3 Review of administrative data such as claims/encounters; and

 

  8.14.7.4 Demographic and grievance system data.

 

  8.14.8 Care Managers shall establish and maintain a Care Management Plan for each member enrolled in Contractor’s Care Management Program. The Care Management Plan, at a minimum, shall:

 

  8.14.8.1 Describe the clinical interventions recommended to the treatment team;

 

  8.14.8.2 Identify coordination gaps, strategies to improve care coordination with the member’s service providers;

 

  8.14.8.3 Require strategies to monitor referrals and follow-up for specialty care and routine health care services including medication monitoring; and

 

  8.14.8.4 Align with the member’s Individual Recovery Plan, but is neither a part of nor a substitute for that Plan.

 

8.15 Drug Utilization Review

For all populations eligible for covered services under this Contract, the Contractor shall:

 

  8.15.1 Develop and implement a process for ongoing review of the prescribing, dispensing, and use of medications to assure efficacious, clinically appropriate, safe, and cost-effective drug therapy to improve health status and quality of care.

 

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  8.15.2 Ensure coverage decisions are based on scientific evidence, standards of practice, peer-reviewed medical literature, outcomes research data, or practice guidelines (42 CFR 438.236(d)).

 

  8.15.3 Perform pattern analyses that evaluate clinical appropriateness, over and underutilization, therapeutic duplications, contraindications, drug interactions, incorrect duration of drug treatment, clinical abuse or misuse, use of generic products, and mail order medications (42 CFR 438.204(b)(3)).

 

  8.15.4 Provide education to prescribers on drug therapy problems based on utilization patterns with the aim of improving safety, prescribing practices, and therapeutic outcomes.

 

8.16 Pre-Admission Screening and Resident Review (PASRR) Requirements

The Contractor shall:

 

  8.16.1 Administer the PASRR Level II evaluations and meet required time frames for assessment and submission to ADHS/DBHS.

 

  8.16.2 Determine the appropriateness of admitting persons with mental illness to Medicaid-certified nursing facilities, to determine if the level of care provided by the nursing facility is needed and whether specialized services for persons with mental impairments are required.

 

  8.16.3 Subcontract for these services if necessary, and demonstrate that a licensed physician who is Board-certified or Board-eligible in psychiatry conducts PASRR Level II evaluations in conformance with 42 CFR Part 483, Subpart C and the ADHS/DBHS Policy and Procedures Manual Section on Pre-Admission Screening and Resident Review (PASRR).

 

  8.16.4 Submit a PASRR packet that includes an invoice to the ADHS/DBHS.

 

8.17 Nursing Facility Service Requirements

 

  8.17.1 Provide medically necessary nursing facility services.

 

  8.17.2 Provide medically necessary nursing facility services for a member with a pending ALTCS application currently residing in a nursing facility.

 

  8.17.3 Notify ADHS/DBHS when a member has been residing in a nursing facility for forty-five (45) days in accordance with Section 4.7, “Nursing Facility”. The Contractor shall notify the ADHS Office of Medical Management, by Email, when a member has been residing in a nursing facility, alternative residential facility or receiving home and community based services for forty-five (45) days. This will allow ADHS 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 DBHSMedicalManagement@azdhs.gov. Notifications must include:

 

  8.17.3.1 Member Name,

 

  8.17.3.2 AHCCCS ID,

 

  8.17.3.3 Date of Birth,

 

  8.17.3.4 Name of Facility,

 

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  8.17.3.5 Admission Date to the Facility,

 

  8.17.3.6 Date they reach the 45 days, and

 

  8.17.3.7 Name of Contractor of enrollment.

 

  8.17.4 Provide medically necessary nursing facility services.

 

  8.17.5 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 for forty-five (45) days. This will allow 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 ninety (90) day per contract year maximum.

 

8.18 Medical Management Reporting Requirements

 

  8.18.1 The Contractor shall submit all deliverables related to Medical Management in accordance with Exhibit 9.

 

9 APPOINTMENT AND REFERRAL REQUIREMENTS

 

9.1 Appointments

For all populations covered under this Contract, the Contractor shall:

 

  9.1.1 Develop and implement policies and procedures to actively monitor and track provider compliance with appointment availability standards and timeliness of appointments for members as required in ACOM Policy 417, and disseminate information regarding appointment standards to members, subcontractors and providers in conformance with the ADHS/DBHS Policy on Appointment Standards and Timeliness of Services.

 

  9.1.2 Except as otherwise specified in Section 9.2 and in conformance with the ADHS/DBHS Policy on Appointment Standards and Timeliness of Services, provide appointments to members as follows:

 

  9.1.2.1 Emergency appointments within twenty-four (24) hours of referral, including, at a minimum, the requirement to respond to hospital referrals for Title XIX/XXI members and Non-Title XIX members with SMI;

 

  9.1.2.2 Routine appointment for initial assessment within seven (7) days of referral; and

 

  9.1.2.3 Routine appointments for ongoing services within twenty-three (23) days of initial assessment.

 

  9.1.3 Actively monitor and ensure that a member’s waiting time for a scheduled appointment is no more than forty-five (45) minutes, except when the provider is unavailable due to an emergency.

 

  9.1.4

For referrals from a PCP or Health Plan Behavioral Health Coordinator for a member to receive a psychiatric evaluation or medication management, appointments with a behavioral health medical professional, will be provided according to the needs of the

 

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  member, and within the appointment standards described above, with appropriate interventions to prevent a member from experiencing a lapse in medically necessary psychotropic medications.

 

  9.1.5 Monitor subcontractor compliance with appointment standards and require corrective action when the standards are not met (42 CFR 438.206(c)(1)(iv), (v) and (vi)).

 

  9.1.6 Require all disputes to be resolved promptly and intervene and resolve disputes regarding the need for emergency or routine appointments between the subcontractor and the referral source that cannot be resolved informally.

 

  9.1.7 Provide transportation to all Medicaid eligible members for covered services including SMI members receiving physical health care services so that the member arrives no sooner than one (1) hour before the appointment, and does not have to wait for more than one (1) hour after the conclusion of the appointment for return transportation.

 

  9.1.8 Require that transportation services be pre-arranged for members with recurring and on-going behavioral and physical health care needs, including, but not limited to, dialysis, radiation, chemotherapy, etc.

 

  9.1.9 Implement appointment standards of practice as they are identified by ADHS.

 

  9.1.10 Have written policies and procedures about educating its provider network regarding appointment time requirements. The Contractor must develop a corrective action plan (CAP) 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.

 

  9.1.11 Respond to all requests for services and schedule emergency and routine appointments consistent with the appointment standards in this Contract.

 

  9.1.12 On a quarterly basis conduct review of the availability of the providers in sufficient quantity to ensure results are meaningful and representative of the Contractor’s network.

 

  9.1.13 For medically necessary non-emergent transportation, 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 (1) hour after the conclusion of the treatment for transportation home; nor be picked up prior to the completion of treatment. The Contractor must develop and implement a quarterly performance auditing protocol to evaluate compliance with the standards for all subcontracted transportation vendors/brokers and require corrective action if standards are not met.

 

9.2 Additional Appointment Requirements for SMI Members

For SMI members eligible to receive physical health care services, the Contractor shall:

 

  9.2.1 Provide timely access to care in conformance with the appointment standards in Section 9.2.3 below.

 

  9.2.2 Monitor appointment availability utilizing the methodology found in the AHCCCS Contractor Operations Manual Appointment Availability Monitoring and Reporting Policy. 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 member’s health. The Contractor shall have procedures in place that ensure the following standards are met.

 

  9.2.3 Establish and implement procedures as indicated by the member’s condition not to exceed the following standards:

 

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For Primary Care Appointments:

 

  9.2.3.1 Emergency: same day of request or within twenty-four (24) hours of the member’s phone call or other notification;

 

  9.2.3.2 Urgent: within two (2) days of request; and

 

  9.2.3.3 Routine: within twenty-one (21) days of request.

For Specialty Care Appointments:

 

  9.2.3.4 Emergency: within twenty-four (24) hours of referral;

 

  9.2.3.5 Urgent: within three (3) days of referral; and

 

  9.2.3.6 Routine: within forty-five (45) days of referral.

For Dental Appointments: to SMI members under age twenty-one (21).

 

  9.2.3.7 Emergency: within twenty-four (24) hours of request;

 

  9.2.3.8 Urgent: within three (3) days of request; and

 

  9.2.3.9 Routine: within forty-five (45) days of request.

For Maternity Care appointments for initial prenatal care for pregnant SMI members:

 

  9.2.3.10 First trimester: within fourteen (14) days of request;

 

  9.2.3.11 Second trimester: within seven (7) days of request;

 

  9.2.3.12 Third trimester: within three (3) days of request; and

 

  9.2.3.13 High risk pregnancies: within three (3) days of a maternity care provider’s identification of high risk or immediately if an emergency exists.

 

  9.2.4 Utilize the results from appointment standards monitoring to assure adequate appointment availability in order to reduce unnecessary emergency department or crisis services utilization.

 

  9.2.5 Consider utilizing non-emergency facilities to address member non-emergency care issues occurring after regular office hours or on weekends.

 

  9.2.6 Develop and distribute written policies and procedures for network providers regarding appointment time standards and requirements.

 

  9.2.7 Establish processes to monitor and reduce the appointment “no show” rate by provider and service type. As best practices are identified, AHCCCS/ADHS may require implementation by the Contractor.

 

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9.3 Referral Requirements

For all populations covered under this Contract, the Contractor shall:

 

  9.3.1 Establish written criteria and procedures for accepting and acting upon referrals, including emergency referrals.

 

  9.3.2 Accept and respond to emergency referrals of Title XIX/XXI eligible members and Non-Title XIX members with SMI twenty-four (24) hours a day, seven (7) days a week. Emergency referrals do not require prior authorization. Emergency referrals include those initiated for Title XIX/XXI eligible and Non-Title XIX with SMI members admitted to a hospital or treated in the emergency room.

 

  9.3.3 Respond within twenty-four (24) hours upon receipt of an emergency referral.

 

  9.3.4 Include in the written criteria the definition of a referral as any oral, written, faxed or electronic request for services made by the member or member’s legal guardian, family member, an AHCCCS acute Contractor, PCP, hospital, court, Tribe, IHS, school, or other state or community agency.

 

  9.3.5 Record, track and trend all referrals, including the date of the scheduled appointment, the date of the referral for services, date and location of initial scheduled appointment, final disposition of referral, and the reason why the member declined the offered appointment.

 

  9.3.6 Have a process to refer any member who requests information or is about to lose AHCCCS eligibility or other benefits to options for low-cost or no-cost health care services.

 

  9.3.7 Ensure that training and education are available to PCPs regarding behavioral health referrals and consultation procedures.

 

9.4 Disposition of Referrals

For all populations covered under this Contract the Contractor shall, when appropriate:

 

  9.4.1 Communicate the final disposition of each referral from PCPs, AHCCCS Health Plans, Department of Education/School Districts and state social service agencies to the referral source and Health Plan Behavioral Health Coordinator within thirty (30) days of the member receiving an initial assessment. If a member declines behavioral health services, the final disposition must be communicated to the referral source and health plan behavioral health coordinator within thirty (30) days of the referral, when applicable. The final disposition shall include, at a minimum:

 

  9.4.1.1 The date the member received an initial assessment;

 

  9.4.1.2 The name and contact information of the provider accepting primary responsibility for the member’s behavioral health care; or

 

  9.4.1.3 Indicate that a follow-up to the referral was conducted but no services were delivered and the reason why no services were delivered including members who failed to present for an appointment.

 

  9.4.2 Document the reason for non-delivery of services to demonstrate that the Contractor or provider either attempted to contact the member on at least three (3) occasions and was unable to locate the member or contacted the member and the member declined services.

 

9.5 Provider Directory

For all populations covered under this Contract, the Contractor shall:

 

  9.5.1 Distribute provider directories and any available periodic updates to AHCCCS Health Plans for distribution to the PCPs, if a Contractor does not maintain a centralized referral and intake system as the sole mechanism for receiving behavioral health referrals.

 

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9.6 Referral for a Second Opinion

For all populations covered under this Contract, the Contractor shall:

 

  9.6.1 Upon a member’s request, provide for a second opinion from a qualified health care professional within the network, or arrange for a member to obtain one outside the network at no cost to the member (42 CFR 438.206(b)(3)). For purposes of this paragraph, a qualified health care professional is a provider who meets the qualifications to be an AHCCCS registered provider of covered health care services, and who is a physician, a physician assistant, a nurse practitioner, a psychologist, or an independent Master’s level therapist.

 

9.7 Additional Referral Requirements for SMI Members

For SMI members receiving physical health care services, the Contractor shall:

 

  9.7.1 Establish and implement written procedures for referrals to specialists or other services, to include, at a minimum, the following:

 

  9.7.1.1 Use of referral forms clearly identifying the Contractor;

 

  9.7.1.2 Referrals to specialty physician services shall be from a PCP, except as follows:

 

  9.7.1.2.1 Women shall have direct access to in-network OB/GYN providers, including physicians, physician assistants and nurse practitioners within the scope of their practice, without a referral for preventive and routine services (42 CFR 438.206(b)(2)).

 

  9.7.1.3 SMI members that need a specialized course of treatment or regular care monitoring shall have a mechanism for direct access to a specialist (for example through a standing referral or an approved number of visits) as appropriate for the member’s condition and identified needs. Any waiver of this requirement by the Contractor must be approved in advance by ADHS/DBHS. Specialty physicians shall not begin a course of treatment for a medical condition other than that for which the member was referred, unless approved by the member’s PCP.

 

  9.7.1.4 A process for the member’s PCP to receive all specialist and consulting reports and a process for the PCP to follow-up on all referrals including CRS, Dental and EPSDT referrals for behavioral health services.

 

  9.7.2 Comply with all applicable physician referral requirements and conditions defined in Sections 1903(s) and 1877 of the Social Security Act and corresponding 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, at a minimum:

 

  9.7.2.1 Clinical laboratory services,

 

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  9.7.2.2 Physical therapy services,

 

  9.7.2.3 Occupational therapy services,

 

  9.7.2.4 Radiology services,

 

  9.7.2.5 Radiation therapy services and supplies,

 

  9.7.2.6 Durable medical equipment and supplies,

 

  9.7.2.7 Parenteral and enteral nutrients, equipment and supplies,

 

  9.7.2.8 Prosthetics, orthotics and prosthetic devices and supplies,

 

  9.7.2.9 Home health services,

 

  9.7.2.10 Outpatient prescription drugs, and

 

  9.7.2.11 Inpatient and outpatient hospital services.

 

  9.7.3 Have a process for referral to Medicare Managed Care Plan.

 

10 QUALITY MANAGEMENT

 

10.1 General Requirements

The Contractor shall:

 

  10.1.1 Employ in sufficient number qualified staff with experience in both physical and behavioral health to carry out the Quality Management program requirements.

 

  10.1.2 Implement, monitor, evaluate and comply with applicable requirements in the ADHS/DBHS Policy and Procedure Manual, the ADHS/DBHS Bureau of Quality and Integration (BQ&I) Specifications Manual and the AHCCCS Medical Policy Manual, Chapter 900.

 

  10.1.3 Provide quality care and services to eligible members, regardless of payer source or eligibility category.

 

  10.1.4 Establish a Quality Management/Quality Improvement unit within its organizational structure that is separate and distinct from any other units or departments such as Medical Management and Case Management.

 

  10.1.5 Establish a Quality Management (QM) Committee, Children QM and Peer Review committees and other subcommittees under QM Committee as required.

 

  10.1.6 Require its QM Committee, Peer Review Committee, and subcommittees to meet at least quarterly and be chaired by the local Chief Medical Officer.

 

  10.1.7 Execute processes to assess, plan, implement and evaluate quality management and performance improvement activities related to services provided to members in conformance with the ADHS Policy and Procedure Manual and the AHCCCS Medical Policy Manual (42 CFR 438.240(a)(1) and (e)(2) and 42 CFR 42 447.26)).

 

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  10.1.8 Integrate quality management processes in all areas of Contractor’s organization, with ultimate responsibility for quality management/quality improvement residing within the QM unit.

 

  10.1.9 Demonstrate improvement in the quality of care provided to members through established quality management and performance improvement processes.

 

  10.1.10 Identify Quality of Care (QOC) issues throughout behavioral health system and report to ADHS/DBHS QM area for investigation.

 

  10.1.11 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:

Is identified in the State plan at: http://www.azahcccs.gov/reporting/PoliciesPlans/stateplan.aspx)

 

  10.1.12 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,

 

  10.1.13 Has a negative consequence for the beneficiary,

 

  10.1.14 Is auditable.

 

  10.1.15 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))].

 

  10.1.16 Report an HCAC or OPPC occurrence, when identified, to ADHS/DBHS and conduct a quality of care investigation as outlined in AMPM Chapter 900 and Exhibit 9, [42 CFR 438.6(f)(2)(ii) and 42 CFR 434.6(a)(12)(ii)].

 

  10.1.17 Regularly disseminate subcontractor and provider quality improvement information including performance measures, dashboard indicators and member outcomes to ADHS/DBHS and key stakeholders, including members and family members.

 

  10.1.18 Develop and maintain mechanisms to solicit feedback and recommendations from key stakeholders, subcontractors, members, and family members to monitor service quality and develop strategies to improve member outcomes and quality improvement activities related to the quality of care and system performance.

 

  10.1.19 Participate in community initiatives including applicable activities of the Medicare Quality Improvement Organization (QIO).

 

  10.1.20 Maintain the confidentiality of a member’s medical record in conformance with Section 18.10, Medical Records and the AHCCCS Medical Policy Manual..

 

  10.1.21 Comply with requirements to assure member rights and responsibilities in conformance with the ADHS Policy and Procedure Manual Sections on Title XIX/XXI Notice and Appeal Requirements; Special Assistance for Persons Determined to have a Serious Mental Illness; Notice and Appeal Requirements (SMI and NON-SMI/NON-TITLE XIX/XXI); Member Grievance Resolution; and the ADHS/DBHS Policy on Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons and the AHCCCS Medical Policy Manual (42 CFR 438.100(a)(2)); and comply with any other applicable federal and State laws (such as Title VI of the Civil Rights Act of 1964, etc.) including other laws regarding privacy and confidentiality (42 CFR 438.100(d)).

 

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  10.1.22 Have an ongoing quality management program for the provision of services to members that include the requirements listed in AMPM Chapter 400, 900 and the following:

 

  10.1.22.1 A written annual Quality Management and Performance Improvement (QM/PI) plan, work plan, and evaluation of the previous year’s QM/PI program;

 

  10.1.22.2 Quality Management Quarterly reports that address strategies for performance improvement;

 

  10.1.22.3 QM/PI Program monitoring and evaluation activities that includes Peer Review and Quality Management Committees chaired by the Contractor’s Chief Medical Officer;

 

  10.1.22.4 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;

 

  10.1.22.5 Member rights and responsibilities;

 

  10.1.22.6 Uniform provisional credentialing, initial credentialing, re-credentialing and organizational credential verification [42 CFR 438.206(b)(6)] and the AHCCCS Medical policy Manual;

 

  10.1.22.7 Documentation of implemented corrective action plan(s) (CAP) or action(s) taken to resolve the concern;

 

  10.1.22.8 Analysis of the effectiveness of the interventions taken;

 

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

 

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

 

  10.1.23 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 behavioral health providers as required.

 

  10.1.24 Actively participate in ADHS/DBHS Quarterly RBHA QM Coordinators Meeting.

 

  10.1.25 Require that all QM/QI positions performing work functions related to the Contract must have a direct reporting relationship to the local Chief Medical Officer (CMO) and the Chief Corporate Officer (CEO). The 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 perform functions under this Contract related to QM and QI shall have the work directed and prioritized by the Contractor’s CEO and CMO.

 

  10.1.26 Require its QM Committee to proactively and regularly review member grievance, SMI grievance and appeal data to identify outlier members who have filed multiple complaints, grievances or appeals regarding services or against the Contractor or who contact governmental entities for assistance, including ADHS/DBHS and AHCCCS for the purposes of assigning a care coordinator to assist the member in navigating the health care system.

 

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  10.1.27 Assure 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 to the Quality Management area.

 

  10.1.28 Develop and implement guidelines to determine the cause of Provider-Preventable condition including Health Care Acquired Condition (HCAC) or Other Provider-Provider Condition (OPPC).

 

10.2 Credentialing

The Contractor shall:

 

  10.2.1 Conduct provider credentialing and review and make a network determination through the Contractor’s Credentialing Committee, chaired by the Contractor’s local Medical Director (42 CFR 438.214) and the AHCCCS Medical Policy Manual.

 

  10.2.2 Comply with uniform provisional credentialing, initial credentialing, re-credentialing and organizational credential verification as follows:

 

  10.2.2.1 Document provisional credentialing, initial credentialing, re-credentialing and organizational credential verification of providers who have signed contracts or participation agreements with the Contractor (42 CFR 438.206(b)(1-2));

 

  10.2.2.2 Not discriminate against particular providers that serve high-need populations or specialize in conditions that require costly treatment; and

 

  10.2.2.3 Not employ or contract with providers excluded from participation in federal health care programs. (42 CFR 438.214(d)).

 

  10.2.3 Utilize the established centralized Credential Verification Organization (CVO) through the Arizona Association of Health Plans as part of its credentialing and re-credentialing process in order to support the effort to ease the administrative burden for providers that contract with Medicaid contractors.

 

  10.2.4 Comply with initial and re-credentialing timelines for providers that submit their credentialing data and forms to the centralized CVO.

 

  10.2.5 Create a process in accordance with the Contractor’s credentialing/recredentialing policy of providers and organizations that monitors, at a minimum on an annual basis, occurrences which may jeopardize the validity of the credentialing process.

 

10.3 Incident, Accident and Death Reports

The Contractor shall:

 

  10.3.1 Develop and implement policies and procedures that require individual and organizational providers to report to the Contractor, the Regulator and other appropriate authorities incident, accident and death (IAD) reports, to include abuse, neglect, injury, exploitation, alleged human rights violation, and death, in conformance with the ADHS/DBHS Policy and Procedure Manual Section 6, chapter 1700 under Reporting Requirements; Policy 1703 Reporting of Incidents, Accidents and Deaths and the AHCCCS Medical Policy Manual.

 

  10.3.2 Incident, accident and death (IAD) reports must be submitted in accordance with requirements established by ADHS.

 

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10.4 Quality of Care Concerns and Investigations

The Contractor shall:

 

  10.4.1 Establish mechanisms to assess the quality and appropriateness of care provided to members. (42 CFR 438.420(b)(4)).

 

  10.4.2 Establish mechanisms to track and trend quality of care and quality of service allegations.

 

  10.4.3 Develop a process that requires the provider to report incidents of healthcare acquired conditions, abuse neglect, exploitation, injuries, high profile cases and unexpected death to the Contractor.

 

  10.4.4 Develop a process to report incidents of healthcare acquired conditions, abuse, neglect, exploitation, injuries, high profile cases and unexpected death to ADHS/DBHS Quality Management.

 

  10.4.5 Develop and implement policies and procedures that analyze quality of care issues through identifying the issue, initial assessment of the severity of the issue, and prioritization of action(s) needed to resolve immediate care needs when appropriate.

 

  10.4.6 Establish a process to ensure that staff, having contact with members or providers, are trained on how to refer suspected quality of care issues to quality management. This training must be provided during new employee orientation and annually thereafter.

 

  10.4.7 Track and trend member and provider issues including quality of care and quality of service, and investigate and analyze QOC issues, abuse, neglect, exploitation, high profile, human rights violations and unexpected deaths and include the following:

 

  10.4.7.1 Acknowledgement letter to the originator of the concern;

 

  10.4.7.2 Documentation of each step in the investigation and resolution process;

 

  10.4.7.3 Follow-up with the member to assist in meeting immediate health care needs; and

 

  10.4.7.4 Closure or resolution letter to the member with sufficient detail to describe:

 

  10.4.7.4.1 The resolution of the issue,

 

  10.4.7.4.2 Any responsibilities for the member to make sure covered, medically necessary care needs are met,

 

  10.4.7.4.3 Contact name and telephone number to call for assistance or to express any unresolved concerns,

 

  10.4.7.4.4 Documentation of any implemented corrective action plan or action taken to resolve the concern, and

 

  10.4.7.4.5 Analysis of the effectiveness of the interventions taken.

 

  10.4.8 Conduct a quality of care investigation and report the HCAC or OPPC occurrence and results of the investigation to ADHS/DBHS Quality Management.

 

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10.5 Performance Measures

The Contractor shall:

 

  10.5.1 Complete descriptions of the AHCCCS clinical quality Performance Measures and links to the CMS and the measure host sites can be found on the AHCCCS web site. Note that the performance measure titled “EPSDT Participation “is based on the methodology established in CMS “Form 416” which can be found on the AHCCCS web site or the CMS web site at: http://www.azahcccs.gov/reporting/quality/performancemeasures.aspx.

 

  10.5.2 Implement Performance improvement programs including performance measures and performance improvement projects based upon data analysis and trending, and/or as directed by ADHS/DBHS (42 CFR 438.240(a)(2)).

 

  10.5.3 Design a quality management program to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in the areas of clinical care and non-clinical care that are expected to have a favorable effect on health outcomes and member satisfaction (42 CFR 438.240(a)(2), (b)(2) and (c)).

 

  10.5.4 Comply with 10.1.1 to improve performance for all established performance measures.

 

  10.5.5 Comply with national performance measures and levels identified and developed by the CMS or those that are developed in consultation with AHCCCS and/or other relevant stakeholders, and established or adopted by AHCCCS, and any resulting changes when current established performance measures are finalized and implemented (42 CFR 438.24(c)).

 

  10.5.6 Ensure that performance measures are analyzed and reported separately, by line of business Acute, DDD, (Acute and SMI populations, DDD and CMDP), In addition, Contractors should evaluate performance based on sub-categories of populations when requested to do such.

 

  10.5.7 Collect and provide data from medical records with supporting documentation, as instructed by ADHS/DBHS, for each hybrid measure as requested. Copies of the chart records shall be available as requested and for validation purposes.

 

  10.5.8 Comply with recognized sampling guidelines, which may be affected by the Contractor’s previous rate on the same performance measure.

 

  10.5.9 Comply with and implement the hybrid methodology with the following measures and as indicated in the Performance Measure methodologies posted on the AHCCCS website:

 

  10.5.9.1 HbA1c Testing;

 

  10.5.9.2 LCL-C Screening;

 

  10.5.9.3 Timeliness of Prenatal Care visit in the first trimester or within 42 days of enrollment; and

 

  10.5.9.4 Postpartum Care Rate.

 

  10.5.10 Comply with and implement a hybrid methodology for collecting and reporting additional measures in future contract years using a hybrid methodology for collecting and reporting Performance Measure rates, as allowed in standardized methodologies.

 

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SOLICITATION NO: ADHS15-00004276

 

  10.5.11 Implement a process for internal monitoring of Performance Measure rates, using a standard methodology established or approved by ADHS/DBHS, for each required Performance Measure. AHCCCS-reported rates are the official rates utilized for determination of Contractor compliance with performance requirements. 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.

 

  10.5.12 Meet and sustain specified Minimum Performance Standards (MPS) in the table below for each population/eligibility category according to the following [42 CFR 438.240(a)(2), (b)(2) and (c)]:

 

  10.5.12.1 Minimum Performance Standard: A Minimum Performance Standard 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;

 

  10.5.13 A Contractor must show demonstrable and sustained improvement toward meeting AHCCCS/ADHS Performance Standards. AHCCCS/ADHS may impose sanctions on Contractors that do not show statistically significant improvement in a measure rate as calculated by AHCCCS/ADHS. 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/ADHS MPS, or a rate that has a significant impact to the aggregate rate for the State. AHCCCS/ADHS may require the Contractor to demonstrate that they are allocating increased administrative resources to improving rates for a particular measure or service area. AHCCCS/ADHS 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. AHCCCS/ADHS may require the Contractor to conduct an Administrative Review Chart Audit for validation of any performance measure that falls below the minimum performance standard. The Contractor must meet, and ensure that each subcontractor meets, AHCCCS/ADHS Minimum Performance Standards. [42 CFR 438.240(b)(1), (2), and (d)(1)].

Contractor Minimum Performance (MPS) Standards and Goals

 

Performance Measures for Members Receiving Physical Health Care Services

            

Performance Measure

   Minimum Performance
Standard
    Goal  

Inpatient Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Emergency Department (ED) Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Hospital Readmissions (behavioral health-related primary diagnosis) (within 30 days of discharge)

     *TBD        *TBD   

Follow-Up After Hospitalization (within 7 days) (behavioral health-related primary diagnosis)

     50     80

Follow-Up After Hospitalization (within 30 days) (behavioral health-related primary diagnosis)

     70     90

 

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Performance Measures for Members Receiving Physical Health Care Services

            

Performance Measure

   Minimum Performance
Standard
    Goal  

Adults’ Access to Preventive/Ambulatory Health Services

     75     90

Access to Behavioral Health Provider -(encounter for a visit) within 7 days

     75     85

Access to Behavioral Health Provider- (encounter for a visit) within 23 days

     90     95

Breast Cancer Screening

     50     60

Cervical Cancer Screening: Women Age 21-64 with a Cervical Cytology performed every three (3) yrs.

     64     70

Cervical Cancer Screening: Women Age 30-64 with a Cervical Cytology/ HPV Co-testing performed every five (5) yrs.

     64     70

Chlamydia Screening in Women Age 21-24

     63     70

Comprehensive Diabetes Management:

    

— HbA1c Testing

     77     89

HbA1c Poor Control (>9.0%)

     *TBD     

— LDL-C Screening

     70     91

— Eye Exam

     49     68

Diabetes, Short Term Complications

     *TBD        *TBD   

Adult Asthma Hospital Admission Rate

     *TBD        *TBD   

Use of Appropriate Medications for People with Asthma

     86     93

Flu Shots for Adults:

    

— Ages 18-64

     75     90

— Ages 65+

     75     90

Annual Monitoring for Patients on Persistent Medications (combined rate)

     75     80

Chronic Obstructive Pulmonary Disease (COPD) Hospital Admission Rate

     *TBD        *TBD   

Asthma in Younger Adults Admissions*

     *TBD        *TBD   

Congestive Heart Failure (CHF) Hospital Admission Rate

     *TBD        *TBD   

Timeliness of Prenatal Care; Prenatal Care visit in the first trimester or within 42 days of enrollment

     80     90

Prenatal and Postpartum Care Postpartum Care Rate (second component to CHIPRA core measure “Timeliness of Prenatal Care)

     64     90

EPSDT Participation (18-21 year olds)

     68     80

 

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Performance Measures for Members Receiving Behavioral Health Services

            

Performance Measure

   Minimum Performance
Standard
    Goal  

Inpatient Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Emergency Department (ED) Utilization (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Ambulatory Care - Emergency Department (ED) Visits*

     *TBD        *TBD   

Hospital Readmissions within 30 days of discharge (behavioral health-related primary diagnosis)

     *TBD        *TBD   

Follow-Up After Hospitalization (within 7 days) (behavioral health-related primary diagnosis)

     50     *TBD   

Follow-Up After Hospitalization (within 30 days) (behavioral health-related primary diagnosis)

     70     90

Access to Behavioral Health Provider within 7 days

     75     *TBD   

Access to Behavioral Health Provider within 23 days

     90     *TBD   

* For each of the benchmarks above identified as TBD, the Contractor is responsible for establishing their own.

     N/A        N/A   

Notes: (*) AHCCCS/ADHS will develop Minimum Performance Standards and Goals once baseline data has been analyzed for these measures.

     N/A        N/A   

 

  10.5.14 Be subject to a financial sanction when performance measure results do not show statistically significant improvement in a measure rate including in those instances when a performance measure shows a statistically significant decrease in its rate, even if it meets or exceeds the Minimum Performance Standard. This sanction may include the Contractor to demonstrate an increase in allocation for administrative resources to improve rates for a particular measure or service area.

 

  10.5.15 Implement an evidence based corrective action plan (CAP) that outlines the problem, planned actions for improvement, responsible staff and associated timelines as well as a place holder for evaluation of activities as directed by ADHS/DBHS that meets the following criteria:

 

  10.5.15.1 Is submitted to ADHS/AHCCCS within thirty (30) days of notification of the deficiency;

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  10.5.15.2 Is approved by ADHS/AHCCCS prior to implementation; and

 

  10.5.15.3 Verifies compliance with a corrective action plan (CAP) with one (1) or more follow up on-site reviews.

 

  10.5.16 Have its performance evaluated quarterly and annually.

 

  10.5.17 Have its compliance with performance measures validated by the ADHS/ AHCCCS and/or an External Quality Review Organization (EQRO).

 

  10.5.18 Take affirmative steps to increase EPSDT participation rates as measured utilizing methodologies developed by CMS, including the EPSDT Dental Participation Rate.

 

  10.5.19 Monitor the following quality measures:

 

  10.5.19.1 Individual level clinical outcomes,

 

  10.5.19.2 Experience of care outcomes,

 

  10.5.19.3 Quality of care outcomes, and

 

  10.5.19.4 Quality of service outcomes.

 

  10.5.20 The Contractor must participate in the delivery and/or results review of member surveys as requested by AHCCCS/ADHS. Surveys may include Home and Community Based 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) to improve any areas of concern noted by AHCCCS/ADHS. Failure to effectively develop or implement AHCCCS-approved CAPs and drive improvement may result in additional regulatory action.

 

10.6 Performance Improvement Projects

 

  10.6.1 Implement an ongoing program of performance improvement projects (PIP) that focus on clinical and non-clinical areas as specified in the AHCCCS Medical Policy Manual and that involve the following:

 

  10.6.1.1 Measurement of performance using objective quality indicators;

 

  10.6.1.2 Implementation of system interventions to achieve improvement in quality;

 

  10.6.1.3 Evaluation of the effectiveness of the interventions; and

 

  10.6.1.4 Planning and initiation of activities for increasing or sustaining improvement (42 CFR 438.240(b)(1) (2) and (c) (d)(1)).

 

  10.6.2 Comply with PIPs mandated by ADHS/DBHS, and also self-select additional projects based on opportunities for improvement identified by internal data and information, tracking and trending.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  10.6.3 Report the status and results of each project to ADHS/DBHS as requested using the PIP Reporting Template included in the Specifications Manual.

 

  10.6.4 Complete each PIP in a reasonable time period or as specified by ADHS in order to use the information on the success of performance improvement projects in the aggregate to produce new information on quality of care each year (42 CFR 438.240(d)(2)).

 

10.7 Data Collection Procedures

The Contractor shall:

 

  10.7.1 Submit data for standardized Performance Measures and Performance Improvement Projects as required by the ADHS/DBHS within specified timelines and according to procedures for collecting and reporting the data in conformance with Section 10.1.2.

 

  10.7.2 Submit data that is valid, reliable and collected using qualified staff and in the format and according to instructions from ADHS/DBHS by the due date specified.

 

  10.7.3 Ensure that data collected by multiple 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.

 

  10.7.4 Subject to approval by ADHS/DBHS, request an extension for additional time to collect and report data in writing in advance of the initial due date and is subject to approval by ADHS/DBHS.

 

10.8 Member Satisfaction Survey

The Contractor shall:

 

  10.8.1 Implement the annual Member Satisfaction Survey in conjunction with subcontractors when necessary in accordance with Statewide Consumer Survey protocol and report results to ADHS/DBHS when requested (42 CFR 438.6(h)).

 

  10.8.2 Use findings from the Member Satisfaction Survey in designing quality improvement activities to improve care for members.

 

  10.8.3 Participate in additional surveys in conformance with Section 19.3, Surveys, including surveys mandated by AHCCCS.

 

  10.8.4 Perform surveys at ADHS and AHCCCS’ request. ADHS may provide the survey tool or require the Contractor to develop the survey tool which shall be approved in advance by ADHS and AHCCCS.

 

  10.8.5 ADHS and AHCCCS may conduct surveys of a representative sample of the Contractor’s membership and providers. The results of the surveys will become public information and available to all interested parties on the ADHS and/or AHCCCS website. The Contractor may be required to participate in workgroups and efforts that are initiated as a result of the survey results.

 

10.9 Provider Monitoring

The Contractor shall:

 

  10.9.1 Develop and submit a subcontractor performance monitoring plan as a component of annual QM plan, to include the following quality management functions:

 

  10.9.1.1 Peer Review processes;

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

  10.9.1.2 Incident, accident, death (IAD) report timely completion and submission;

 

  10.9.1.3 Quality of Care (QOC) Concerns and investigations;

 

  10.9.1.4 ADHS/DBHS required Performance Measures;

 

  10.9.1.5 Performance Improvement Project; and

 

  10.9.1.6 Temporary, provisional, initial and re-credentialing processes and requirements.

 

  10.9.2 Conduct an annual Administrative Review audit of subcontracted provider services and service sites, and assess each provider’s performance on satisfying established quality management and performance measures standards.

 

  10.9.3 Develop and implement a corrective action plan utilizing the ADHS/DBHS QM corrective action plan (CAP) Template when provider monitoring activities reveal poor performance as follows:

 

  10.9.3.1 When performance falls below the minimum performance level; or

 

  10.9.3.2 Shows a statistically significant decline from previous period performance.

 

10.10 Centers of Excellence

Centers of Excellence are facilities that are recognized as providing the highest levels of leadership, quality, and service. Centers of Excellence align physicians and other providers to achieve higher value through greater focus on appropriateness of care, clinical excellence, and patient satisfaction. Designation as a Center of Excellence is based on criteria such as procedure volumes, clinical outcomes, and treatment planning and coordination. To encourage Contractor activity which incentivizes utilization of the best value providers for select, evidenced based, high volume procedures or conditions, the Contractor shall submit a Centers of Excellence Report to ADHS/DBHS as specified in Exhibit 9, outlining the Contractor’s approach to developing at least two (2) Centers of Excellence for at least two (2) different procedures or conditions.

 

  10.10.1 The Centers of Excellence Report must:

 

  10.10.1.1 Identify why the selected procedures or conditions were chosen,

 

  10.10.1.2 Outline how the Contractor will identify and select providers with the highest quality outcomes,

 

  10.10.1.3 Provide a high-level summary of potential contracting approaches,

 

  10.10.1.4 Identify how the Contractor plans to drive utilization to the Centers of Excellence, and

 

  10.10.1.5 Identify any barriers or challenges with the development of such Centers of Excellence.

 

10.11 Quality Management Reporting Requirements

 

  10.11.1 The Contractor shall submit deliverables related to Quality Management in accordance with Exhibit 9.

 

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ADHS REGIONAL BEHAVIORAL HEALTH AUTHORITY- GREATER ARIZONA

SOLICITATION NO: ADHS15-00004276

 

11 COMMUNICATIONS

 

11.1 Member Information

For all populations eligible for services under this Contract, the Contractor shall:

 

  11.1.1 Be accessible by phone during normal business hours and require subcontracted providers to be accessible by phone for general member information during normal business hours.

 

  11.1.2 Establish and maintain one toll-free phone number with options for a caller to connect to appropriate services and departments and inform members of its existence and availability. (42 CFR 438.10(b)(3)). At a minimum, when appropriate, members calling the toll-free number should be connected to the following:

 

  11.1.2.1 Nurse On Call consultations for SMI members receiving physical health care services under this Contract; and

 

  11.1.2.2 Free resources for members or potential members to obtain information about accessing services, using a grievance system process or any other information related to covered services or the health care service delivery system (42 CFR 438.10(c)(4) and 438.10(c)(5)(i) and (ii)).

 

  11.1.3 Require vital materials to be provided to members. See Exhibit 1, Definitions, “Vital Materials”, for an explanation.

 

  11.1.4 Provide Title XIX/XXI members with written notice in conformance with Section 18.21, Material Change in Operation.

 

  11.1.5 Require all information that is prepared for distribution to members and potential members to be written using an easily understood language and format, and in conformance with the AHCCCS Contractor Operations Manual Member Information Policy using a font, type, style, and size which can be easily read by members with varying degrees of visual impairment or limited reading proficiency (42 CFR 438.10(d)(l)(i)).

 

  11.1.6 Notify members and potential members of the availability and method for access to materials in alternative formats and provide such materials to accommodate members with special needs, for example, members or potential members who are visually impaired or have limited reading proficiency (42 CFR 438.10(d)(1)(i) and (ii); 42 CFR 438.10(d)(2)).

 

  11.1.7 Comply with all translation requirements for all member informational materials in Section 12.3 Translation Services.

 

  11.1.8 Notify members that oral interpretation and language assistance services including services for the hearing impaired are available in conformance with Section 12.1.4, Cultural Competency (42 CFR 438.10(c)(5)(i)).

 

  11.1.9 Provide each member that receives an initial covered service with a ”Provider Directory” that includes, at a minimum, primary care, specialty hospitals and pharmacy providers; telephone numbers; and non-English languages spoken by providers.

 

  11.1.10 Upon request, assist ADHS/DBHS in the dissemination of information prepared by ADHS/DBHS, AHCCCS, or other governmental agency, to its members and pay for the cost to disseminate and communicate information.

 

  11.1.11 Make available easy access of information by members, family members, providers, stakeholders, and the general public in compliance with the Americans with Disabilities Act (ADA).

 

  11.1.12 Comply with ADHS/DBHS policy or policies for communications, marketing, outreach, websites and social media and monitor subcontractor compliance with the policies.

 

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SOLICITATION NO: ADHS15-00004276

 

11.2 Member Handbooks

For all populations eligible for services under this Contract, the Contractor shall:

 

  11.2.1 Print and distribute Member Handbooks in conformance with the Contractor’s established procedures and the ADHS/DBHS Policy on the Member Handbook; (42 CFR 438.10(f)).

 

  11.2.2 Submit the Contractor’s Member Handbook to ADHS/DBHS for approval within thirty (30) days of receiving the ADHS/DBHS Template, unless otherwise specified.

 

  11.2.3 Provide the Contractor’s Member Handbook to each member as follows:

 

  11.2.3.1 For Non-Title XIX/XXI members or Title XIX/XXI members enrolled with an AHCCCS Health Plan, within twelve (12) business days of the member receiving the initial behavioral health covered service; and

 

  11.2.3.2 For SMI members receiving physical health care services from Contractor, within twelve (12) business days of receipt of notification of the date of the initial covered service (42 CFR 438.10(f)(3)).

 

  11.2.4 Require network providers to have Contractor’s Member Handbooks available and easily accessible to members at all provider locations.

 

  11.2.5 Provide, upon request, a copy of the Contractor’s Member Handbook to known peer and family advocacy organizations and other human service organizations in within the Contractor’s assigned geographical service area.

 

  11.2.6 Review the Contractor’s Member Handbook, at least annually, and revise the handbook with the updated ADHS/DBHS Member Handbook Template, when applicable, to accurately reflect current Contractor specific policies, procedures and practices.

 

  11.2.7 Include, at a minimum, in the Contractor’s Member Handbook the information contained in the ADHS/DBHS Member Handbook Template.