Attached files

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10-K - FORM 10-K - IASIS Healthcare LLCd275632d10k.htm
EX-31.2 - EX-31.2 - IASIS Healthcare LLCd275632dex312.htm
EX-31.1 - EX-31.1 - IASIS Healthcare LLCd275632dex311.htm
EX-21 - EX-21 - IASIS Healthcare LLCd275632dex21.htm
EX-10.28 - EX-10.28 - IASIS Healthcare LLCd275632dex1028.htm
EX-10.26 - EX-10.26 - IASIS Healthcare LLCd275632dex1026.htm
EX-10.24 - EX-10.24 - IASIS Healthcare LLCd275632dex1024.htm
EX-10.21 - EX-10.21 - IASIS Healthcare LLCd275632dex1021.htm
EX-10.20 - EX-10.20 - IASIS Healthcare LLCd275632dex1020.htm
EX-10.18 - EX-10.18 - IASIS Healthcare LLCd275632dex1018.htm
EX-10.17 - EX-10.17 - IASIS Healthcare LLCd275632dex1017.htm
EX-10.14 - EX-10.14 - IASIS Healthcare LLCd275632dex1014.htm
EX-10.13 - EX-10.13 - IASIS Healthcare LLCd275632dex1013.htm
EX-10.12 - EX-10.12 - IASIS Healthcare LLCd275632dex1012.htm

Exhibit 10.19

 

LOGO  

 

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

AHCCCS Contract Number: YH17-0001-02

CONTRACT COVER PAGE

 

 

1.      AMENDMENT #:

1

 

2.      CONTRACT:

YH17-0001-02

 

3.      EFFECTIVE DATE OF AMENDMENT: July 1, 2016

 

4.      PROGRAM DHCM-RBHA

Greater Arizona

 

5.      CONTRACTOR NAME AND ADDRESS: Health Choice Integrated Care, LLC

1300 South Yale Street

Flagstaff, AZ 86001

 

6. PURPOSE: The purpose of this amendment is to amend the Contract for the period July 1, 2016 through September 30, 2016 and to the amend Sections, Uniform Terms and Conditions, Special Terms and Conditions, Scope of Work, Exhibit Summary, and Exhibits.

 

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

This Contract amendment is entered into by and between the Regional Behavioral Health Authority and the Arizona Health Care Cost Containment System (AHCCCS).

Arizona Laws 2015, Chapter 19, Section 9 (SB 1480) enacts that from and after June 30, 2016, the provision of behavioral health services under the Division of Behavioral Health Services (DBHS) in the Department of Health Services is transferred to and shall be administered by the Arizona Health Care Cost Containment System (AHCCCS). From and after June 30, 2016, the AHCCCS administration succeeds to the authority, powers, duties and responsibilities of DBHS with the exception of the Arizona State Hospital. Administrative rules and orders that were adopted by DBHS continue in effect until superseded by administrative action by AHCCCS. Until administrative action is taken by AHCCCS, any reference to DBHS in rules and orders is considered to refer to AHCCCS.

All administrative matters, contracts and judicial and quasi-judicial actions, whether completed, pending or in process, of DBHS on July 1, 2016 are transferred to and retain the same status with AHCCCS.

This contract amendment constitutes a full removal and replacement of the prior contract between the Regional Behavioral Health Authority and the Arizona Department of Health Services/Division of Behavioral Health Services under Contract #ADHS15-085892.

Contract Sections Amended:

 

    Uniform Terms and Conditions - Replaced with Terms and Conditions

 

    Special Terms and Conditions - Replaced with Terms and Conditions

 

    Scope of Work

 

    Exhibit Summary- RESERVED

 

    Exhibit-1, Definitions

 

    Exhibit-2, Acronyms- RESERVED

 

    Exhibit-3, Medicare Requirement to Coordinate Care for Dual Eligible SMI Members

 

    Exhibit-4, PLACEHOLDER

 

    Exhibit-5, Arizona Vision – Twelve Principles for Children Services Delivery - Reserved

 

    Exhibit-7, Documents Incorporated by Reference - RESERVED

 

    Exhibit-8, Informational Documents - RESERVED

 

    Exhibit-9, Deliverables

 

    Exhibit-11, Capitation Rates – NAME REVISED TO: Capitation Rates and Contractor Specific Requirements

 

    Exhibit-12, PLACEHOLDER

 

    Exhibit-13, Pledge to Protect Confidential Information – RESERVED

 

    Exhibit-14, Enrollee Grievance System Standards

 

    Exhibit-15, Provider Claim Dispute Standards

 

    Endnotes

Refer to the individual Contract sections for specific changes.

 

8. Authority: AHCCCS is duly authorized to execute and administer agreements pursuant to A.R.S. §36-2903 et seq. and §36-2932 et seq. These contracts/amendments are exempt from the Procurement Code pursuant to A.R.S. §41-2501(H) (as effective on July 1, 2016).

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

 

9.      SIGNATURE OF AUTHORIZED REPRESENTATIVE:

 

10.    SIGNATURE OF AHCCCS CONTRACTING OFFICER:

  LOGO
TYPED NAME:   TYPED NAME:
SHAWN NAU   MEGGAN HARLEY, MSW, CPPO
TITLE:   TITLE:
CHIEF EXECUTIVE OFFICER   PROCUREMENT MANAGER
DATE:   DATE:
  5/16/2016

 

1


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

TERMS AND CONDITIONS

 

  1. ADVERTISING AND PROMOTION OF CONTRACT

The Contractor shall not advertise or publish information for commercial benefit concerning this contract without the prior written approval of the Contracting Officer.

 

  2. APPLICABLE LAW

Arizona Law - The law of Arizona applies to this contract including, where applicable, the Uniform Commercial Code, as adopted in the State of Arizona.

Implied Contract Terms - Each provision of law and any terms required by law to be in this contract are a part of this contract as if fully stated in it.

 

  3. ARBITRATION

The parties to this contract agree to resolve all disputes arising out of or relating to this contract through arbitration, after exhausting applicable administrative review, to the extent required by A.R.S. §12-1518 except as may be required by other applicable statutes.

 

  4. ASSIGNMENT AND DELEGATION

The Contractor shall not assign any rights nor delegate all of the duties under this contract. Delegation of less than all of the duties of this contract must conform to the requirements of Scope of Work, Subcontracting Requirements.

 

  5. ASSIGNMENT OF CONTRACT AND BANKRUPTCY

This contract is voidable and subject to immediate cancellation by AHCCCS upon the Contractor becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States Code, or assigning rights or obligations under this contract without the prior written consent of AHCCCS.

 

  6. AUDITS AND INSPECTIONS

The Contractor shall comply with all provisions specified in applicable A.R.S. §35-214 and §35-215 and AHCCCS rules and policies and procedures relating to the audit of the Contractor’s records and the inspection of the Contractor’s facilities. The Contractor shall fully cooperate with AHCCCS staff and allow them reasonable access to the Contractor’s staff, subcontractors, members, and records [42 CFR 438.6(g)].

At any time during the term of this contract, and five (5) years thereafter unless a longer time is otherwise required by law, the Contractor’s or any subcontractor’s books and records shall be subject to audit by AHCCCS and, where applicable, the Federal government, to the extent that the books and records relate to the performance of the contract or subcontracts [42 CFR 438.242(b)(3)].

AHCCCS, or its duly authorized agents, and the Federal government may evaluate through on-site inspection or other means, the quality, appropriateness and timeliness of services performed under this contract.

 

2


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  7. AUTHORITY

This contract is issued under the authority of the Contracting Officer who signed this contract. Changes to the contract, including the addition of work or materials, the revision of payment terms, or the substitution of work or materials, directed by an unauthorized state employee or made unilaterally by the Contractor are violations of the contract and of applicable law. Such changes, including unauthorized written contract amendments, shall be void and without effect, and the Contractor shall not be entitled to any claim under this contract based on those changes.

 

  8. CHANGES

AHCCCS may at any time, by written notice to the Contractor, make changes within the general scope of this contract. If any such change causes an increase or decrease in the cost of, or the time required for, performance of any part of the work under this contract, the Contractor may assert its right to an adjustment in compensation paid under this contract. The Contractor must assert its right to such adjustment within 30 days from the date of receipt of the change notice. Any dispute or disagreement caused by such notice shall constitute a dispute within the meaning of Section, Contract Terms and Conditions, Disputes, and be administered accordingly.

Contract amendments are subject to approval by the Centers for Medicare and Medicaid Services (CMS), and approval is withheld until all amendments are signed by the Contractor. When AHCCCS issues an Amendment to modify the Contract, the Contractor shall ensure contract amendments are signed and submitted to AHCCCS by the date specified by AHCCCS. The provisions of such amendment will be deemed to have been accepted on the day following the date AHCCCS requires an executed amendment, even if the amendment has not been signed by the Contractor, unless within that time the Contractor notifies AHCCCS in writing that it refuses to sign the amendment. If the Contractor provides such notification, AHCCCS will initiate termination proceedings.

 

  9. CHOICE OF FORUM

The parties agree that jurisdiction over any action arising out of or relating to this contract shall be brought or filed in a court of competent jurisdiction located in the State of Arizona.

 

  10. COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS

The Contractor shall comply with all applicable Federal and State laws and regulations including Title VI of the Civil Rights Act of 1964; Title IX of the Education Amendments of 1972 (regarding education programs and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973 (regarding education programs and activities), and the Americans with Disabilities Act; EEO provisions; Copeland Anti-Kickback Act; Davis-Bacon Act; Contract Work Hours and Safety Standards; Rights to Inventions Made Under a Contract or Agreement; Clean Air Act and Federal Water Pollution Control Act; Byrd Anti-Lobbying Amendment. The Contractor shall maintain all applicable licenses and permits.

 

  11. CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION

The Contractor shall safeguard confidential information in accordance with Federal and State laws and regulations, including but not limited to, 42 CFR 431, Subpart F, A.R.S. §36-107, §36-2903 (for Acute), §36-2932 (for ALTCS), §41-1959 and §46-135, the Health Insurance Portability and Accountability Act (Public Law 107-191 Statutes 1936), 45 CFR parts 160 and 164, and AHCCCS Rules.

 

3


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

The Contractor shall establish and maintain procedures and controls that are acceptable to AHCCCS for the purpose of assuring that no information contained in its records or obtained from AHCCCS or others carrying out its functions under the contract shall be used or disclosed by its agents, officers or employees, except as required to efficiently perform duties under the contract. Except as required or permitted by law, the Contractor also agrees that any information pertaining to individual persons shall not be divulged other than to employees or officers of the Contractor as needed for the performance of duties under the contract, unless otherwise agreed to, in writing, by AHCCCS.

The Contractor shall not, without prior written approval from AHCCCS, either during or after the performance of the services required by this contract, use, other than for such performance, or disclose to any person other than AHCCCS personnel with a need to know, any information, data, material, or exhibits created, developed, produced, or otherwise obtained during the course of the work required by this contract. This nondisclosure requirement shall also pertain to any information contained in reports, documents, or other records furnished to the Contractor by AHCCCS.

 

  12. CONFLICT OF INTEREST

The Contractor shall not undertake any work that represents a potential conflict of interest, or which is not in the best interest of AHCCCS or the State without prior written approval by AHCCCS. The Contractor shall fully and completely disclose any situation that may present a conflict of interest. If the Contractor is now performing or elects to perform during the term of this contract any services for any AHCCCS health plan, provider or Contractor or an entity owning or controlling same, the Contractor shall disclose this relationship prior to accepting any assignment involving such party.

 

  13. CONTINUATION OF PERFORMANCE THROUGH TERMINATION

The Contractor shall continue to perform, in accordance with the requirements of the contract, up to the date of termination and as directed in the termination notice.

 

  14. CONTRACT

The Contract between AHCCCS and the Contractor shall include: 1) the Request for Proposal (RFP) including AHCCCS policies and procedures incorporated by reference as part of the RFP, 2) the proposal submitted by the Contractor in response to the RFP including any Best and Final Offers, and 3) any Contract amendments. In the event of a conflict in language between the proposal (including any Best and Final Offers) and the RFP (including AHCCCS policies and procedures incorporated by reference), the provisions and requirements set forth and/or referenced in the RFP (including AHCCCS policies and procedures incorporated by reference) shall govern.

The Contract shall be construed according to the laws of the State of Arizona. The State of Arizona is not obligated for the expenditures under the contract until funds have been encumbered.

 

  15. CONTRACT INTERPRETATION AND AMENDMENT

No Parole Evidence - This contract is intended by the parties as a final and complete expression of their agreement. No course of prior dealings between the parties and no usage of the trade shall supplement or explain any term used in this contract.

 

4


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

No Waiver - Either party’s failure to insist on strict performance of any term or condition of the contract shall not be deemed a waiver of that term or condition even if the party accepting or acquiescing in the non-conforming performance knows of the nature of the performance and fails to object to it.

Written Contract Amendments - The contract shall be modified only through a written contract amendment within the scope of the contract signed by the procurement officer on behalf of the State and signed by a duly authorized representative of the Contractor.

 

  16. COOPERATION WITH OTHER CONTRACTORS

AHCCCS may award other contracts for additional work related to this contract and Contractor shall fully cooperate with such other contractors and AHCCCS employees or designated agents. The Contractor shall not commit or permit any act which will interfere with the performance of work by any other Contractor or by AHCCCS employees.

 

  17. COVENANT AGAINST CONTINGENT FEES

The Contractor warrants that no person or agency has been employed or retained to solicit or secure this contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee. For violation of this warranty, AHCCCS shall have the right to annul this contract without liability.

 

  18. DATA CERTIFICATION

The Contractor shall certify that financial and encounter data submitted to AHCCCS is complete, accurate and truthful. Certification of financial and encounter data must be submitted concurrently with the data. Certification may be provided by the Contractor CEO, CFO or an individual who is delegated authority to sign for, and who reports directly to the CEO or CFO [42 CFR 438.604 et seq.].

 

  19. DISPUTES

Contract claims and disputes shall be adjudicated in accordance with State Law, AHCCCS Rules and this contract.

Except as provided by 9 A.A.C. Chapter 22, Article 6, the exclusive manner for the Contractor to assert any dispute against AHCCCS shall be in accordance with the process outlined in 9 A.A.C. Chapter 34 and A.R.S. §36-2932. All disputes except as provided under 9 A.A.C. Chapter 22, Article 6 shall be filed in writing and be received by AHCCCS no later than 60 days from the date of the disputed notice. All disputes shall state the factual and legal basis for the dispute. Pending the final resolution of any disputes involving this contract, the Contractor shall proceed with performance of this contract in accordance with AHCCCS’ instructions, unless AHCCCS specifically, in writing, requests termination or a temporary suspension of performance.

 

  20. E-VERIFY REQUIREMENTS

In accordance with A.R.S §41-4401, the Contractor warrants compliance with all Federal immigration laws and regulations relating to employees and warrants its compliance with Section A.R.S. §23-214, Subsection A.

 

5


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  21. EFFECTIVE DATE

The effective date of this contract shall be the Offer and Acceptance date referenced on page 1 of this contract.

ELIGIBILITY FOR STATE OR LOCAL PUBLIC BENEFITS; DOCUMENTATION AND VIOLATIONS To the extent permitted by Federal Law:

The Contractor shall comply with A.R.S § 1-502. A.R.S § 1-502 requires each person applying or receiving a public benefit to provide documented proof which demonstrates a lawful presence in the United States.

The State shall reserve the right to conduct unscheduled, periodic process and documentation audits to ensure Contractor compliance. All available Contract remedies, up to and including termination may be taken for failure to comply with A.R.S § 1-502 in the delivery of services under this Contract.

 

  22. EMPLOYEES OF THE CONTRACTOR

All employees of the Contractor employed in the performance of work under the Contract shall be considered employees of the Contractor at all times, and not employees of AHCCCS or the State. The Contractor shall comply with the Social Security Act, Workman’s Compensation laws and Unemployment laws of the State of Arizona and all State, local and Federal legislation relevant to the Contractor’s business.

 

  23. FEDERAL IMMIGRATION AND NATIONALITY ACT

The Contractor shall comply with all Federal, State and local immigration laws and regulations relating to the immigration status of their employees during the term of the contract. Further, the Contractor shall flow down this requirement to all subcontractors utilized during the term of the contract. The State shall retain the right to perform random audits of Contractor and subcontractor records or to inspect papers of any employee thereof to ensure compliance. Should the State determine that the Contractor and/or any subcontractors be found noncompliant, the State may pursue all remedies allowed by law, including, but not limited to; suspension of work, termination of the contract for default and suspension and/or debarment of the Contractor.

 

  24. GRATUITIES

AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it determines that employment or a gratuity was offered or made by the Contractor or a representative of the Contractor to any officer or employee of the State for the purpose of influencing the outcome of the procurement or securing the contract, an amendment to the contract, or favorable treatment concerning the contract, including the making of any determination or decision about contract performance. AHCCCS, in addition to any other rights or remedies, shall be entitled to recover exemplary damages in the amount of three times the value of the gratuity offered by the Contractor.

 

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TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  25. INCORPORATION BY REFERENCE

This solicitation and all attachments and amendments, the Contractor’s proposal, best and final offer accepted by ADHS/DBHS, and any approved subcontracts are hereby incorporated by reference into the contract.

 

  26. INDEMNIFICATION

Contractor/Vendor Indemnification (Not Public Agency):

The parties to this contract agree that the State of Arizona, its departments, agencies, boards and commissions shall be indemnified and held harmless by the Contractor for the vicarious liability of the State as a result of entering into this contract. The Contractor agrees to indemnify, defend, and hold harmless the State from and against any and all claims, losses, liability, costs, and expenses, including attorney’s fees and costs, arising out of litigation against AHCCCS including, but not limited to, class action lawsuits challenging actions by the Contractor. The requirement for indemnification applies irrespective of whether or not the Contractor is a party to the lawsuit. Each Contractor shall indemnify the State, on a pro rata basis based on population, attorney’s fees and costs awarded against the State as well as the attorney’s fees and costs incurred by the State in defending the lawsuit. The Contractor shall also indemnify AHCCCS, on a pro rata basis based on population, the administrative expenses incurred by AHCCCS to address Contractor deficiencies arising out of the litigation. The parties further agree that the State of Arizona, its departments, agencies, boards and commissions shall be responsible for its own negligence and/or willful misconduct. Each party to this contract is responsible for its own negligence and/or willful misconduct.

Contractor/Vendor Indemnification (Public Agency):

Each party (“as indemnitor”) agrees to indemnify, defend, and hold harmless the other party (“as indemnitee”) from and against any and all claims, losses, liability, costs, or expenses (including reasonable attorney’s fees) (hereinafter collectively referred to as ‘claims’) arising out of bodily injury of any person (including death) or property damage but only to the extent that such claims which result in vicarious/derivative liability to the indemnitee, are caused by the act, omission, negligence, misconduct, or other fault of the indemnitor, its officers, officials, agents, employees, or volunteers.

 

  27. INDEMNIFICATION - PATENT AND COPYRIGHT

To the extent permitted by applicable law the Contractor shall defend, indemnify and hold harmless the State against any liability including costs and expenses for infringement of any patent, trademark or copyright arising out of contract performance or use by the State of materials furnished or work performed under this contract. The State shall reasonably notify the Contractor of any claim for which it may be liable under this paragraph.

 

  28. INSURANCE

The Contractor is required to maintain insurance, at a minimum, as specified in Attachment E-1 Standard Professional Service Contracts. For policies for insurance for professional service contracts working with children or vulnerable adults, the policy may be endorsed to include coverage for sexual abuse and molestation.

 

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TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

ATTACHMENT E-1

STANDARD PROFESSIONAL SERVICE CONTRACT

INDEMNIFICATION CLAUSE:

To the fullest extent permitted by law, Contractor shall defend, indemnify, save and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as “Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as “Claims”) for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any claim or amount arising out of or recovered under the Workers’ Compensation Law or arising out of the failure of such Contractor to conform to any Federal, State or local law, statute, ordinance, rule, regulation or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for primary loss investigation, defense and judgment costs where this indemnification is applicable. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents and employees for losses arising from the work performed by the Contractor for the State of Arizona.

This indemnity shall not apply if the Contractor or subcontractor(s) is/are an agency, board, commission or university of the State of Arizona.

 

  1. INSURANCE REQUIREMENTS:

Contractors shall procure and maintain until all of their obligations have been discharged, including any warranty periods under this Contract, insurance against claims for injury to persons or damage to property arising from or in connection with the performance of the work hereunder by the Contractor, its agents, representatives, employees or subcontractors.

The insurance requirements herein are minimum requirements for this Contract and in no way limit the indemnity covenants contained in this Contract. The State of Arizona in no way warrants that the minimum limits contained herein are sufficient to protect the Contractor from liabilities that arise out of the performance of the work under this contract by the Contractor, its agents, representatives, employees or subcontractors, and the Contractor is free to purchase additional insurance.

 

A. MINIMUM SCOPE AND LIMITS OF INSURANCE: Contractor shall provide coverage with limits of liability not less than those stated below.

 

  1. Commercial General Liability (CGL) – Occurrence Form

Policy shall include bodily injury, property damage, and broad form contractual liability coverage.

 

•        General Aggregate

   $ 2,000,000   

•        Products – Completed Operations Aggregate

   $ 1,000,000   

•        Personal and Advertising Injury

   $ 1,000,000   

•        Damage to Rented Premises

   $ 50,000   

•        Each Occurrence

   $ 1,000,000   

 

  a. The policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

 

  b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

 

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TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  2. Business Automobile Liability

Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles used in the performance of this Contract.

 

    Combined Single Limit (CSL) $1,000,000

 

  a. Policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, leased, hired, and/or non-owned by the Contractor.

 

  b. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

 

  c. Policy shall contain a severability of interest provision.

 

  3. Worker’s Compensation and Employers’ Liability

 

    Workers’ Compensation Statutory

 

    Employers’ Liability

 

Each Accident

   $ 500,000   

Disease – Each Employee

   $ 500,000   

Disease – Policy Limit

   $ 1,000,000   

 

  a. Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

 

  b. This requirement shall not apply to each Contractor or subcontractor that is exempt under A.R.S. §23-901, and when such Contractor or subcontractor executes the appropriate waiver form (Sole Proprietor or Independent Contractor).

 

  4. Professional Liability (Errors and Omissions Liability)

 

Each Claim

   $ 1,000,000   

Annual Aggregate

   $ 2,000,000   

 

  a. In the event that the Professional Liability insurance required by this Contract is written on a claims-made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this Contract; and either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two years beginning at the time work under this Contract is completed.

 

  b. The policy shall cover professional misconduct or negligent acts for those positions defined in the Scope of Work of this Contract.

 

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TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

B. ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be endorsed to include, as required by this written agreement, the following provisions:

 

  1. The Contractor’s policies shall stipulate that the insurance afforded the Contractor shall be primary and that any insurance carried by AHCCCS, its agents, officials, employees or the State of Arizona shall be excess and not contributory insurance, as provided by A.R.S. §41-621 (E).

 

  2. Insurance provided by the Contractor shall not limit the Contractor’s liability assumed under the indemnification provisions of this Contract.

 

C. NOTICE OF CANCELLATION: For each insurance policy required by the insurance provisions of this Contract, the Contractor must provide to the State of Arizona, within two (2) business days of receipt, a notice if a policy is suspended, voided, or cancelled for any reason. Such notice shall be sent to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034.

 

D. ACCEPTABILITY OF INSURERS: Contractor’s insurance shall be placed with companies licensed in the State of Arizona or hold approved non-admitted status on the Arizona Department of Insurance List of Qualified Unauthorized Insurers. Insurers shall have an “A.M. Best” rating of not less than A- VII. The State of Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect the Contractor from potential insurer insolvency.

 

E. VERIFICATION OF COVERAGE: Contractor shall furnish the State of Arizona with certificates of insurance (valid ACORD form or equivalent approved by the State of Arizona) as required by this Contract and as specified in Exhibit-9, Deliverables. An authorized representative of the insurer shall sign the certificates.

All certificates and endorsements, as required by this written agreement, are to be received and approved by the State of Arizona before work commences. Each insurance policy required by this Contract must be in effect at or prior to commencement of work under this Contract. Failure to maintain the insurance policies as required by this Contract, or to provide evidence of renewal, is a material breach of Contract.

All certificates required by this Contract shall be sent directly to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034. All subcontractors are required to maintain insurance and to provide verification upon request. The AHCCCS project/contract number and project description shall be noted on the certificate of insurance. The State of Arizona and AHCCCS reserves the right to require complete, certified copies of all insurance policies required by this Contract at any time.

 

F. SUBCONTRACTORS: Contractors’ certificate(s) shall include all subcontractors as insureds under its policies or Contractor shall be responsible for ensuring and/or verifying that all subcontractors have valid and collectable insurance as evidenced by the certificates of insurance and endorsements for each subcontractor. All coverages for subcontractors shall be subject to the AHCCCS Minimum Subcontract Provisions located on the AHCCCS website. AHCCCS reserves the right to require, at any time throughout the life of this contract, proof from the Contractor that its subcontractors have the required coverage.

 

G. APPROVAL AND MODIFICATIONS: AHCCCS, in consultation with State Risk, reserves the right to review or make modifications to the insurance limits, required coverages, or endorsements throughout the life of this contract, as deemed necessary. Such action will not require a formal contract amendment but may be made by administrative action.

 

[END OF ATTACHMENT E-1]

 

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TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  29. IRS W9 FORM

In order to receive payment under any resulting contract, the Contractor shall have a current IRS W9 Form on file with the State of Arizona.

 

  30. LOBBYING

No funds paid to the Contractor by AHCCCS, or interest earned thereon, shall be used for the purpose of influencing or attempting to influence an officer or employee of any Federal or State agency, a member of the United States Congress or State Legislature, an officer or employee of a member of the United States Congress or State Legislature in connection with awarding of any Federal or State contract, the making of any Federal or State grant, the making of any Federal or State loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment or modification of any Federal or State contract, grant, loan, or cooperative agreement. The Contractor shall disclose if any funds paid to the Contractor by AHCCCS have been used or will be used to influence the persons and entities indicated above and will assist AHCCCS in making such disclosures to CMS.

 

  31. NO GUARANTEED QUANTITIES

AHCCCS does not guarantee the Contractor any minimum or maximum quantity of services or goods to be provided under this contract.

 

  32. NON-DISCRIMINATION

In accordance with A.R.S. §41-1461 et seq. and Executive Order 2009-09, the Contractor shall provide equal employment opportunities for all persons, regardless of race, color, religion, creed, sex, age, national origin, disability or political affiliation. The Contractor shall comply with the Americans with Disabilities Act.

 

  33. NON-EXCLUSIVE REMEDIES

The rights and the remedies of AHCCCS under this contract are not exclusive.

 

  34. OFF-SHORE PERFORMANCE OF WORK PROHIBITED

Any services that are described in the specifications or scope of work that directly serve the State of Arizona or its clients and involve access to secure or sensitive data or personal client data shall be performed within the defined territories of the United States. Unless specifically stated otherwise in the specifications, this paragraph does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the performance of the contract. This provision applies to work performed by subcontractors at all tiers.

 

  35. ORDER OF PRECEDENCE

The parties to this contract shall be bound by all terms and conditions contained herein. For interpreting such terms and conditions the following sources shall have precedence in descending order: The Constitution and laws of the United States and applicable Federal regulations; the terms of the CMS 1115 waiver for the State of Arizona; the Constitution and laws of Arizona, and applicable State Rules; the terms of this contract which consists of the RFP, the proposal of the successful Offeror, and any Best and Final Offer including any attachments, executed amendments and modifications; and AHCCCS policies and procedures.

 

11


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  36. OWNERSHIP OF INFORMATION AND DATA

Materials, reports and other deliverables created under this contract are the sole property of AHCCCS. The Contractor is not entitled to any rights to those materials and may not transfer any rights to anyone else. Except as necessary to carry out the requirements of this contract, as otherwise allowed under this contract, or as required by law, the Contractor shall not use or release data, information or materials, reports, or deliverables derived from that data or information without the prior written consent of AHCCCS. Data, information and reports collected or prepared by the Contractor in the course of performing its duties and obligations under this contract shall not be used by the Contractor for any independent project of the Contractor or publicized by the Contractor without the prior written permission of AHCCCS. Subject to applicable state and Federal laws and regulations, AHCCCS shall have full and complete rights to reproduce, duplicate, disclose and otherwise use all such information.

At the termination of the contract, the Contractor shall make available all such data to AHCCCS within 30 days following termination of the contract or such longer period as approved by AHCCCS, Office of the Director. For purposes of this subsection, the term “data” shall not include member medical records.

Except as otherwise provided in this section, if any copyrightable or patentable material is developed by the Contractor in the course of performance of this contract, the Federal government, AHCCCS and the State of Arizona shall have a royalty-free, nonexclusive, and irrevocable right to reproduce, publish, or otherwise use, and to authorize others to use, the work for state or Federal government purposes. The Contractor shall additionally be subject to the applicable provisions of 45 CFR Part 74.

 

  37. RESERVED

 

  38. RELATIONSHIP OF PARTIES

The Contractor under this contract is an independent Contractor. Neither party to this contract shall be deemed to be the employee or agent of the other party to the contract.

 

  39. RIGHT OF OFFSET

AHCCCS shall be entitled to offset against any sums due the Contractor any expenses or costs incurred by AHCCCS or damages assessed by AHCCCS concerning the Contractor’s non-conforming performance or failure to perform the contract, including but not limited to expenses, costs and damages.

 

  40. RIGHT TO ASSURANCE

If AHCCCS, in good faith, has reason to believe that the Contractor does not intend to perform or is unable to continue to perform this contract, the procurement officer may demand in writing that the Contractor give a written assurance of intent to perform. The demand shall be sent to the Contractor by certified mail, return receipt required. Failure by the Contractor to provide written assurance within the number of days specified in the demand may, at the State’s option, be the basis for terminating the contract.

 

  41. RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS

AHCCCS may, at reasonable times, inspect the part of the plant or place of business of the Contractor or subcontractor that is related to the performance of this contract, in accordance with A.R.S. §41-2547.

 

12


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  42. RESERVED

 

  43. SEVERABILITY

The provisions of this contract are severable. Any term or condition deemed illegal or invalid shall not affect any other term or condition of the contract.

 

  44. SUSPENSION OR DEBARMENT

The Contractor shall not employ, consult, subcontract or enter into any agreement for Title XIX services with any person or entity who is debarred, suspended or otherwise excluded from Federal procurement activity or from participating in non-procurement activities under regulations issued under Executive Order 12549 [42 CFR 438.610(a)(b)] or under guidelines implementing Executive Order 12549. This prohibition extends to any entity which employs, consults, subcontracts with or otherwise reimburses for services any person substantially involved in the management of another entity which is debarred, suspended or otherwise excluded from Federal procurement activity. The Contractor is obligated to screen all employees and contractors to determine whether any of them have been excluded from participation in Federal health care programs. The Contractor can search the HHS-OIG website by the names of any individuals. The database can be accessed at http://www.oig.hhs.gov/fraud/exclusions.asp.

The Contractor shall not retain as a director, officer, partner or owner of 5% or more of the Contractor entity, any person, or affiliate of such a person, who is debarred, suspended or otherwise excluded from Federal procurement activity.

AHCCCS may, by written notice to the Contractor, immediately terminate this contract if it determines that the Contractor has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity.

 

  45. TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR

Temporary Management/Operation by AHCCCS: Pursuant to the Medicaid Managed Care Regulations, 42 CFR 438.700 et seq. and State Law A.R.S. §36-2903, AHCCCS is authorized to impose temporary management for a Contractor under certain conditions. Under Federal law, temporary management may be imposed if AHCCCS determines that there is continued egregious behavior by the Contractor, including but not limited to the following: substantial failure to provide medically necessary services the Contractor is required to provide; imposition on enrollees premiums or charges that exceed those permitted by AHCCCS, discrimination among enrollees on the basis of health status or need for health care services; misrepresentation or falsification of information to AHCCCS or CMS; misrepresentation or falsification of information furnished to an enrollee or provider; distribution of marketing materials that have not been approved by AHCCCS or that are false or misleading; or behavior contrary to any requirements of Sections 1903(m) or 1932 of the Social Security Act. Temporary management may also be imposed if AHCCCS determines that there is substantial risk to enrollees’ health or that temporary management is necessary to ensure the health of enrollees while the Contractor is correcting the deficiencies noted above or until there is an orderly transition or reorganization of the Contractor. Under Federal law, temporary management is mandatory if AHCCCS determines that the Contractor has repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932 of the Social Security Act. Pursuant to 42 CFR 438.706, AHCCCS shall not delay imposition of temporary management to provide a hearing before imposing this sanction.

 

13


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

If AHCCCS undertakes direct operation of the Contractor, AHCCCS, through designees appointed by the Director, shall be vested with full and exclusive power of management and control of the Contractor as necessary to ensure the uninterrupted care to persons and accomplish the orderly transition of persons to a new or existing Contractor, or until the Contractor corrects the contract performance failure to the satisfaction of AHCCCS. AHCCCS shall have the power to employ any necessary assistants, to execute any instrument in the name of the Contractor, to commence, defend and conduct in its name any action or proceeding in which the Contractor may be a party; such powers shall only apply with respect to activities occurring after AHCCCS undertakes direct operation of the Contractor in connection with this Section.

All reasonable expenses of AHCCCS related to the direct operation of the Contractor, including attorney fees, cost of preliminary or other audits of the Contractor and expenses related to the management of any office or other assets of the Contractor, shall be paid by the Contractor or withheld from payment due from AHCCCS to the Contractor.

 

  46. TERM OF CONTRACT AND OPTION TO RENEW

The “Term of Contract” shall commence on the Contract Award Date, include the Contract Transition Period (the time period between the Contract Award Date to the Contract Performance Start Date) and end 36 months after the Contract Performance Start Date. Contract Performance Start Date will begin on October 1, 2015, and shall continue for a period of three years thereafter, unless terminated, canceled or extended as otherwise provided herein. The total Contract term for this section will be for three years delivering services to members, plus the Contract Transition Period. The contract cycle is October 1 through September 30 with an annual October 1 renewal. The State refers to the first three Contract periods during the Term of Contract as:

First Contract period: Starts on the Contract Award Date, includes the Contract Transition Period, and ends 12 months after Contract Performance Start Date.

Second Contract period: Starts after the end of the first Contract period and ends 12 months later.

Third Contract period: Starts after the end of the second Contract period and ends twelve 12 months later.

The terms and conditions of any such contract extension shall remain the same as the original contract, as amended. Any contract extension shall be through contract amendment, and shall be at the sole option of AHCCCS.

If the Contractor has been awarded a contract in more than one GSA, each such contract will be considered separately renewable. AHCCCS may renew the Contractor’s contract in one GSA, but not in another. In the event AHCCCS determines there are issues of noncompliance by the Contractor in one GSA, AHCCCS may request an enrollment cap for the Contractor’s contracts in all other GSAs. Further, AHCCCS may require the Contractor to renew all currently awarded GSAs, or may terminate the contract if the Contractor does not agree to renew all currently awarded GSAs.

 

14


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

When the Contracting Officer issues an amendment to extend the contract, the provisions of such extension will be deemed to have been accepted 30 days after the date of mailing by the Contracting Officer, unless a different time period is specified by AHCCCS, even if the extension amendment has not been signed by the Contractor, unless within that time the Contractor notifies the Contracting Officer in writing that it refuses to sign the extension amendment. Failure of an existing Contractor to accept an amendment (or renew) may result in immediate suspension/termination of member assignment. If the Contractor provides such notification, the Contracting Officer will initiate contract termination proceedings.

If the Contractor chooses not to renew this contract, the Contractor may be liable for certain costs associated with the transition of its members to a different Contractor. The Contractor is required to provide 180 days advance written notice to the Contracts and Purchasing Administrator of its intent not to renew the contract. If the Contractor provides the Contracts and Purchasing Administrator written notice of its intent not to renew this contract at least 180 days before its expiration, this liability for transition costs may be waived by the Contracting Officer.

Contract extension periods shall, if authorized by the State, begin after the “Term of Contract” section of these Contract Terms and Conditions. This Contract is subject to two additional successive periods of up to 24 months per extension period. The State refers to Contract periods four and five during the Contract Extensions period as:

Fourth Contract period: Starts after the end of the third Contract period and is extended for a period of time not to exceed 24 months.

Fifth Contract period: Starts after the end of the fourth Contract period and is extended for a period of time not to exceed 24 months.

 

  47. TERMINATION

AHCCCS reserves the right to terminate this contract in whole or in part by reason of force majeure, due to the failure of the Contractor to comply with any term or condition of the contract, including, but not limited to, circumstances which present risk to member health or safety, and as authorized by the Balanced Budget Act of 1997 and 42 CFR 438.708. The term force majeure means an occurrence that is beyond the control of AHCCCS and occurs without its fault or negligence. Force majeure includes acts of God and other similar occurrences beyond the control of AHCCCS which it is unable to prevent by exercising reasonable diligence.

If the Contractor is providing services under more than one contract with AHCCCS, AHCCCS may deem unsatisfactory performance under one contract to be cause to require the Contractor to provide assurance of performance under any and all other contracts. In such situations, AHCCCS reserves the right to seek remedies under both actual and anticipatory breaches of contract if adequate assurance of performance is not received. The Contracting Officer shall mail written notice of the termination and the reason(s) for it to the Contractor by certified mail, return receipt requested. Pursuant to the Balanced Budget Act of 1997 and 42 CFR 438.708, AHCCCS shall provide the Contractor with a pre-termination hearing before termination of the contract.

Upon termination, all documents, data, and reports prepared by the Contractor under the contract shall become the property of and be delivered to immediately AHCCCS on demand.

AHCCCS may, upon termination of this contract, procure on terms and in the manner that it deems appropriate, materials or services to replace those under this contract. The Contractor shall be liable for any excess costs incurred by AHCCCS in re-procuring the materials or services.

 

15


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  48. TERMINATION - AVAILABILITY OF FUNDS

Funds are not presently available for performance under this contract beyond the current fiscal year. No legal liability on the part of AHCCCS for any payment may arise under this contract until funds are made available for performance of this contract.

Notwithstanding any other provision in the Agreement, this Agreement may be terminated by Contractor, if, for any reason, there are not sufficient appropriated and available monies for the purpose of maintaining this Agreement. In the event of such termination, the Contractor shall have no further obligation to AHCCCS.

 

  49. TERMINATION FOR CONFLICT OF INTEREST

AHCCCS may cancel this contract without penalty or further obligation if any person significantly involved in initiating, negotiating, securing, drafting or creating the contract on behalf of AHCCCS is, or becomes at any time while the contract or any extension of the contract is in effect, an employee of, or a consultant to, any other party to this contract with respect to the subject matter of the contract. The cancellation shall be effective when the Contractor receives written notice of the cancellation unless the notice specifies a later time.

If the Contractor is a political subdivision of the State, it may also cancel this contract as provided by A.R.S. §38-511.

 

  50. TERMINATION FOR CONVENIENCE

AHCCCS reserves the right to terminate the contract in whole or in part at any time for the convenience of the State without penalty or recourse. The Contracting Officer shall give written notice by certified mail, of the termination at least 90 days before the effective date of the termination. Upon receipt of written notice, the Contractor shall stop all work, as directed in the notice, notify all subcontractors of the effective date of the termination and minimize all further costs to the State. In the event of termination under this paragraph, all documents, data and reports prepared by the Contractor under the contract shall become the property of and be delivered to AHCCCS immediately on demand. The Contractor shall be entitled to receive just and equitable compensation for work in progress, work completed and materials accepted before the effective date of the termination.

 

  51. TERMINATION UPON MUTUAL AGREEMENT

This Contract may be terminated by mutual written agreement of the parties effective upon the date specified in the written agreement. If the parties cannot reach agreement regarding an effective date for termination, AHCCCS will determine the effective date.

 

  52. THIRD PARTY ANTITRUST VIOLATIONS

The Contractor assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to the Contractor toward fulfillment of this contract.

 

16


TERMS AND CONDITIONS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  53. TYPE OF CONTRACT

Fixed-Price, stated as capitated per member per month, except as otherwise provided.

 

  54. WARRANTY OF SERVICES

The Contractor warrants that all services provided under this contract will conform to the requirements stated herein. AHCCCS’ acceptance of services provided by the Contractor shall not relieve the Contractor from its obligations under this warranty. In addition to its other remedies, AHCCCS may, at the Contractor’s expense, require prompt correction of any services failing to meet the Contractor’s warranty herein. Services corrected by the Contractor shall be subject to all of the provisions of this contract in the manner and to the same extent as the services originally furnished.

 

17


TABLE OF CONTENTS

REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

INTRODUCTION

     25  
1.1   

OVERVIEW

     25  
1.2   

System Values and Guiding Principles

     26  
1.3   

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

     26  
2   

MEDICAID ELIGIBILTY

     28   
2.1   

Medicaid Eligible Populations

     28  
2.2   

Special Medicaid Eligibility-Members Awaiting Transplants

     29  
2.3   

Reserved

     30  
2.4   

Eligibility and Member Verification

     30  
2.5   

Medicaid Eligibility Determination

     31  
3   

ENROLLMENT AND DISENROLLMENT

     31   
3.1   

Enrollment and Disenrollment of Populations

     31   
3.2   

Opt-Out For Cause

     33   
3.3   

Prior Quarter Coverage

     35  
3.4   

Prior Period Coverage

     35   
3.5   

Hospital Presumptive Eligibility

     36   
4   

SCOPE OF SERVICES

     36  
4.1   

Overview

     36   
4.2   

General Requirements for the System of Care

     36   
4.3   

Behavioral Health Covered Services

     39  
4.4   

Behavioral Health Service Delivery Approach

     39  
4.5   

Behavioral Health Services for Adult Members

     39  
4.6   

Behavioral Health Services for Child Members

     39  
4.7   

Physical Health Care Covered Services

     41  
4.8   

Integrated Health Care Service Delivery for SMI Members

     50  
4.9   

Health Education and Health Promotion Services

     51  
4.10   

American Indian Member Services

     52  
4.11   

Medications

     52   
4.12   

Prescription Medications

     53   
4.13   

Medication Management Services

     53   
4.14   

Laboratory Testing Services

     53  
4.15   

Crisis Services Overview

     54  
4.16   

Crisis Services-General Requirements

     54  
4.17   

Crisis Services-Telephone Response

     56  

 

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REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

4.18   

Crisis Services-Mobile Crisis Teams

     57  
4.19   

Crisis Services- Crisis Stabilization Settings

     57  
4.20   

Pediatric Immunizations and the Vaccines for Children Program

     58  
4.21   

Medicaid School Based Claiming Program (MSBC)

     58  
4.22   

Special Health Care Needs

     59  
4.23   

Special Assistance for SMI Members

     60  
4.24   

Psychiatric Rehabilitative Services-Employment

     60   
4.25   

Psychiatric Rehabilitative Services-Peer Support

     60   
5   

CARE COORDINATION AND COLLABORATION

     61   
5.1   

Care Coordination

     61  
5.2   

Care Coordination for Dual Eligible SMI Members

     63  
5.3   

Coordination with AHCCCS Contractors and Primary Care Providers

     65  
5.4   

Collaboration with System Stakeholders

     66  
5.5   

Collaboration to Improve Health Care Service Delivery

     69  
5.6   

Collaboration with Peers and Family Members

     69  
5.7   

Collaboration with Tribal Nations

     69   
5.8   

Coordination for Transitioning Members

     70   
6   

PROVIDER NETWORK

     73  
6.1   

Network Development

     73  
6.2   

Network Development for Integrated Health Care Service Delivery

     75  
6.3   

Network Management

     76  
6.4   

Out of Network Providers

     76   
6.5   

Material Change to Provider Network

     77   
6.6   

Provider Affiliation Transmission

     77   
7   

PROVIDER REQUIREMENTS

     78   
7.1   

Provider General Requirements

     78  
7.2   

Provider Registration Requirements

     78  
7.3   

Provider Manual Policy Requirements

     78  
7.4   

Provider Manual Policy Network Requirements

     81  
7.5   

Specialty Service Providers

     82  
7.6   

Primary Care Provider Standards

     82  
7.7   

Maternity Care Provider Standards

     84  
7.8   

Federally Qualified Health Centers and Rural Health Clinics

     85  

 

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REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

8   

MEDICAL MANAGEMENT

     86   
8.1   

General Requirements

     86   
8.2   

Utilization Data Analysis and Data Management

     89   
8.3   

Prior Authorization

     90   
8.4   

Concurrent Review

     91   
8.5   

Additional Authorization Requirements

     91   
8.6   

Discharge Planning

     91   
8.7   

Inter- rater Reliability

     92   
8.8   

Retrospective Review

     92   
8.9   

Practice Guidelines

     92   
8.10   

New Medical Technologies and New Uses of Existing Technologies

     92   
8.11   

Care Coordination

     92   
8.12   

Disease Management

     93   
8.13   

Care Management Program-Goals

     93   
8.14   

Care Management Program-General Requirements

     94   
8.15   

Drug Utilization Review

     95   
8.16   

Pre-Admission Screening and Resident Review (PASRR) Requirements

     95   
8.17   

Medical Management Reporting Requirements

     96   
9   

APPOINTMENT AND REFERRAL REQUIREMENTS

     96   
9.1   

Appointments

     96   
9.2   

Additional Appointment Requirements for SMI Members

     98   
9.3   

Referral Requirements

     99   
9.4   

Disposition of Referrals

     100   
9.5   

Provider Directory

     100   
9.6   

Referral for a Second Opinion

     100   
9.7   

Additional Referral Requirements for SMI Members

     100   
10   

QUALITY MANAGEMENT

     102   
10.1   

General Requirements

     102   
10.2   

Credentialing

     104   
10.3   

Incident, Accident and Death Reports

     105   
10.4   

Quality of Care Concerns and Investigations

     105   
10.5   

Performance Measures

     106   
10.6   

Performance Improvement Projects

     111   
10.7   

Data Collection Procedures

     111   
10.8   

Member Satisfaction Survey

     112   

 

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GREATER ARIZONA

 

10.9   

Provider Monitoring

     112   
10.10   

Centers of Excellence

     113   
10.11   

Quality Management Reporting Requirements

     113   
11   

COMMUNICATIONS

     114   
11.1   

Member Information

     114   
11.2   

Member Handbooks

     115   
11.3   

Member Newsletters

     116   
11.4   

Health Promotion

     117   
11.5   

Marketing

     118   
11.6   

Web Site Requirements

     119   
11.8   

Outreach

     119   
11.9   

Identification Cards for SMI Members Receiving Physical Health Care Services

     119   
12   

CULTURAL COMPETENCY

     119   
12.1   

General Requirements

     119   
12.2   

Cultural Competency Program

     120   
12.3   

Translation Services

     121   
13   

GRIEVANCE SYSTEM REQUIREMENTS

     122   
13.1   

General Requirements

     122   
13.2   

Member Grievances

     124   
13.3   

TXIX/XXI Member Appeals

     124   
13.4   

Claim Disputes

     125   
13.5   

Grievance System Reporting Requirements

     125   
14   

CORPORATE COMPLIANCE PROGRAM

     125   
14.1   

General Requirements

     125   
14.2   

Fraud, Waste and Abuse

     126   
14.3   

Disclosure of Ownership and Control

     127   
14.4   

Disclosure of Information on Persons Convicted of Crimes

     128   
15   

FINANCIAL MANAGEMENT

     131   
15.1   

General Requirements

     131   
15.2   

Performance Bond

     131   
15.3   

Financial Reports

     132   
15.4   

Financial Viability/Performance Standards

     133   
15.5   

Health Insurer Fee

     134   
15.6   

Compensation

     135   

 

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GREATER ARIZONA

 

15.7   

Capitation Rates and Contractor Specific Requirement Adjustments

     137   
15.8   

Payments

     139   
15.9   

Community Reinvestment

     140  
15.10   

Recoupments

     140  
15.11   

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

     141  
15.12   

Advances, Equity Distributions, Loans, and Investments

     142   
15.13   

Member Billing and Liability for Payment

     142  
15.14   

Medicare Services and Cost Sharing Requirements

     142  
15.15   

Capitalization Requirements

     144  
15.16   

Coordination of Benefits and Third Party Liability Requirements

     144  
15.17   

Post-payment Recovery Requirements

     147  
15.18   

Retroactive Recoveries

     147  
15.19   

Total Plan Case Requirements

     148  
15.20   

Other Financial Obligations

     149  
16   

PROVIDER AGREEMENT REIMBURSEMENT

     149   
16.1   

Physician Incentive Requirements

     149  
16.2   

Nursing Facility Reimbursement

     150  
17   

INFORMATION SYSTEMS AND DATA EXCHANGE REQUIREMENTS

     150   
17.1   

Overview

     150  
17.2   

Systems Function and Capacity

     150  
17.3   

Management Information System (MIS)

     152  
17.4   

Data and Document Management Requirements

     153  
17.5   

System and Data Integration Requirements

     154  
17.6   

Electronic Transactions

     154  
17.7   

System Upgrade Plan

     154  
17.8   

Participation in Information Systems Work Groups/Committees

     154  
17.9   

Enrollment and Eligibility Data Exchange

     156  
17.10   

Claims and Encounter Submission and Processing Requirements

     156  
17.11   

Encounter Reporting

     159  
17.12   

Encounter Corrections

     159  
17.13   

AHCCCS Encounter Data Validation Study (EDVS)

     160  
17.14   

Claims Payment System Requirements

     160   
17.15   

General Claims Processing Requirements

     162  

 

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GREATER ARIZONA

 

17.16   

Claims System Reporting

     164  
17.17   

Claims Audits

     164  
17.18   

Demographic Data Submission

     165  
17.19   

Other Electronic Data Requests

     165  
18   

ADMINISTRATIVE REQUIREMENTS

     165   
18.1   

General Requirements

     165  
18.2   

AHCCCS Guidelines, Policies and Manuals

     166   
18.3   

Organizational Structure

     166  
18.4   

Peer Involvement and Participation

     169  
18.5   

Key Staff

     169  
18.6   

Organizational Staff

     171  
18.7   

Liaisons and Coordinators

     179  
18.8   

Training Program Requirements

     182  
18.9   

Training Reporting Requirements

     184  
18.10   

Medical Records

     184  
18.11   

Consent and Authorization

     185  
18.12   

Advance Directives

     185  
18.13   

Business Continuity and Recovery Plan

     186  
18.14   

Emergency Preparedness

     187  
18.15   

Legislative, Legal and Regulatory Issues

     187  
18.16   

Pending Legislation and Other Issues

     189  
18.17   

Copayments

     190  
18.18   

Administrative Performance Standards

     190  
18.19   

SMI Eligibility Determination

     192  
18.20   

Material Change to Business Operations

     192  
18.21   

Integrated Health Care Development Program

     193  
18.22   

Governance Board

     194  
18.23   

Merger, Acquisition, Reorganization, Joint Venture And Change In Ownership

     194   
18.24   

Separate Incorporation and Prohibition Against Direct Service Delivery

     194   
19   

MONITORING AND OPERATIONAL REVIEWS

     195   
19.1   

Reporting Requirements

     195  
19.2   

Records Retention

     195   
19.3   

Requests for Information

     196   
19.4   

Surveys

     196   

 

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19.5   

Monitoring and Independent Review of the Contractor

     197   
19.6   

Sanctions

     199   
20   

SUBCONTRACTING REQUIREMENTS

     200   
20.1   

Subcontract Relationships and Delegation

     200  
20.2   

Hospital Subcontracts and Reimbursement

     202  
20.3   

Management Services Agreements

     203  
20.4   

Prior Approval

     204  
20.6   

Subcontracting Reporting Requirements

     207   
  

EXHIBITS

  
  

Exhibit Summary-Reserved

     208   
  

Exhibit 1- Definitions

     209   
  

Exhibit 2- Acronyms Reserved

     233   
  

Exhibit 3- Medicare Requirement to Coordinate Care for Dual Eligible SMI Members

     234   
  

Exhibit 4- Placeholder

     236   
  

Exhibit 5- Reserved

     237   
  

Exhibit 6- Adult Service Delivery System-Nine Guiding Principles

     238   
  

Exhibit 7- Reserved

     240   
  

Exhibit 8- Reserved

     241   
  

Exhibit-9- Deliverables

     242   
  

Exhibit 10- Greater Arizona Zip Codes

     270   
  

Exhibit 11- Capitation Rates and Contractor Specific Requirements

     272   
  

Exhibit 12- Placeholder

     273   
  

Exhibit 13- Reserved

     274   
  

Exhibit-14- Enrollee Grievance Standards

     275   
  

Exhibit-15 -Provider Claim Dispute Standards

     280   
  

Endnotes

     282   

 

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INTRODUCTION

 

  1.1 Overview

The purpose of this contract is to delineate Contractor requirements to administer behavioral health services for eligible children, adults and their families. In addition, pursuant to A.R.S. §36-2901 et seq., AHCCCS and the Contractor will oversee an integrated physical and behavioral health care delivery system for eligible adults determined to have a Serious Mental Illness (SMI).

The Contractor shall be responsible for the performance of all contract requirements. The Contractor may delegate responsibility for services and related activities under this contract, but remains ultimately responsible for compliance with the terms of this contract, 42 CFR 438.230(a).

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

 

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

 

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

Arizona Laws 2015, Chapter 19, Section 9 (SB 1480), enacts that from and after June 30, 2016, the provision of behavioral health services under the Division of Behavioral Health Services (DBHS) in the Department of Health Services is transferred to and shall be administered by the Arizona Health Care Cost Containment System (AHCCCS).

Integrating the delivery of behavioral and physical health care is a significant step forward in improving the overall health of members determined to be SMI. Under this Contract, the Contractor is the single entity that is responsible for administrative and clinical integration of health care service delivery for members with SMI, which includes coordinating Medicare and Medicaid benefits for members with SMI who are dual eligible. 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.

 

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

 

  1.1.4 Behavioral health services to Medicaid eligible children and adults enrolled in the AHCCCS Acute Care program, CMDP, ALTCS DDD, and members enrolled in the American Indian Health Program electing to receive behavioral health services from the Contractor; excluding adults enrolled in the Acute Care program who are dual-eligible and have General Mental Health and/or Substance Abuse needs;

 

  1.1.5 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 excluding members with SMI who are enrolled in ALTCS DDD, CRS, and American Indian members who do not choose to receive services from the Contractor; and

 

  1.1.6 Crisis Services as outlined in the Contract Section on, Crisis Services.

 

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

 

         

Contractor

  

Responsibilities

         
    

GMH/SA

  

(18 +Years)

  

SMI

  

(18+ Years)

  

Children (0-17)

Years

Population

  

Non Dual

Behavioral Health

  

Dual- Behavioral

Health

  

Behavioral

Health

  

Physical

Health

  

Behavioral Health

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(3)    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)    TRBHA   

TRBHA

Integrated Acute

   TRBHA    AIHP Acute Plan Integrated RBHA    TRBHA

 

(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.
(3) Responsibilities for the CRS members also enrolled in DD and CMDP remain the same with the exception of DD providing LTC services.

 

  1.1.8 The Contractor shall be responsible for the provision of Title XIX/XXI services as set forth in this contract and for the provision of those services as set forth in Contract YH17-0003. The Contractor shall ensure effective coordination of care for delivery of services to eligible members.

 

  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 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 Principles for Children Service Delivery as outlined in AMPM Policy 430.

 

  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

 

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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. The principles below describe AHCCCS’ 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, member input, family involvement, person-centered care, communication and commitment are examples that describe well-established expectations AHCCCS 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. AHCCCS 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.

 

  1.3.1 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:

 

  1.3.2 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.

 

  1.3.3 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.

 

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

 

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

 

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

 

  1.3.7 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.

 

  1.3.8 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.

 

  1.3.9 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.

 

  1.3.10 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.

 

  1.3.11 System goals shall be achieved using the following strategies:

 

  1.3.11.1 Use of health education and health promotion services;

 

  1.3.11.2 Increased use of primary care prevention strategies;

 

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  1.3.11.3 Use of validated screening tools;

 

  1.3.11.4 Focused, targeted, consultations for behavior health conditions;

 

  1.3.11.5 Cross-specialty collaboration;

 

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

 

  1.3.11.7 Ongoing outcome measurement and treatment plan modification;

 

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

 

  1.3.11.9 Member, family and community education;

 

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

 

  1.3.11.11 Reduced rates of unnecessary or inappropriate Emergency Room use;

 

  1.3.11.12 Reduced need for repeated hospitalization and re-hospitalization;

 

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

 

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

 

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

 

  2.1.1.10 Young Adult Transitional Insurance (YATI) Program: Individuals age 18 through age 25 who were enrolled in the foster care program under jurisdiction of DCS/CMDP in Arizona on their 18th birthday;

 

  2.1.1.11 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

 

  2.1.1.12 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 of two 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 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 Reserved

 

  2.4 Eligibility and Member Verification

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.

 

  2.4.4 Utilize one or more of the following systems to verify AHCCCS eligibility and service coverage 24 hours a day, seven days a week in conformance with the AHCCCS 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);

 

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  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 AHCCCS’ 270/271 Eligibility Look-up.

 

  2.4.5 Screen persons requesting covered services for Medicaid and Medicare eligibility in conformance with the AHCCCS 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 Contract Sections on, 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 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.

 

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 Comply with the requirements in the AHCCCS Policy on Enrollment, Disenrollment and Other Data Submission.

 

  3.1.3

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

 

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  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].i

 

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

 

  3.1.4.1 In a RBHA to receive both physical health services and behavioral services;

 

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

 

  3.1.4.3 In AIHP for physical health services and receive behavioral health services from a TRBHA.

 

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

 

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

 

  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 TRBHA.

 

  3.1.6 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.

 

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

 

  3.1.7.1 The member becomes ineligible for Medicaid;

 

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

 

  3.1.7.3 There is a change in AHCCCS’ enrollment policy.

 

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

 

  3.1.9 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.

 

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

 

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

 

  3.1.12 Notification must be received no later than one day from the date of birth. AHCCCS is available to receive notification 24 hours a day, seven days a week via the AHCCCS website.

 

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

 

  3.1.14 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 30 days to make a choice.

 

  3.1.15 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).ii

 

  3.1.16 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.iii

 

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

 

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

 

  3.1.17.2 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).

 

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

 

  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 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

 

  3.2.1.4 The member established that due to the enrollment and affiliation with the 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:

 

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

 

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  3.2.1.4.2 Exercising client choice in provider,

 

  3.2.1.4.3 Privacy rights,

 

  3.2.1.4.4 Quality of services provided, or

 

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

 

  3.2.2 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 RBHA.

 

  3.2.3 The Contractor shall take the following actions:

 

  3.2.3.1 Reduce 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.

 

  3.2.3.2 Complete an SMI Member Request to Transfer from a RBHA to an AHCCCS Acute Care Contractor Form, or its successor.

 

  3.2.3.3 Confirm and document that the member is enrolled in SMI RBHA program.

 

  3.2.3.4 Provide documentation of efforts to investigate and resolve member’s concern.

 

  3.2.3.5 Include any evidence provided by the member of actual or reasonable likelihood of discriminatory or disparate treatment.

 

  3.2.3.6 Recommend approval or denial of request, and forward completed packet to AHCCCS for approval or denial within seven calendar days of request.

AHCCCS shall:

 

  3.2.3.7 Review completed request packets received from the Contractor.

 

  3.2.3.8 Approve or deny the request in writing within 10 calendar days of request from the member.

 

  3.2.4 Provide notice that includes the reasons for the denial and appeal/hearing rights to the member for requests which are denied. In the event the member files an appeal:

 

  3.2.4.1 AHCCCS will forward a copy of the appeal to the Contractor.

 

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  3.2.4.2 The Contractor will continue efforts to resolve the concerns identified in the appeal and ensure needed coordination activities take place with the relevant parties throughout the appeal process.

 

  3.2.4.3 AHCCCS will notify the Contractor of the date and time of the hearing and other relevant administrative proceedings.

 

  3.2.4.4 The Contractor will provide AHCCCS with a summary, prior to the hearing and within a timeframe requested by AHCCCS, of all efforts taken to resolve the member’s concerns.

 

  3.2.4.5 The Contractor will designate a representative to participate in the hearing and provide AHCCCS with information on how to contact the representative during the time of the hearing.

 

  3.2.4.6 AHCCCS will notify the RBHA of the outcome of the appeal.

 

  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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  3.5 Hospital Presumptive Eligibility

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

 

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.

The Contractor is required to comply with all terms in this Contract and all applicable requirements in each document, guide and manual, however, particular attention to requirements for effective service delivery should be paid to the following:

 

  4.1.6 Covered Behavioral Health Services Guide, or its successor,

 

  4.1.7 ADHS/DBHS Policy and Procedures Manual,

 

  4.1.8 AHCCCS Medical Policy Manual (AMPM), and

 

  4.1.9 AHCCCS Contractor Operations Manual (ACOM);

 

  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.

 

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  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.

 

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

 

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

 

  4.2.15.2 Place no financial or administrative burden on AHCCCS;

 

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

 

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  4.2.15.4 Be accepted by AHCCCS in writing; and

 

  4.2.15.5 Acknowledge an adjustment to Capitation Rates and Contractor Specific Requirements, depending on the nature of the proposed solution.

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

 

  4.2.16 Require subcontracted providers to offer the services described in Contract Section on, 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, and consistent with the terms of the demonstration, covered services must be provided by or coordinated with a primary care provider.

 

  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 AHCCCS according to instructions provided by AHCCCS, 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 AHCCCS 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 AHCCCS 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.

 

  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;

 

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  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 medically necessary and clinically appropriate covered behavioral health services to eligible members in conformance with the Covered Behavioral Health Services Guide, or its successor.

 

  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, or its successor.

 

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

 

  4.4.3 Make referrals to service providers.

 

  4.4.4 Coordinate care as described in Contract Section on, 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 Services 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 Utilize the American Society of Addiction Medicine (ASAM) Criteria (Third Edition, 2013) in substance use disorder assessments, service planning, and level of care placement.

 

  4.5.3 Implement Supported Employment.

 

  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 Clinical Guidance Documents:

 

  4.6.1.2 Support and Rehabilitation Services for Children, Adolescents and Young Adults;

 

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  4.6.1.3 Youth Involvement in Arizona Behavioral Health System;

 

  4.6.1.4 The Unique Behavioral Health Service Needs of Children, Youth and Families Involved with Department of Child Safety(DCS) (formerly known as CPS);

 

  4.6.1.5 Children’s Out-of-Home Services;

 

  4.6.1.6 The Child Family Team;

 

  4.6.1.7 Family and Youth Involvement in the Children’s Behavioral Health System.

 

  4.6.1.8 The Arizona Vision-Twelve Principles for Children Service Delivery as outlined in AMPM Policy 430; and

 

  4.6.1.9 Technical Specifications Manual.

 

  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.

 

  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 AHCCCS’ method for in-depth review of Child and Family Team (CFT) practice.

 

  4.6.6 Utilize acuity measure instruments as directed by AHCCCS.

 

  4.6.7 Implement service delivery models as directed by AHCCCS.

 

  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 Department of Child Safety @ 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 Department of Child Safety 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 months unless services are refused by the guardian or the child is no longer in Department of Child Safety custody. Services must be provided to:

 

  4.6.9.1.1 Mitigate and address the child’s trauma;

 

  4.6.9.1.2 Support the child’s temporary caretakers;

 

  4.6.9.1.3 Promote stability and well-being; and

 

  4.6.9.1.4 Address the permanency goal of the child and family.

 

  4.6.10 A minimum of one monthly documented service is required.

 

  4.6.11 Provide a monthly reconcile Department of Child Safety Removal List with Individuals Receiving a Rapid Response:

 

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  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 Department of Child Safety 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 Department of Child Safety Rapid Response Monthly Reconciliation Report that will minimally include:

 

  4.6.12.1 The number of individuals removed by Department of Child Safety;

 

  4.6.12.2 The number of individuals referred by Department of Child Safety 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 Department of Child Safety custody who were not initially referred by Department of Child Safety 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.

 

  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 include 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 18 through 20 receiving Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.

 

  4.7.4 Chiropractic Services includes chiropractic services to members age 18 through 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.

 

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  4.7.6 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) The Contractor shall provide comprehensive health care services through primary prevention, early intervention, diagnosis and medically necessary treatment to correct or ameliorate defects and physical or mental illnesses discovered by the screenings for members under age 21. The Contractor shall ensure that these members receive required health screenings including a comprehensive history, developmental and behavioral health screenings, 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 and 430-1A in the AMPM), including appropriate oral health screening intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician’s assistant or nurse practitioner. The Contractor shall submit all applicable EPSDT reports as required by the AHCCCS Medical Policy Manual. 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 21 years of age and older. These services include, but are not limited to, screening and treatment for hypertension; elevated cholesterol; colon cancer; sexually transmitted diseases; tuberculosis; HIV/AIDS; breast 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 24 hour a day, seven 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.

 

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  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.

 

  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 10 calendar days of presentation for emergency services. Claims submission by the hospital within 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 AHCCCS.

 

  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 and consistent with the terms of the demonstration, for all members (male and female) who choose to delay or prevent pregnancy. These include medical, surgical, pharmacological, laboratory

 

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  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 18 through 20 includes foot and ankle care services for members age 18 through 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 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 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.

 

  4.7.20 Home Health Services 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. The Contractor is prohibited from paying for an item or service (other than an emergency item or service, not including items or services furnished in an emergency room of a hospital) for home health care services provided by an agency or organization, unless AHCCCS Provider Registration verifies compliance with the surety bond requirements specified in Sections 1861(o)(7) and 1903(i)(18) of the Social Security Act.iv

 

  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.

 

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  4.7.23 Immunizations include immunizations for adults age 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 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 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 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.

 

  4.7.25 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 AHCCCS.

 

  4.7.26 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 on, Maternity Care Provider Standards. The Contractor shall allow women to receive up to 48 hours of inpatient hospital care after a routine vaginal delivery and up to 96 hours of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the mother, may discharge the mother 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 15 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.

 

  4.7.27

Medical Foods includes foods subject to the limitations defined in the AMPM for members diagnosed with a metabolic condition included under the ADHS

 

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  Newborn Screen Program and specified in the AMPM. The medical foods, including metabolic formula and modified low protein foods, must be prescribed or ordered under the supervision of a physician.

 

  4.7.28 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 21 or older, AHCCCS will not pay for microprocessor controlled lower limbs and microprocessor controlled joints for lower limbs. Medical equipment may be rented or purchased only if other sources are not available which provide the items at no cost. The total cost of the rental must not exceed the purchase price of the item. Reasonable repairs or adjustments of purchased equipment are covered to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit and include exclusions as stated in AMPM Chapter 300.

 

  4.7.29 Nursing Facility includes services in nursing facilities, including religious non-medical health care institutions for members who require short-term convalescent care not to exceed 90 days per Contract Year. In lieu of a nursing facility, the member may be placed in an assisted living facility, an alternative residential setting, or receive home and community based services as defined in the Scope of Work, Section on, Physical Health Care Covered Services.

 

  4.7.30 Nursing facility services must be provided in a dually-certified Medicare/Medicaid nursing facility, which includes in the per-diem rate: nursing services; basic patient care equipment and sickroom supplies; dietary services; administrative physician visits; non-customized DME; necessary maintenance and rehabilitation therapies; over-the-counter medications; social, recreational and spiritual activities; and administrative, operational medical direction services. Additional detail on Nursing Facility Reimbursement is contained in the Scope of Work.

 

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

 

  4.7.31.1 Member name,

 

  4.7.31.2 AHCCCS ID,

 

  4.7.31.3 Date of birth,

 

  4.7.31.4 Name of facility,

 

  4.7.31.5 Admission date to the facility,

 

  4.7.31.6 Date the member will reach the 90 days, and

 

  4.7.31.7 Name of Contractor of enrollment.

 

  4.7.32

Nutrition includes nutritional assessments conducted as a part of the EPSDT screenings for members age 18 through 20, and to assist members 21 years of age and older whose health status may improve with over and under nutritional

 

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  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.

 

  4.7.33 Oral Health includes medically necessary dental services for members, age 18 through 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:

 

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

 

  4.7.33.2 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 18 through 20 may request dental services without referral and may choose a dental provider within the Contractor’s provider network;

 

  4.7.33.3 For members 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

 

  4.7.33.4 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.

 

  4.7.34 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:

 

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

 

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

 

  4.7.34.3 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.

 

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

 

  4.7.36 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:

 

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

 

  4.7.36.2 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 hour after the treating provider’s request or could not be contacted for pre-approval.

 

  4.7.37 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.

 

  4.7.38 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:

 

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

 

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

 

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

 

  4.7.38.4 The member is discharged.

 

  4.7.39 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 and meet the requirements specified in the AMPM. The Certificate must certify that, in the physician’s professional judgment, the criteria have been met.

 

  4.7.40

Prescription Medications includes medications ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the

 

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  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 Section on, Medications. Additional detail for coverage of Medicare Part D prescription medications is contained in Scope of Work, Section on, Medicare Services and Cost Sharing.

 

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

 

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

 

  4.7.43 Medicare Part D: AHCCCS covers those drugs 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, 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 by AHCCCS. This applies to members who are enrolled in Medicare Part D or are eligible for Medicare Part D. See AMPM Chapter 300, Section 310-V.

 

  4.7.44 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.

 

  4.7.45 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.

 

  4.7.46 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.

 

  4.7.47 Occupational Therapy and Speech therapy services provided on an outpatient basis are only covered for members age 18 through 20. Physical Therapy is covered for all members in both inpatient and outpatient settings. Outpatient physical therapy under the age of 21 is subject to visit limits per contract year as described in the AMPM.

 

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  4.7.48 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.

 

  4.7.49 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.

 

  4.7.50 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.

 

  4.7.51 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.

 

  4.7.52 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 18 to through 20. For members who are 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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  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, Contract Sections on, Care Management Program Goals, and Care Management Program General Requirements;

 

  4.8.7 Coordination of care as described in Contract Section on, Care Coordination;

 

  4.8.8 Health education and health promotion services described in the Contract Section on, 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 Providers 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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  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, or its successor.

 

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

 

  4.11.2.1 The available medications on the AHCCCS Drug List 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, or its successor 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 AHCCCS Financial Reporting Guide for RBHA Contractors.

 

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  4.12 Prescription Medications

 

  4.12.1 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.

 

  4.13 Medication Management Services

 

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

 

  4.13.2 Tool Kits: 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. The Contractor shall ensure that PCPs who have an interest or are actively treating members with these disorders are aware of these resources and/or are utilizing other recognized, clinical tools/evidence-based guidelines. The Contractor shall develop a monitoring process to ensure that PCPs utilize evidence-based guidelines/recognized clinical tools when prescribing medications to treat depression, anxiety, and ADHD.

 

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

 

  4.14 Laboratory Testing Services

The Contractor shall:

 

  4.14.1 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.

 

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

 

  4.14.3 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.

 

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  4.14.4 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.

 

  4.14.5 Apply the following requirements to all clinical laboratories:

 

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

 

  4.14.5.2 Clinical laboratory providers who do not comply with the requirements in the Scope of Work, Laboratory Testing Services, may not be reimbursed;

 

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

 

  4.14.5.4 Laboratories with a Certificate of Registration are allowed to perform a full range of laboratory tests;

 

  4.14.5.5 Manage and oversee the administration of laboratory services through subcontracts with qualified services providers to deliver laboratory services;

 

  4.14.5.6 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; and

 

  4.14.5.7 Use the data in Contract Section on, Laboratory Testing Services, exclusively for quality improvement activities and health care outcome studies required and approved by AHCCCS.

 

  4.15 Crisis Services Overview

AHCCCS 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.

 

  4.16 Crisis Services-General Requirements

The Contractor shall:

 

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

 

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

 

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

 

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

 

  4.16.5 Meet or exceed urgent and emergent response requirements in conformance with ACOM Policy 417.

 

  4.16.6 Not require prior authorization for crisis services;

 

  4.16.7 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;

 

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

 

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

 

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

 

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

 

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

 

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

 

  4.16.13.1 Fire,

 

  4.16.13.2 Police,

 

  4.16.13.3 Emergency medical services,

 

  4.16.13.4 Hospital emergency departments,

 

  4.16.13.5 AHCCCS Acute Care Health Plans, and

 

  4.16.13.6 Providers of public health and safety services.

 

  4.16.14 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;

 

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

 

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

 

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

 

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  4.16.18 Submit the deliverables related to Crisis Services reporting in accordance with Exhibit-9, Deliverables.

 

  4.16.19 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.

 

  4.16.20 For AHCCCS members who do not receive behavioral health services through the RBHA, but receive behavioral health through their Contractor of enrollment for physical health services, the RBHA Contractor shall notify the Contractor of enrollment within 24 hours of a member engaging in crisis services so subsequent services can be initiated by the Contractor of enrollment. The Contractor of enrollment is as follows:

 

  4.16.20.1 Acute Care Contractor for a dual-eligible member with General Mental Health/Substance Abuse needs;

 

  4.16.20.2 CRS Contractor for a member enrolled with the CRS Contractor for behavioral health needs; and

 

  4.16.20.3 For AHCCCS members who receive behavioral health services through a RBHA, the Contractor shall develop policies and procedures to ensure timely communication with Crisis Services Vendors, the assigned RBHA (if the Contractor is not the assigned RBHA), and the Contractor of enrollment for physical health services for members who have engaged crisis services. The Contractor shall ensure timely follow up and care coordination for members after receiving crisis services, whether the member received services within, or outside the Contractor’s GSA at the time services were provided, to ensure stabilization of the member and appropriate delivery of ongoing necessary treatment and services.

 

  4.17 Crisis Services-Telephone Response

The Contractor shall:

 

  4.17.1 Establish and maintain a 24 hours per day, seven days per week crisis response system.

 

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

 

  4.17.3 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.

 

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

 

  4.17.5 Answer calls to the crisis response line within three telephone rings, with a call abandonment rate of less than three per cent.

 

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

 

  4.17.7 Conduct a follow-up call within 72 hours to make sure the caller has received the necessary services.

 

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

 

  4.17.9 Provide Nurse On-Call services 24 hours per day, seven 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.

 

  4.18 Crisis Services-Mobile Crisis Teams

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

 

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

 

  4.18.2 Ability to assess and provide immediate crisis intervention.

 

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

 

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

 

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

 

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

 

  4.18.7 Develop incentives for those mobile team providers who respond to crisis calls within 45 minutes of the initial call.

 

  4.19 Crisis Services-Crisis Stabilization Settings

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

 

  4.19.1 Offer 24 hour substance use disorder/psychiatric crisis stabilization services including 23 hour crisis stabilization/observation capacity.

 

  4.19.2 Provide short-term crisis stabilization services (up to 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.

 

  4.19.3 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:

 

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

 

  4.19.3.2 Outpatient clinics offering 24 hours per day, seven days per week access.

 

  4.19.3.3 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.

 

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  4.20 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 the age of 19. Any provider, licensed by the state to administer immunizations, may register with Arizona Department of Health Services (ADHS) as a VFC provider and receive free vaccines.

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

 

  4.20.1 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.

 

  4.20.2 Not utilize Medicaid funding to purchase vaccines for SMI members, age 18.

 

  4.20.3 Not utilize AHCCCS funding to purchase vaccines for members under the age of 19. If vaccines are not available through the VFC program, the Contractor shall contact the AHCCCS Division of Health Care Management, Clinical Quality Management for guidance.

 

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

 

  4.20.5 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.

 

  4.20.6 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.

 

  4.20.7 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.

 

  4.20.8 Monitor compliance with the following reporting requirements:

 

  4.20.8.1 Report all immunizations given to only SMI members that are age 18; and

 

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

 

  4.21 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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For Medicaid eligible SMI members, ages 18 through 20, receiving physical health care services, the Contractor shall:

 

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

 

  4.21.2 Not duplicate services;

 

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

 

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

 

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

 

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

 

  4.22 Special Health Care Needs

AHCCCS has specified in its Quality Assessment and Performance Improvement Strategy certain populations with special health care needs as defined by the State, 42 CFR 438.208(c)(1).v Members with special health care needs are those members who have serious and chronic physical, developmental, or behavioral conditions requiring medically necessary health and related services of a type or amount beyond that required by members generally. A member will be considered as having special health care needs if the medical condition simultaneously meets the following criteria:vi

 

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

 

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

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

 

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

 

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

 

  4.22.5 Members diagnosed with HIV/AIDS

 

  4.22.6 Arizona Long Term Care System:

 

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

 

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

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

 

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The Contractor shall:

 

  4.22.9 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).

 

  4.22.10 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).

 

  4.22.11 Utilize appropriate health care professionals in the assessment process.

 

  4.22.12 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).

 

  4.22.13 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).

 

  4.23 Special Assistance for SMI Members

The Contractor shall:

 

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

 

  4.23.2 Cooperate with the Human Rights Committee in meeting its obligations in the ADHS/DBHS Policy on Special Assistance for Persons Determined to have a Serious Mental Illness or its successor.

 

  4.23.3 Submit the deliverables related to Special Assistance Services reporting in accordance with Exhibit-9, Deliverables.

 

  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 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.

 

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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.

 

  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.

 

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  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.

 

  5.1.14 Comply with the AMPM and the ACOM 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 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 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.

 

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

 

  5.1.26 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 TRBHA prescriber for evaluation and/or continued medication management services, the Contractor shall:

 

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

 

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  5.1.26.2 Include this provision in all affected subcontracts; and

 

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

 

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

 

  5.1.27.1 Guidelines for when a transition of the member to the RBHA or TRBHA for ongoing treatment is indicated;

 

  5.1.27.2 Protocols for notifying the RBHA or TRBHA of the member’s transfer, including reason for transfer, diagnostic information, and medication history;

 

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

 

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

 

  5.1.27.5 Contractor monitoring activities to ensure that members are appropriately transitioned to the RBHA or TRBHA 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, 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 RBHA. The Contractor will contract with CMS to be a Medicare Dual Eligible Special Needs Plan (D-SNP) or offer a D-SNP product through one of the equity partners in the organization. The Contractor may not delegate or subcontract with another entity except as specified below, in Exhibit-3 and the Scope of Work Sections on, Organizational Structure and Management Services Agreements.

 

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  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.

 

  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 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 Contract Section on, Medical Management, for care coordination requirements.

 

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

 

  5.2.10 Dual marketing focuses on enrollment in the Contractor’s Medicare Dual Special Needs Plan (D-SNP) or a D-SNP product offered through one of the equity partners in the organization. The State understands that the Medicare D-SNP is able to enroll any dual eligible member, but to increase alignment, encourages the Contractor to only market to individuals enrolled in its AHCCCS plan. Marketing to dual eligible Contractor enrollees may include print advertisements, radio advertisements, billboards, bus advertising, and television.

 

  5.2.11 In the case of marketing materials for dual eligible enrollees the process will be as follows:

 

  5.2.11.1 AHCCCS does not review for approval dual marketing materials that have been approved by CMS and/or that do not include reference to AHCCCS benefits and/or service information. However, all dual marketing materials that have not been approved by CMS and/or include reference to AHCCCS benefits and/or service information require submission to AHCCCS as specified in Exhibit-9, Deliverables. The Contractor may request an expedited review, but the request must be clearly marked as expedited and also indicate the reason for the shortened timeframe.

 

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  5.2.11.2 While AHCCCS may accept CMS approval of dual marketing materials as sufficient for distribution of materials, AHCCCS retains and reserves the right to review before or after the fact, materials that have received CMS approval.

 

  5.2.11.3 The Contractor must adhere to the following regarding use of billboards which use the terms ‘Medicaid’ or ‘AHCCCS’:

 

  5.2.11.3.1 Limited to two in each urban county (Maricopa and Pima), and

 

  5.2.11.3.2 Limited to one in each rural county.

 

  5.3 Coordination with AHCCCS Contractors and Primary Care Providers

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 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.

 

  5.3.5 Use the AHCCCS required, standardized forms to transmit the information required in Contract Section on, Care Coordination for Dual Eligible SMI Members.

 

  5.3.6 Obtain proper consent and authorization in conformance with Contract Section on, 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.

 

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  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 Contract Section on, Care Coordination for Dual Eligible SMI Members, 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 AHCCCS, DHCM, if the Contractor is unable to resolve issues with other 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.

 

  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 (DCS);

 

  5.4.1.2 Arizona Department of Economic Security/Division of Developmental Disabilities (DDD);

 

  5.4.1.3 The Veteran’s Administration; and

 

  5.4.1.4 Children’s Rehabilitative Services (CRS).

 

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  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 AHCCCS.

 

  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 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 120 days of Contract Award Date.

 

  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 AHCCCS 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.

 

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  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 (HIPAA) 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 Program,

 

  5.4.9.2.12 Primary Care Provider’s Name,

 

  5.4.9.2.13 Primary Care Provider’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,

 

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  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 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 AHCCCS to participate at these meetings.

 

  5.6 Collaboration with Peers and Family Members

The Contractor shall:

 

  5.6.1 At least every six 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 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.

 

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  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 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 AHCCCS and 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.

 

  5.7.12 Collaborate with AHCCCS 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 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.

 

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

 

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

 

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

 

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

 

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

 

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

 

  5.8.6 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 refer to Contract Section on, Primary Care Provider Standards.

 

  5.8.7 When individuals transition to the Contractor 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.

 

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

 

  5.8.9

Contract Termination: In the event that the contract or any portion thereof is terminated for any reason, or expires, the Contractor shall assist AHCCCS in the transition of its members to other Contractors. In addition, AHCCCS reserves the right to extend the term of the contract on a month-to-month basis to assist in any transition of members. AHCCCS may discontinue enrollment of new members with the Contractor three months prior to the contract termination date. The Contractor shall make provisions for continuing all management and administrative services until the transition of all members is completed and all other requirements of this contract are satisfied. The Contractor shall submit a

 

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  detailed plan to AHCCCS for approval regarding the transition of members in the event of contract expiration or termination. The name and title of the Contractor’s transition coordinator shall be included in the transition plan. The Contractor shall be responsible for providing all reports set forth in this contract and necessary for the transition process, and shall be responsible for the following, 42 CFR 438.610(c)(3); 42 CFR 434.6(a)(6):

 

  5.8.10 Notifying subcontractors and members;

 

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

 

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

 

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

 

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

 

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

 

  5.8.16 Submitting quarterly Quality Management and Medical Management reports as required by Scope of Work Sections on, Quality Management Reporting Requirements and, Medical Management Reporting Requirements, as appropriate to provide AHCCCS with information on services rendered up to the date of contract termination. This will include Quality Of Care (QOC) concern reporting based on the date of service;

 

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

 

  5.8.18 Maintaining a Performance Bond in accordance with Scope of Work Section on, Financial Management, and the Paragraph on, Performance Bond or Bond Substitute. A formal request to release the performance bond, as well as a balance sheet, must be submitted when appropriate;

 

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

 

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

 

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

 

  5.8.22 Preserving and making available all records for a period of five years from the date of final payment under contract. Records covered under HIPAA must be preserved and made available for six years per, 45 CFR 164.530(j)(2).

 

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

 

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6 PROVIDER NETWORK

 

  6.1 Network Development

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 culturally and linguistically diverse populations.

 

  6.1.3 Ensures its membership has access at least equal to community norms. Services shall be as accessible to AHCCCS members in terms of timeliness, amount, duration and scope as those services are available to non-AHCCCS persons within the same service area, 42 CFR 438.210 (a)(2).

 

  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 Current and anticipated utilization of services;

 

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

 

  6.1.6.3 The number of providers not accepting new referrals;

 

  6.1.6.4 Geographically convenient flow of patients among network providers to maximize member choice;

 

  6.1.6.5 Consumer Satisfaction Survey data;

 

  6.1.6.6 Member Grievance, SMI grievance and appeal data;

 

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

 

  6.1.6.8 Demographic data; and

 

  6.1.6.9 Geo-mapping data.

 

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

 

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  6.1.8 Responds to routine, urgent and emergent needs within the established timeframes in conformance with ACOM Policy 417, 42 CFR 438.206.

 

  6.1.9 Provides emergency services on a 24 hours a day, seven 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.

 

  6.1.12 Includes peer and family support specialists.

 

  6.1.13 Includes the Arizona State Hospital.

 

  6.1.14 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.

 

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

 

  6.1.16 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 18 through 20 and infants and toddlers under the age of five years, 42 CFR 438.214(c).

 

  6.1.17 Provides services to members who typically receive care in border communities.

 

  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 AHCCCS program, reimbursement or indemnification against any provider based solely on the provider’s type of licensure or certification, 42 CFR 438.12(a)(1).

 

  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 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).

 

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  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. 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 90% of all eligible members residing within the GSA will have geographical access to a contracted mobile crisis team within 60 minutes.

Meets all Network Standards set forth in ACOM Policy 436. AHCCCS may impose sanctions for material deficiencies in the Contractor’s provider network.

 

  6.2 Network Development for Integrated Health Care Service Delivery

The Contractor shall maximize the availability and access to community based primary care and specialty care providers.

 

  6.2.1 The Contractor shall reduce utilization of the following:

 

  6.2.1.1 Non-emergent utilization of emergency room services;

 

  6.2.1.2 Single day hospital admissions;

 

  6.2.1.3 Avoidable hospital re-admissions;

 

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

 

  6.2.1.5 Hospitalization for preventable medical conditions.

 

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

 

  6.2.3 Subcontracts with homeless clinics in Pima County at the AHCCCS FFS rate for Primary Care services. Subcontracts must stipulate that:

 

  6.2.3.1 Only those SMI members that request a homeless clinic as their PCP receive such assignment; and

 

  6.2.3.2 SMI members assigned to a homeless clinic may be referred to out-of network providers for needed specialty services.

 

  6.2.3.3 Assists homeless clinics with administrative issues such as obtaining prior authorization, and resolving claims issues.

 

  6.2.3.4 Attends meetings as necessary with homeless clinics to resolve administrative issues and perceived barriers to the homeless members receiving care.

 

  6.2.4 Complies with the network requirements in Contract Section on, Primary Care Provider Standards.

 

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  6.2.5 Complies with the network requirements in Contract Section on, Maternity Care Provider Standards.

 

  6.2.6 Submit a Provider Network Development and Management Plan in accordance with ACOM Policy 415, 42 CFR 438.207(b).

 

  6.3 Network Management

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).

 

  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 Contract Section on, Network Management.

 

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

 

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

 

  6.3.6 Comply with ACOM Policy 439.

 

  6.4 Out of Network Providers

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).

 

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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 not less than the AHCCCS capped fee-for-service schedule for physical health services.

 

  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.

 

  6.5 Material Change to Provider Network

 

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

 

  6.5.2 The Contractor must submit the request for approval of a material change to the provider network with information including, but not limited to, how the change will affect the delivery of covered services, the Contractor’s plans for maintaining the quality of member care, and communications to providers and members, as outlined in ACOM Policy 439 and as specified in, Exhibit-9, Deliverables. AHCCCS will review and respond to the Contractor within 30 days of the submission. A material change in the Contractor’s provider network requires 30 days advance written notice from the Contractor to members and providers. In the event unforeseen circumstances prevent the Contractor from providing 30 days advance written notice to members and providers, the Contractor shall notify AHCCCS within one business day of identifying the material change to the provider network for AHCCCS determination of notification requirements.

 

  6.5.3 For emergency situations, AHCCCS will expedite the approval process.

 

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

 

  6.6 Provider Affiliation Transmission

The Contractor shall:

 

  6.6.1 Comply with the requirements to collect and submit information to AHCCCS in conformance with the specifications in the Provider Affiliation Transmission (PAT) User Manual.

 

  6.6.2

Validate its compliance with minimum network requirements against the network information provided in the PAT through the submission of a completed Minimum

 

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  Network Requirements Verification Template (see ACOM Policy 436 for Template). The PAT and the Minimum Network Requirements Verification Template must be submitted as specified in Exhibit-9, Deliverables.

 

  6.6.3 Be subject to corrective action, if required, when the provider affiliation transmission information is untimely, inaccurate or incomplete.

 

7 PROVIDER REQUIREMENTS

 

  7.1 Provider General Requirements

The Contractor shall:

 

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

 

  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 AHCCCS.

 

  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 Covered Behavioral Health Services Guide, or its successor, or other state or federal law and regulations.

 

  7.2.2 Require through verification and monitoring that subcontracted providers:

 

  7.2.2.1 Register with AHCCCS in conformance with the Covered Behavioral Health Services Guide, or its successor;

 

  7.2.2.2 Sign the Provider Participation Agreement;

 

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

 

  7.2.2.4 For specific requirements on Provider Registration, refer to the AHCCCS website.

 

  7.3 Provider Manual Policy Requirements

The Contractor shall:

 

  7.3.1 Develop, distribute and maintain a Provider Manual consistent with the requirements in ACOM Policy 416.

 

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

 

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

 

  7.3.4 Complete and disseminate Provider Manual changes to all subcontracted providers as outlined in ACOM Policy 416.

 

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

 

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

 

  7.3.7 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:

 

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

 

  7.3.7.2 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);

 

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

 

  7.3.7.4 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);

 

  7.3.7.5 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

 

  7.3.7.6 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).

 

  7.3.8 Consistent with the above Contract Section on, Provider Manual Policy Requirements, include the following policies:

 

  7.3.8.1 Quality Management, including annual Quality Management Plan, Quality Management Work Plan, Quality Management Evaluation, EPSDT Narrative Plan, EPSDT Work Plan, EPSDT Work Plan Evaluation Dental Narrative Plan, Dental Work Plan, Dental Work Plan Evaluation, Maternity/Family Planning Services Care Plan, Maternity/Family Planning Services Work Plan and the Maternity/Family Planning Services Work Plan Evaluation.

 

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

 

  7.3.8.3 Financial management, audit and reporting, and disclosure;

 

  7.3.8.4 Fraud, waste, and abuse and Corporate Compliance;

 

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

 

  7.3.8.6 Special service delivery systems;

 

  7.3.8.7 Responsibility for clinical oversight and point of contact;

 

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

 

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

 

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

 

  7.3.8.11 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services in conformance with the scope of work Section on, Physical Health Care Covered Services, including a description of dental services coverage and limitations and the other EPSDT requirements in the scope of work;

 

  7.3.8.12 Maternity services in conformance with Physical Health Care Covered Services, scope of work Section on, Maternity and the Section on, Maternity Care Provider Standards;

 

  7.3.8.13 Family Planning services in conformance with scope of work Sections, Maternity Care Provider Standards and, Family Planning;

 

  7.3.8.14 PCP assignments;

 

  7.3.8.15 Physical and behavioral health coordination of care;

 

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

 

  7.3.8.17 Claims medical review;

 

  7.3.8.18 Medication management services; and

 

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

 

  7.3.9 SMI Member Transition policies on:

 

  7.3.9.1 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.;

 

  7.3.9.2 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;

 

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

 

  7.3.9.4 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;

 

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

 

  7.3.9.6 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

 

  7.3.9.7 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, 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 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, quality of care concerns, 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;

 

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

 

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  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 AHCCCS 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 AHCCCS. AHCCCS 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 and Contractor Specific Requirements development or risk sharing arrangement of any reimbursement exceeding that payable under the relevant AHCCCS specialty contract.

 

  7.5.4 Cooperate with AHCCCS during the term of specialty contracts if 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 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 and adjust the PCP’s ability to meet the requirements in ACOM Policy 417.

 

  7.6.3.2 Consider the PCP’s total panel size;

 

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

 

  7.6.3.4 Be informed by AHCCCS 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 within its network in selecting a PCP consistent with, 42 CFR 438.6(m) and 438.52(d) and this contract. Any American Indian who is enrolled with the Contractor and who is eligible to receive services from a participating I/T/U provider may elect that I/T/U as his or her primary care provider, if that I/T/U participates in the network as a primary care provider and has capacity to provide the services per ARRA Section 5006(d) and SMD letter 10-001).ix

 

  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.

 

  7.6.9 Ensure individuals 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 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.

 

  7.6.10 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.

 

  7.6.11 Inform the member in writing of his or her enrollment and PCP assignment within 12 business days of the Contractor’s receipt of notification by AHCCCS. See ACOM Policy 404 for member information requirements.

 

  7.6.12 Include with the notification required in Contract Section on, Primary Care Provider Standards;

 

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

 

  7.6.12.2 The process for changing the PCP assignment; and

 

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

 

  7.6.13 Inform the member in writing of any PCP change.

 

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

 

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

 

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

 

  7.6.15.2 Initiation of referrals for medically necessary specialty care;

 

  7.6.15.3 Maintaining continuity of care for each assigned member;

 

  7.6.15.4 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;

 

  7.6.15.5 Utilizing the AHCCCS approved EPSDT Tracking Forms;

 

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

 

  7.6.15.7 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

 

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

 

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

 

  7.6.17 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 who 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 Include the following maternity care providers in its provider network:

 

  7.7.2.1 Arizona licensed allopathic and/or osteopathic physicians that are Obstetricians or general practice/family practice providers to provide maternity care services;

 

  7.7.2.2 Physician Assistants,

 

  7.7.2.3 Nurse Practitioners,

 

  7.7.2.4 Certified Nurse Midwives, and

 

  7.7.2.5 Licensed Midwives.

 

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  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, Deliverables.

 

  7.8 Federally Qualified Health Centers and Rural Health Clinics

 

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

The Contractor shall:

 

  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.xi

 

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

 

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  7.8.4 Be aware that AHCCCS 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.

 

  7.8.5 For services not eligible for PPS reimbursement, AHCCCS 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.

 

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

 

  7.8.7 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 A.A.C. R9-22-710 (C) for further details.

 

  7.8.8 Submit member information, if required, for Title XIX and Title XXI members for each FQHC/RHC/FQHC Look-Alikes as specified in Exhibit-9, Deliverables and the AHCCCS Financial Reporting Guide for RBHA Contractors. AHCCCS may perform periodic audits of the member information submitted.

 

  7.8.9 The Contractor should refer to the AHCCCS Financial Reporting Guide for RBHA Contractors for further guidance. The FQHCs//RHCs/FQHC Look-Alikes registered with AHCCCS are listed on the AHCCCS website.

 

8 MEDICAL MANAGEMENT

 

  8.1 General Requirements

The Contractor shall:

 

  8.1.1 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 Quality Management.

 

  8.1.2 Implement, monitor, evaluate and comply with applicable requirements in the ADHS/DBHS Policy and Procedure Manual, or its successor, the Contractor Provider Manual, ADHS/DBHS Bureau of Quality and Integration (BQ&I) Specifications Manual, or its successor, and AHCCCS Medical Policy Manual, Chapter 1000.

 

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

 

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

 

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

 

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  8.1.3.3 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 months to AHCCCS regarding criteria to identify members, count of members and outcomes;

 

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

 

  8.1.3.5 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);

 

  8.1.3.6 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 as specified in Exhibit-9, Deliverables; and

 

  8.1.3.7 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.

 

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

 

  8.1.5 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.

 

  8.1.6 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.

 

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  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 Contract Section on, Medical Management, General Requirements.

 

  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.

 

  8.1.14 The Contractor must identify and track members who utilize Emergency Department (ED) services inappropriately four or more times within a six month period. Interventions must be implemented to educate the member on the appropriate use of the ED and divert members to the right care in the appropriate place of service. The Contractor shall submit a semi-annual report as specified in AMPM Policy 1020 and Exhibit-9, Deliverables.

The Contractor shall implement and report the following:

 

  8.1.15 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;

 

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

 

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

 

  8.1.18 High Need/High Cost Program: The Contractor shall collaborate with the AHCCCS Contractors indicated below to select members for the High Need/High Cost Program and implement interventions for care coordination in order to promote appropriate utilization of services and improve member outcomes The Contractor is required to include the number of members indicated below, by RBHA Geographic Service Area.

 

   

# 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  

 

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AIHP - Statewide   20   40   20
CMDP - Statewide   5   5   10
DDD - Statewide   5   5   10
Total   130   230   310

 

* 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

 

  8.1.19 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.xii

 

  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, Deliverables of this contract.

 

  8.2 Utilization Data Analysis and Data Management

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, or its successor.

 

  8.2.2 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:

 

  8.2.2.1 Under and over utilization of service and cost data;

 

  8.2.2.2 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;

 

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

 

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  8.2.2.4 Follow up after discharge;

 

  8.2.2.5 Outpatient civil commitments;

 

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

 

  8.2.2.7 Prior authorization/denial and notices of action;

 

  8.2.2.8 Pharmacy utilization;

 

  8.2.2.9 Laboratory and diagnostic utilization; and

 

  8.2.2.10 Medicare utilization.

 

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

 

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

AHCCCS will provide the Contractor:

 

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

 

  8.2.4.2 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.

 

  8.3 Prior Authorization

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 Contract Section on, General Requirements for the System of Care.

 

  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.

 

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  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/ and QM/MM/UM Performance Improvement Specifications Manual, or its successor.

 

  8.4 Concurrent Review

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

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.

 

  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), or its successor.

 

  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

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.

 

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  8.7 Inter-rater Reliability

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 90 days of hire and annually thereafter.

 

  8.8 Retrospective Review

The Contractor shall:

 

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

 

  8.8.2 Conduct a quality of care investigation and report the HCAC or OPPC occurrence to AHCCCS Clinical Quality Management quarterly.

 

  8.9 Practice Guidelines

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).

 

  8.10 New Medical Technologies and New Uses of Existing Technologies

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 AHCCCS 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

The Contractor shall:

 

  8.11.1 Comply with all requirements in Contract Sections on, 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.

 

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  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

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.

 

  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 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;

 

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  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).

 

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

 

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

 

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

 

  8.14.3.2 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;

 

  8.14.3.3 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;

 

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

 

  8.14.3.5 Criteria for disenrolling members from the Care Management Program.

 

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

 

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

 

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

 

  8.14.7 Communicate Care Management activities with the Contractor’s Medical Management, Quality Management and Provider Network departments.

 

  8.14.8 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:

 

  8.14.8.1 A medical record chart review;

 

  8.14.8.2 Consultation with the member’s treatment team;

 

  8.14.8.3 Review of administrative data such as claims/encounters; and

 

  8.14.8.4 Demographic and grievance system data.

 

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  8.14.9 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:

 

  8.14.9.1 Describe the clinical interventions recommended to the treatment team;

 

  8.14.9.2 Identify coordination gaps, strategies to improve care coordination with the member’s service providers;

 

  8.14.9.3 Require strategies to monitor referrals and follow-up for specialty care and routine health care services including medication monitoring; and

 

  8.14.9.4 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

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.

 

  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.

 

  8.15.5 Engage in activities to monitor controlled and non-controlled medication use as outlined in AMPM Policy 310-FF to ensure members receive clinically appropriate prescriptions. The Contractor is required to report to AHCCCS, as specified in Exhibit-9, Deliverables, a Pharmacy and/or Prescriber - Member Assignment Report which includes the number of members which on the date of the report are restricted to using a specific Pharmacy or Prescriber/Providers due to excessive use of prescriptive medications (narcotics and non-narcotics).

 

  8.15.6 Report to AHCCCS, as specified in Exhibit-9, Deliverables, a monthly Hepatitis C Virus (HCV) Medication Report using the template provided by Medical Management.

 

  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 AHCCCS.

 

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  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 on Pre-Admission Screening and Resident Review (PASRR),or its successor.

 

  8.16.4 Submit a PASRR packet that includes an invoice to the AHCCCS.

 

  8.17 Medical Management Reporting Requirements

 

  8.17.1 The Contractor shall submit all deliverables related to Medical Management in accordance with Exhibit-9, Deliverables.

 

9 APPOINTMENT AND REFERRAL REQUIREMENTS

 

  9.1 Appointments for Behavioral Health Services

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.

 

  9.1.2 The Contractor shall ensure that providers offer a range of appointment availability, per appointment timeliness standards, for intakes and ongoing services based upon the clinical need of the member. The exclusive use of same-day only appointment scheduling and/or open access is prohibited within the contractor’s network.

 

  9.1.3 Provide appointments to members as follows:

 

  9.1.3.1 Emergency appointments within 24 hours of referral, including, at a minimum, the requirement to respond to hospital referrals for Title XIX/XXI members, and members with SMI;

 

  9.1.3.2 Routine appointment for initial assessment within seven days of referral; and

 

  9.1.4 Routine appointments for ongoing services within 23 days of initial assessment. For children in the foster care system, routine appointments for ongoing services within 21 days of initial assessment. Pursuant to A.R.S. 8-201.01, for children in the foster care system, if an initial behavioral health appointment is not provided within 21 days of the initial assessment the member may access services directly from any AHCCCS registered provider regardless of whether the provider is contracted with the Contractor. If the provider is not contracted with the Contractor, the provider must submit the claim to the Contractor and the Contractor shall reimburse the provider at the lesser of 130% of the AHCCCS system’s negotiated rate or the provider’s standard rate.

 

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

 

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  9.1.6 If the Contractor’s network is unable to provide medically necessary services required under contract, the Contractor must adequately and timely cover these services through an out of network provider until a network provider is contracted. The Contractor shall ensure coordination with respect to authorization and payment issues in these circumstances, 42 CFR 438.206(b)(4) and (5). For Members who are inpatient or in a residential treatment facility who are discharge-ready and require covered, post discharge behavioral health services, the Contractor shall have policies and procedures in place which ensure the member remain in that setting until the service is available or until such time the Contractor can ensure appropriate, intensive outpatient services/case management/peer services are available to the member while waiting for the desired service.

 

  9.1.7 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 member, and within the appointment standards described above, with appropriate interventions to prevent a member from experiencing a lapse in medically necessary psychotropic medications.

 

  9.1.8 For CMDP enrolled members, the Contractor shall ensure that a behavioral health screening is conducted within 72 hours of removal from the member’s home, as outlined in ADHS/DBHS Policy 102, Appointment Standards and Timeliness of Service or its successor.

 

  9.1.9 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).

 

  9.1.10 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.

 

  9.1.11 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 hour before the appointment, and does not have to wait for more than one hour after the conclusion of the appointment for return transportation.

 

  9.1.12 Develop and implement a quarterly performance auditing protocol to evaluate compliance with the standards for all subcontracted transportation providers and require corrective action if standards are not met.

 

  9.1.13 Accept and respond to emergency referrals of Title XIX/XXI eligible members with SMI 24 hours a day, seven days a week. Emergency referrals do not require prior authorization. Emergency referrals include those initiated for Title XIX/XXI eligible with SMI members admitted to a hospital or treated in the emergency room.

 

  9.1.14 Respond within 24 hours upon receipt of an emergency referral.

 

  9.1.15 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.

 

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  9.1.16 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.

 

  9.1.17 Respond to all requests for services and schedule emergency and routine appointments consistent with the appointment standards in this Contract.

 

  9.1.18 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.

 

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

 

  9.2 Additional Appointment Requirements for SMI Members

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

 

  9.2.1 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.

 

  9.2.2 Establish and implement procedures as indicated by the member’s condition not to exceed the following standards:

 

  9.2.3 For Primary Care Appointments:

 

  9.2.3.1 Emergency: same day of request or within 24 hours of the member’s phone call or other notification;

 

  9.2.3.2 Urgent: within two days of request; and

 

  9.2.3.3 Routine: within 21 days of request.

 

  9.2.4 For Specialty Care Appointments:

 

  9.2.4.1 Emergency: within 24 hours of referral;

 

  9.2.4.2 Urgent: within three days of referral; and

 

  9.2.4.3 Routine: within 45 days of referral.

 

  9.2.5 For Dental Appointments: to SMI members under age 21.

 

  9.2.5.1 Emergency: within 24 hours of request;

 

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  9.2.5.2 Urgent: within three days of request; and

 

  9.2.5.3 Routine: within 45 days of request.

 

  9.2.6 For Maternity Care appointments for initial prenatal care for pregnant SMI members:

 

  9.2.6.1 First trimester: within 14 days of request;

 

  9.2.6.2 Second trimester: within seven days of request;

 

  9.2.6.3 Third trimester: within three days of request; and

 

  9.2.6.4 High risk pregnancies: within three days of a maternity care provider’s identification of high risk or immediately if an emergency exists.

 

  9.2.7 Utilize the results from appointment standards monitoring to assure adequate appointment availability in order to reduce unnecessary emergency department or crisis services utilization.

 

  9.2.8 Consider utilizing non-emergency facilities to address member non-emergency care issues occurring after regular office hours or on weekends.

 

  9.2.9 Develop and distribute written policies and procedures for network providers regarding appointment time standards and requirements.

 

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

 

  9.3 Referral Requirements

The Contractor shall:

 

  9.3.1 Establish written criteria and procedures for accepting and acting upon referrals, including emergency referrals.

 

  9.3.2 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.

 

  9.3.3 Respond to all requests for services and schedule emergency and routine appointments consistent with the appointment standards in this Contract.

 

  9.3.4 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.

 

  9.3.5 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.

 

  9.3.6 Ensure that training and education are available to PCPs regarding behavioral health referrals and consultation procedures.

 

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  9.4 Disposition of Referrals

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 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 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 occasions and was unable to locate the member or contacted the member and the member declined services.

 

  9.5 Provider Directory

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.

 

  9.5.2 For additional Provider Directory requirements see the Contract Section on, Communications.

 

  9.6 Referral for a Second Opinion

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;

 

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  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).

 

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

 

  9.7.3 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.

 

  9.7.4 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.

 

  9.7.5 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.

 

  9.7.6 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:

 

  9.7.6.1 Clinical laboratory services,

 

  9.7.6.2 Physical therapy services,

 

  9.7.6.3 Occupational therapy services,

 

  9.7.6.4 Radiology services,

 

  9.7.6.5 Radiation therapy services and supplies,

 

  9.7.6.6 Durable medical equipment and supplies,

 

  9.7.6.7 Parenteral and enteral nutrients, equipment and supplies,

 

  9.7.6.8 Prosthetics, orthotics and prosthetic devices and supplies,

 

  9.7.6.9 Home health services,

 

  9.7.6.10 Outpatient prescription drugs, and

 

  9.7.6.11 Inpatient and outpatient hospital services.

 

  9.7.7 Have a process for referral to Medicare Managed Care Plan.

 

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10 QUALITY MANAGEMENT

 

  10.1 General Requirements

The Contractor shall:

 

  10.1.1 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:

 

  10.1.1.1 Ensure the protection and confidentiality 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.

 

  10.1.1.2 The Contractor must employ sufficient, qualified local staff and utilize appropriate resources to achieve contractual compliance. The Contractor’s resource allocation must be adequate to achieve quality outcomes. Staffing adequacy will be evaluated based on outcomes and compliance with contractual and AHCCCS policy requirements.

 

  10.1.1.3 The Contractor shall have local staff available 24 hours per day, seven days per week to work with AHCCCS and/or other State agencies, such as Arizona Department of Health Services/Office of Licensure, on urgent issue resolutions. Urgent issue resolutions include Immediate Jeopardies (IJ), fires, or other public emergency situations. These staff shall have access to information necessary to identify members who may be at risk and their current health/service status, the ability to initiate new placements/services, and have the ability to perform status checks at affected facilities and perform ongoing monitoring, if necessary. The Contractor shall supply AHCCCS, Clinical Quality Management (CQM) with the contact information for these staff, as specified in Exhibit-9, Deliverables. At a minimum the contact information shall include a current 24/7 telephone number. CQM must be notified and provided back up contact information when the primary contact person will be unavailable.

 

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

 

  10.1.1.5 Implement, monitor, evaluate and comply with applicable requirements in the AHCCCS Bureau of Quality and Integration (BQ&I) Specifications Manual, or its successor and the AHCCCS Medical Policy Manual.

 

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  10.1.1.6 Provide quality care and services to eligible members, regardless of payer source or eligibility category.

 

  10.1.1.7 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/Care Management

 

  10.1.1.8 Establish a Quality Management (QM) Committee, a Peer Review Committee, a Children’s QM subcommittee and other subcommittees under QM Committee as required or as a need is identified.

 

  10.1.1.9 Require its QM Committee, Peer Review Committee and subcommittees to meet at least quarterly and be chaired by the local Chief Medical Officer.

 

  10.1.1.10 Implement processes to assess, plan, implement and evaluate quality management and performance improvement activities related to services provided to members in conformance with the AHCCCS Medical Policy Manual, 42 CFR 438.240(a)(1) and (e)(2) and 42 CFR 42 447.26).

 

  10.1.1.11 Integrate quality management processes in all areas of the Contractor’s organization, with ultimate responsibility for quality management/quality improvement residing within the QM unit.

 

  10.1.1.12 Demonstrate improvement in the quality of care provided to members through established quality management and performance improvement processes.

 

  10.1.2 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:xiii

 

  10.1.2.1 Is identified in the State plan;

 

  10.1.2.2 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;

 

  10.1.2.3 Has a negative consequence for the beneficiary;

 

  10.1.2.4 Is auditable, and

 

  10.1.2.5 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))].

 

  10.1.3 If an HCAC or OPPC is identified, report the occurrence to AHCCCS and conduct a quality of care investigation as outlined in AMPM Chapter 900 and Exhibit-9, Deliverables [42 CFR 438.6(f)(2)(ii) and 42 CFR 434.6(a)(12)(ii)].xiv

 

  10.1.4 Regularly, and as requested, disseminate subcontractor and provider quality improvement information including performance measures, dashboard indicators and member outcomes to AHCCCS and key stakeholders, including members and family members.

 

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  10.1.5 Develop and maintain mechanisms to solicit feedback and recommendations from key stakeholders, subcontractors, members, and family members to monitor service quality and to develop strategies to improve member outcomes and quality improvement activities related to the quality of care and system performance.

 

  10.1.6 Participate in community initiatives including applicable activities of the Medicare Quality Improvement Organization (QIO).

 

  10.1.7 Maintain the confidentiality of a member’s medical record in conformance with Contract Section on, Medical Records.

 

  10.1.8 Comply with requirements to assure member rights and responsibilities in conformance with the ADHS/DBHS Policy and Procedures Manual policies 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); Member Grievance Resolution Process, or their successor documents; and the AHCCCS 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).

 

  10.1.9 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 AHCCCS for the purposes of assigning a care coordinator to assist the member in navigating the health care system.

 

  10.2 Credentialing

The Contractor shall:

 

  10.2.1 Demonstrate that its providers are credentialed and reviewed through the Contractor’s Credentialing Committee that is chaired by the Contractor’s local Medical Director, 42 CFR 438.214. The Contractor should refer to the AMPM and Exhibit-9, Deliverables for reporting requirements.

 

  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 or have seen 25 or more of the Contractor’s members, 42 CFR 438.206(b)(1-2);

 

  10.2.2.2 Not discriminate against particular providers that serve high-risk 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).

 

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REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

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

 

  10.2.4 Credentialing Timelines: The Contractor is required to process credentialing applications in a timely manner. To assess the timeliness of provisional and initial credentialing a Contractor shall calculate and report to AHCCCS as outlined in AMPM Policy 950. The Contractor must report the credentialing information with regard to all credentialing applications as specified in Exhibit-9, Deliverables.

 

  10.2.5 The Contractor shall ensure that they have in place a process to monitor, at a minimum, on an annual basis, occurrences which may have jeopardized 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 and other proper authorities incident, accident and death (IAD) reports of abuse, neglect, injury, alleged human rights violation, exploitation and death in conformance with the AHCCCS Medical Policy Manual, Chapter 900.

 

  10.3.2 Incident, accident and death (IAD) reports must be submitted in accordance with requirements established by AHCCCS.

 

  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, including members with special health care needs, 42 CFR 438.420(b)(4).

 

  10.4.2 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.

 

  10.4.3 Develop a process to report incidents of healthcare acquired conditions, abuse, neglect, exploitation, injuries, high profile cases and unexpected death to AHCCCS Quality Management.

 

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REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  10.4.4 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.

 

  10.4.5 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.

 

  10.4.6 Establish mechanisms to track and trend member and provider issues, which includes, but is not limited to, investigation and analysis of quality of care issues, abuse, neglect, exploitation, high profile, human rights violations and unexpected deaths. The resolution process must include:

 

  10.4.6.1 Acknowledgement letter to the originator of the concern;

 

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

 

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

 

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

 

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

 

  10.4.6.6 Analysis of the effectiveness of the interventions taken.

 

  10.4.7 Implement mechanisms to assess the quality and appropriateness of care furnished to members with special health care needs.

 

  10.5 Performance Measures

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

The Contractor shall:

 

  10.5.1 Comply with national performance measures and levels identified and developed by the Centers for Medicare and Medicaid Services (CMS) or those that are developed in consultation with AHCCCS and/or other relevant stakeholders, and any resulting changes when current established performance measures are finalized and implemented, 42 CFR 438.24(c).

 

  10.5.2 Implement Performance improvement programs including performance measures and performance improvement projects as directed by AHCCCS, 42 CFR 438.240(a)(2).

 

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REGIONAL BEHAVIORAL HEALTH AUTHORITY

GREATER ARIZONA

 

  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 Improve performance for all established performance measures.

 

  10.5.5 Ensure that performance measures are analyzed and reported separately, by line of business Acute, DDD, (Acute, SMI populations, DDD and CMDP), In addition, Contractors should evaluate performance based on sub-categories of populations when requested to do such.

 

  10.5.6 Collect data from medical records, electronic records or through approved processes such as those utilizing a health information exchange and provide these data with supporting documentation, as instructed by AHCCCS, for each hybrid measure. The number of records that each Contractor collects will be based on HEDIS, External Quality Review Organization (EQRO), or other sampling guidelines and may be affected by the Contractor’s previous performance rate for the measure being collected.

 

  10.5.7 Comply with and implement the hybrid methodology data collection as directed by AHCCCS.

 

  10.5.8 Implement a process for internal monitoring of Performance Measure rates, using a standard methodology established or approved by AHCCCS, 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.

 

  10.5.9 Have a mechanism for its QM Committee to report Contractor’s performance on an ongoing basis to its CEO/COO and other key staff.

 

  10.5.10 Meet and sustain specified Minimum Performance Standards (MPS) in the table below for each population/eligibility category according to the following:

 

  10.5.10.1 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.

 

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

 

  10.5.12

An evidence-based corrective action plan that outlines the problem, planned actions for improvement, responsible staff and associated timelines as well as a place holder for evaluation of activities must be received by AHCCCS within 30

 

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GREATER ARIZONA

 

  days of receipt of notification of the deficiency from AHCCCS. This plan must be approved by AHCCCS prior to implementation. AHCCCS may conduct one or more follow-up desktop or on-site reviews to verify compliance with a corrective action plan.

 

  10.5.13 AHCCCS may also require the Contractor to conduct a 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 Minimum Performance Standards, 42 CFR 438.240(b)(1), (2), and (d)(1).

GMH/SA Performance Measures:

 

Measure

   Minimum Performance Standard

Follow-Up After Hospitalization for Mental Health, 7 Days

   85%

Follow-Up After Hospitalization for Mental Health, 30 Days

   95%

Mental Health Utilization

   Baseline Measurement Year

Use of Multiple Concurrent Antipsychotics in Children and Adolescents

   Baseline Measurement Year

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

   Baseline Measurement Year

GMH/SA Performance Measures with Reserve Status*:

 

Measure

   Minimum Performance Standard

Access to Behavioral Health Professional Services, 7 Days

   75%

Access to Behavioral Health Professional Services, 23 Days

   90%

 

* Performance measures remain important to AHCCCS and as such will continue to be monitored by AHCCCS. Should Contractor performance results for Performance Measures in Reserve Status decline, the Contractor may be subject to corrective action. AHCCCS may require individual Contractors to