EXHIBIT 10.1

		ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION DIVISION OF BUSINESS AND FINANCE SECTION A: CONTRACT

1. AMENDMENT		2. CONTRACT		3. EFFECTIVE DATE OF		4. PROGRAM
NUMBER:		NO.:		CONTRACT:
10		YH09-0001		October 1, 2010		DHCM — ACUTE

5. CONTRACTOR’S NAME AND ADDRESS:

6. PURPOSE OF AMENDMENT: To renew the contract for the term October 1, 2010 through September 30, 2011 and to amend Sections B, C, D, E and Attachments B, F and G.

7. THE CONTRACT REFERENCED ABOVE FOLLOWS

	A.		Section B contains revised Capitation Rates and extends the contract term from October 1, 2010 through September 30, 2011. (See attached rate sheet.)
	B.		Section C has had 3 definitions revised (ADHS Behavioral Health Recipient, Medicare Part D Excluded Drugs, and Title XXI Member) and one definition deleted (HIFA).
	C.		Section D contains technical corrections and revised/clarifying language in Paragraphs 3 (Enrollment and Disenrollment), 6 (Auto-Assignment Algorithm), 10 (Scope of Services), 12 (Behavioral Health), 14 (Medicaid School Based Claiming Program), 16 (Staff Requirements), 18 (Member Information), 19 (Surveys), 23 (Quality Management), 24 (Medical Management), 27 (Network Development), 29 (Network Management), 34 (FQHC), 37 (Subcontracts), 38 (Claims Payment/Health Information System), 46 (Performance Bond), 50 (Financial Viability Standards), 52 (Merger), 53 (Compensation), 55 (Capitation Adjustments), 57 (Reinsurance), 58 (Coordination of Benefits/TPL, 59 (Copayments), 62 (Corporate Compliance), 65 (Encounter Data Reporting), 74 (Technological Advancement) and 75 (Pending Legislative / Other Issues).
	D.		Section E (Contract Clauses) contains a revision to items 7, Assignment and Delegation and 17, Suspension.
	E.		Attachment B (Minimum Network Standards) has been updated with current information.
	F.		Attachment F (Periodic Reporting Requirements) contains a new column to specify the method for submittal of contract deliverables. Additionally, the Suspension and Modification listing has been updated.
	G.		Attachment G (Auto-Assignment Algorithm) has been updated.

PLEASE REFER TO THE ATTACHED CHANGE MATRIX WHICH LISTS CHANGES MADE TO INDIVIDUAL SECTIONS FOR DETAILS.

By signing this contract, the Contractor is agreeing to the terms of the contract.

NOTE: Please sign, date, and return executed file by E-Mail to: Mark Held at Mark.Held@azahcccs.gov

Sr. Procurement Specialist
AHCCCS Contracts and Purchasing
and Stewart McKenzie at
Stewart.McKenzie@azahcccs.gov

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

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

9. SIGNATURE OF AUTHORIZED REPRESENTATIVE:		10. SIGNATURE OF AHCCCSA CONTRACTING OFFICER:
/s/ Nancy Novick		/s/ Michael Veit
TYPED NAME: NANCY NOVICK		TYPED NAME: MICHAEL VEIT
TITLE: CHIEF EXECUTIVE OFFICER		TITLE: CONTRACTS & PURCHASING ADMINISTRATOR
DATE: 9/9/10		DATE: SEP 01 2010

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CAPITATION RATE SUMMARY — ACUTE RATES (Risk Adjusted with 100% of 2009 factor)
Phoenix Health Plan
10/1/10-9/30/11

																																		Maternity
		TANF				TANF				TANF				TANF				TANF				SSI				SSI								Delivery
Title XIX and KidsCare Rates 1:		<1, M/F				1-13, M/F				14-44, F				14-44, M				45+, M/F				w/ Med				w/o Med				SFP				Supplement				Non-MED				MED
4 Apache/Coconino/Mohave/Navajo		$	566.04			$	116.92			$	274.25			$	170.68			$	384.01			$	109.32			$	859.16			$	12.44			$	6,427.79			$	470.68			$	1,332.74
6 Yavapai		$	538.28			$	113.45			$	283.69			$	180.45			$	398.25			$	132.09			$	863.78			$	16.00			$	6,946.99			$	568.46			$	1,353.15
8 Gila/Pinal		$	476.56			$	109.26			$	266.18			$	176.94			$	386.22			$	132.41			$	888.18			$	13.48			$	6,778.73			$	460.61			$	1,483.32
10 Pima		$	546.28			$	94.54			$	225.39			$	133.15			$	346.44			$	125.65			$	829.01			$	16.65			$	6,507.93			$	410.53			$	1,492.69
12 Maricopa		$	522.32			$	112.23			$	245.15			$	153.56			$	416.37			$	147.24			$	736.24			$	14.73			$	6,715.02			$	481.10			$	1,449.24
		TANF				TANF				TANF				TANF				TANF				SSI				SSI
PPC Rates:		<1, M/F				1-13, M/F				14-44, F				14-44, M				45+, M/F				w/ Med				w/o Med												Non-MED				MED
4 Apache/Coconino/Mohave/Navajo		$	899.64			$	55.34			$	212.09			$	177.93			$	418.61			$	148.41			$	439.26											$	836.86			$	6,204.45
6 Yavapai		$	912.34			$	66.66			$	222.41			$	216.20			$	356.56			$	175.25			$	453.00											$	871.63			$	6,244.93
8 Gila/Pinal		$	896.96			$	58.26			$	230.84			$	172.79			$	353.61			$	142.80			$	445.82											$	852.37			$	6,386.25
10 Pima		$	953.71			$	55.39			$	206.36			$	160.81			$	352.98			$	142.06			$	362.48											$	602.86			$	6,052.93
12 Maricopa		$	890.49			$	57.92			$	204.22			$	170.94			$	346.96			$	156.89			$	346.87											$	944.51			$	6,866.82

		Option 1				Option 2
Other Rates:		Transplant				Transplant
4 Apache/Coconino/Mohave/Navajo		$	16.50			$	16.50
6 Yavapai		$	16.50			$	16.50
8 Gila/Pinal		$	16.50			$	16.50
10 Pima		$	16.50			$	16.50
12 Maricopa		$	16.50			$	16.50

TABLE OF CONTENTS

SECTION A: CONTRACT			1
SECTION B: CAPITATION RATES			6
SECTION C: DEFINITIONS			9
SECTION D: PROGRAM REQUIREMENTS			18
INTRODUCTION			18
1. TERM OF CONTRACT AND OPTION TO RENEW			18
2. ELIGIBILITY CATEGORIES			20
3. ENROLLMENT AND DISENROLLMENT			22
4. ANNUAL ENROLLMENT CHOICE			24
5. ENROLLMENT AFTER CONTRACT AWARD			24
6. AUTO-ASSIGNMENT ALGORITHM			25
7. AHCCCS MEMBER IDENTIFICATION CARDS			25
8. MAINSTREAMING OF AHCCCS MEMBERS			25
9. TRANSITION OF MEMBERS			26
10. SCOPE OF SERVICES			26
11. SPECIAL HEALTH CARE NEEDS			36
12. BEHAVIORAL HEALTH SERVICES			37
13. AHCCCS GUIDELINES, POLICIES AND MANUALS			39
14. MEDICAID SCHOOL BASED CLAIMING PROGRAM (MSBC)			39
15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM			40
16. STAFF REQUIREMENTS AND SUPPORT SERVICES			40
17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS			44
18. MEMBER INFORMATION			44
19. SURVEYS			46
20. CULTURAL COMPETENCY			46
21. MEDICAL RECORDS			47
22. ADVANCE DIRECTIVES			47
23. QUALITY MANAGEMENT (QM)			48
24. MEDICAL MANAGEMENT (MM)			53
25. ADMINISTRATIVE PERFORMANCE STANDARDS			54
26. GRIEVANCE SYSTEM			55
27. NETWORK DEVELOPMENT			56
28. PROVIDER AFFILIATION TRANSMISSION			57
29. NETWORK MANAGEMENT			58
30. PRIMARY CARE PROVIDER STANDARDS			59
31. MATERNITY CARE PROVIDER STANDARDS			60
32. REFERRAL MANAGEMENT PROCEDURES AND STANDARDS			61
33. APPOINTMENT STANDARDS			62
34. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS			63
35. PROVIDER MANUAL			63
36. PROVIDER REGISTRATION			64
37. SUBCONTRACTS			64
38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM			67
39. SPECIALTY CONTRACTS			70
40. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT			71
41. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT			71
42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE			72
43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN			73

44. RESERVED			73
45. RESERVED			73
46. PERFORMANCE BOND OR BOND SUBSTITUTE			74
47. AMOUNT OF PERFORMANCE BOND			74
48. ACCUMULATED FUND DEFICIT			75
49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS			75
50. FINANCIAL VIABILITY STANDARDS			75
51. SEPARATE INCORPORATION			76
52. MERGER, REORGANIZATION AND CHANGE OF OWNERSHIP			76
53. COMPENSATION			77
54. PAYMENTS TO CONTRACTORS			79
55. CAPITATION ADJUSTMENTS			79
56. RESERVED			80
57. REINSURANCE			80
58. COORDINATION OF BENEFITS			85
59. COPAYMENTS			89
60. MEDICARE SERVICES AND COST SHARING			89
61. MARKETING			89
62. CORPORATE COMPLIANCE			90
63. RECORDS RETENTION			91
64. DATA EXCHANGE REQUIREMENTS			91
65. ENCOUNTER DATA REPORTING			92
66. ENROLLMENT AND CAPITATION TRANSACTION UPDATES			94
67. PERIODIC REPORT REQUIREMENTS			95
68. REQUESTS FOR INFORMATION			95
69. DISSEMINATION OF INFORMATION			96
70. OPERATIONAL AND FINANCIAL READINESS REVIEWS			96
71. OPERATIONAL AND FINANCIAL REVIEWS			96
72. SANCTIONS			97
73. BUSINESS CONTINUITY AND RECOVERY PLAN			98
74. TECHNOLOGICAL ADVANCEMENT			99
75. PENDING LEGISLATIVE / OTHER ISSUES			100
76. SUPPORT OF ARIZONA BASED TRANSLATIONAL AND CLINICAL RESEARCH			101
77. RESERVED			101
78. RESERVED			101
SECTION E: CONTRACT CLAUSES			102
1) APPLICABLE LAW			102
2) AUTHORITY			102
3) ORDER OF PRECEDENCE			102
4) CONTRACT INTERPRETATION AND AMENDMENT			102
5) SEVERABILITY			102
6) RELATIONSHIP OF PARTIES			102
7) ASSIGNMENT AND DELEGATION			102
8) INDEMNIFICATION			103
9) INDEMNIFICATION — PATENT AND COPYRIGHT			103
10) COMPLIANCE WITH APPLICABLE LAWS, RULES AND REGULATIONS			103
11) ADVERTISING AND PROMOTION OF CONTRACT			103
12) PROPERTY OF THE STATE			103
13) THIRD PARTY ANTITRUST VIOLATIONS			104
14) RIGHT TO ASSURANCE			104
15) TERMINATION FOR CONFLICT OF INTEREST			104
16) GRATUITIES			104
17) SUSPENSION OR DEBARMENT			104
18) TERMINATION FOR CONVENIENCE			105
19) TEMPORARY MANAGEMENT/OPERATION OF A CONTRACTOR AND TERMINATION			105

20) TERMINATION — AVAILABILITY OF FUNDS			106
21) RIGHT OF OFFSET			106
22) NON-EXCLUSIVE REMEDIES			106
23) NON-DISCRIMINATION			106
24) EFFECTIVE DATE			106
25) INSURANCE			106
26) DISPUTES			107
27) RIGHT TO INSPECT PLANT OR PLACE OF BUSINESS			107
28) INCORPORATION BY REFERENCE			107
29) COVENANT AGAINST CONTINGENT FEES			108
30) CHANGES			108
31) TYPE OF CONTRACT			108
32) AMERICANS WITH DISABILITIES ACT			108
33) WARRANTY OF SERVICES			108
34) NO GUARANTEED QUANTITIES			108
35) CONFLICT OF INTEREST			108
36) CONFIDENTIALITY AND DISCLOSURE OF CONFIDENTIAL INFORMATION			108
37) COOPERATION WITH OTHER CONTRACTORS			109
38) ASSIGNMENT OF CONTRACT AND BANKRUPTCY			109
39) OWNERSHIP OF INFORMATION AND DATA			109
40) AUDITS AND INSPECTIONS			109
41) LOBBYING			110
42) CHOICE OF FORUM			110
43) DATA CERTIFICATION			110
44) OFF SHORE PERFORMANCE OF WORK PROHIBITED			110
45) FEDERAL IMMIGRATION AND NATIONALITY ACT			110
46) IRS W-9 FORM			110
47) CONTINUATION OF PERFORMANCE THROUGH TERMINATION			110
SECTION F: RESERVED			112
SECTION G: RESERVED			113
SECTION H: RESERVED			114
SECTION I: RESERVED			115
SECTION J: LIST OF ATTACHMENTS			116
ATTACHMENT A: MINIMUM SUBCONTRACT PROVISIONS			117
1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES			117
2. AWARDS OF OTHER SUBCONTRACTS			117
3. CERTIFICATION OF COMPLIANCE — ANTI-KICKBACK AND LABORATORY TESTING			117
4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION			117
5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988			118
6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION			118
7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS			118
8. CONFIDENTIALITY REQUIREMENT			118
9. CONFLICT IN INTERPRETATION OF PROVISIONS			118
10. CONTRACT CLAIMS AND DISPUTES			118
11. ENCOUNTER DATA REQUIREMENT			118
12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES			119
13. FRAUD AND ABUSE			119
14. GENERAL INDEMNIFICATION			119
15. INSURANCE			119

16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES			119
17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES			119
18. NON-DISCRIMINATION REQUIREMENTS			119
19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT			120
20. RECORDS RETENTION			120
21. SEVERABILITY			120
22. SUBJECTION OF SUBCONTRACT			120
23. TERMINATION OF SUBCONTRACT			120
24. VOIDABILITY OF SUBCONTRACT			121
25. WARRANTY OF SERVICES			121
26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED			121
27. FEDERAL IMMIGRATION AND NATIONALITY ACT			121
ATTACHMENT B: MINIMUM NETWORK STANDARDS (BY GEOGRAPHIC SERVICE AREA)			122
ATTACHMENT C: RESERVED			132
ATTACHMENT D: SAMPLE LETTER OF INTENT			133
ATTACHMENT E: RESERVED			139
ATTACHMENT F: PERIODIC REPORT REQUIREMENTS			140
ATTACHMENT G: AUTO-ASSIGNMENT ALGORITHM			148
ATTACHMENT H(1): ENROLLEE GRIEVANCE SYSTEM STANDARDS AND POLICY			152
ATTACHMENT H(2): PROVIDER CLAIM DISPUTE STANDARDS AND POLICY			157
ATTACHMENT I: RESERVED			159
ATTACHMENT J: RESERVED			160
ATTACHMENT J(2): RESERVED			161
ATTACHMENT K: COST SHARING COPAYMENTS			162

SECTION B: CAPITATION RATES		Contract/RFP No. YH09-0001

SECTION B: CAPITATION RATES

The Contractor shall provide services as described in this contract. In consideration for these services, the Contractor will be paid Contractor-specific rates per member per month for the term October 1, 2010 through September 30, 2011.

Phoenix Health Plan special contract language

I. Purpose:

The purpose of this amendment is to implement a credit balance review program by Health Management Systems, Inc. (HMS) on behalf of Phoenix Health Plan through HMS’s contract with the Arizona Health Care Cost Containment System (AHCCCS). Credit Balance Review is the process used to identify and recover any Medicare or Third Party resource overpayment retained by a provider for an AHCCCS member.

II. Process:

HMS’s credit balance program is comprised of two parts, which when used in conjunction, have proven to be effective recovery tools. The process begins when HMS notifies the selected provider by mail requesting they conduct a self-audit for credit balances. This will be accompanied by the AHCCCS Health Plan third party resource refund worksheet (Attachment A). Instructions allow a provider to return overpayments, which may exclude them from an on-site review. After sufficient time has been allowed for all to respond, the next step is to select providers for on-site reviews of the provider’s credit balance process. Providers are selected for this review based upon their comparative returns of credit balances in the self-audit, AHCCCS and the Health Plan preference, and the likelihood of credit balances existing. AHCCCS will generate a letter to the provider notifying them of the on-site review, explaining the scope, and including a list of accounts that have been targeted for review. This list will be identified through a series of data analysis programs designed to create a profile of a member/patient with a potential credit balance. To perform this function, HMS will use a combination of data files including paid claims history, encounter data, and eligibility files. In addition, provider accounting procedures are verified to ensure the proper posting of contractual allowances, etc. HMS will schedule these reviews approximately thirty (30) days after the provider receives the notification.

Any credit balance accounts under current review or previously identified by the Health Plans shall be reported to AHCCCS prior to HMS’s scheduled review. These accounts should be reported on the AHCCCS Health Plan credit balance accounts under review worksheet (Attachment B) with supporting documentation.

The providers will be directed to send the refund balances to HMS. HMS will receive and identify these refunds. AHCCCS will require HMS to process these refunds in the same manner as currently required by the AHCCCS contract with HMS. AHCCCS will require HMS to research the refunds and to provide a monthly disbursement report of the refund amounts due to the health plans and program contractors. AHCCCS will disburse a payment in the amount due to the health plans and program contractors.

An electronic report of all claims identified as credit balances where reimbursement is received from the provider, will be generated for the Health Plan and for AHCCCS. HMS will research and verify cases needing adjustments as a result of the credit balance. All recoveries are subject to reporting requirements contained in the AHCCCS Recoupment Request Policy. Depending on the program’s initial success, this program may be implemented quarterly, semi-annually or annually.

SECTION B: CAPITATION RATES		Contract/RFP No. YH09-0001

ATTACHMENT A

Third Party Resource Refund Worksheet

AHCCCS Provider Name:						Page:                      of
						Completed By:
AHCCCS Provider ID Number:						Date:                     /                    /

TOTAL

AMOUNT

PAID BY

THIRD

MEMBER/

TOTAL

THIRD

PARTY

PATIENT

DATE OF

CLAIM

TOTAL

AMOUNT

PARTY

RESOURCE/

REFUND

REASON

MEMBER/PATIENT

AHCCCS

SERVICE PERIOD

REFERENCE

BILLED

PAID BY

RESOURCE/

INSURANCE

AMOUNT

FOR

NAME

ID

FROM

TO

NUMBER (CRN)

CHARGES

AHCCCS

INSURANCE

NAME

DUE

REFUND

This is to certify that the information contained in this report is true, accurate and complete, to the best of my knowledge. I understand that AHCCCS will rely on this certification at the time AHCCCS certifies its expenditures to the Centers for Medicare and Medicaid Services on Form CMS-64.

Authorized Signature		Date:

SECTION B: CAPITATION RATES		Contract/RFP No. YH09-0001

ATTACHMENT B
Credit Balance Accounts Under Review by AHCCCS Program Contractors

Health Plan Name:						Page:                      of
						Completed By:
Health Plan ID Number:						Date:                     /                    /

MEMBER/

AHCCCS

AHCCCS

MEMBER/

PATIENT

DATE OF SERVICE

ENCOUNTER/

THIRD PARTY

PROVIDER

PROVIDER

PATIENT

AHCCCS

PERIOD

CLAIM REFERENCE

TOTAL BILLED

RESOURCE/INSURANCE

NAME

ID NUMBER

NAME

ID

FROM

TO

NUMBER (CRN)

CHARGES

NAME

This is to certify that the information contained in this report is true, accurate and complete, to the best of my knowledge. I understand that AHCCCS will rely on this certification at the time AHCCCS certifies its expenditures to the Centers for Medicare and Medicaid Services on Form CMS-64.

Authorized Signature		Date:

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

SECTION C: DEFINITIONS
638 TRIBAL FACILITY		A facility that is operated by an Indian tribe and that is authorized to provide services pursuant to Public Law (P.L.) 93-638, as amended.
1931 (also referred to as TANF related)		Eligible individuals and families under Section 1931 of the Social Security Act, with household income levels at or below 100% of the federal poverty level (FPL).
ACOM		AHCCCS Contractor Operations Manual, available on the AHCCCS website at www.azahcccs.gov.
ADHS		Arizona Department of Health Services, the state agency mandated to serve the public health needs of all Arizona citizens.
ADHS BEHAVIORAL HEALTH RECIPIENT		A Title XIX or Title XXI acute care member who is receiving behavioral health services through ADHS and its subcontractors.
ADJUDICATED CLAIMS		Claims that have been received and processed by the Contractor, and which resulted in a payment or denial of payment
AGENT		Any person who has been delegated the authority to obligate or act on behalf of another person or entity.
AHCCCS		Arizona Health Care Cost Containment System, which is composed of the Administration, Contractors, and other arrangements through which health care services are provided to an eligible person, as defined by A.R.S. § 36-2902, et seq.
AHCCCS BENEFITS		See “COVERED SERVICES”.
AHCCCS CARE		Eligible individuals and childless adults whose income is less than 100% of the FPL, and who are not categorically linked to another Title XIX program. Also known as “NON MEDICAL EXPENSE DEDUCTION MEMBER (NON-MED)”
AHCCCS MEMBER		See “MEMBER”.
ALTCS		The Arizona Long Term Care System, a program under AHCCCS that delivers long-term, acute, behavioral health and case management services to members, as authorized by A.R.S. § 36-2932.
AMBULATORY CARE		Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and other health care providers.
AMERICAN INDIAN HEALTH PROGRAM (AIHP)		AIHP is an acute care program that delivers acute care health care services to the eligible American Indians who choose to receive services through the Indian Health Service (IHS) or tribal health programs operated under PL 93-638 (known as 638 facilities). AIHP is formerly known as the AHCCCS IHS FFS Program.
AMPM		AHCCCS Medical Policy Manual, available on the AHCCCS website at www.azahcccs.gov.
ANNUAL ENROLLMENT CHOICE (AEC)		The opportunity, given each member annually, to change to another Contractor in their GSA.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

APPEAL RESOLUTION		The written determination by the Contractor concerning an appeal.
ARIZONA ADMINISTRATIVE CODE (A.A.C.)		State regulations established pursuant to relevant statutes. For purposes of this solicitation, the relevant sections of the A.A.C. are referred to throughout this document as “AHCCCS Rules”.
A.R.S.		Arizona Revised Statutes.
BBA		The Balanced Budget Act of 1997.
BIDDER’S LIBRARY		A repository of manuals, statutes, rules and other reference material located on the AHCCCS website at www.azahcccs.gov.
BOARD CERTIFIED		An individual who has successfully completed all prerequisites of the respective specialty board and successfully passed the required examination for certification.
BORDER COMMUNITIES		Cities, towns or municipalities located in Arizona and within a designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding neighboring countries, due to service availability or distance. (R9-22-201.F, R9-22-201.G, R9-22-101.B)
BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)		Eligible individuals under the Title XIX expansion program for women with income up to 250% of the FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.
CAPITATION		Payment to a Contractor by AHCCCS of a fixed monthly payment per person in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S. § 36-2904 and § 36-2907.
CATEGORICALLY LINKED TITLE XIX MEMBER		Member eligible for Medicaid under Title XIX of the Social Security Act including those eligible under 1931 provisions of the Social Security Act, Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), and SSI-related groups. To be categorically linked, the member must be aged 65 or over, blind, disabled, a child under age 19, a parent of a dependent child, or pregnant.
CLAIM DISPUTE		A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance.
CLEAN CLAIM		A claim that may be processed without obtaining additional information from the provider of service or from a third party, but does not include a claim under investigation for fraud or abuse or under review for medical necessity.
CMS		Centers for Medicare and Medicaid Services, an organization within the U.S. Department of Health and Human Services, which administers the Medicare and Medicaid programs and the State Children’s Health Insurance Program.
COMPETITIVE BID PROCESS		A state procurement system used to select Contractors to provide covered services on a geographic basis.
CONTINUING OFFEROR (INCUMBENT)		An AHCCCS Contractor during CYE ‘08 that submits a proposal pursuant to this solicitation.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

CONTRACT SERVICES		See “COVERED SERVICES”.
CONTRACT YEAR (CY)		Corresponds to the federal fiscal year (October 1 through September 30).
CONTRACTOR		An organization or entity agreeing through a direct contracting relationship with AHCCCS to provide the goods and services specified by this contract in conformance with the stated contract requirements, AHCCCS statute and rules, and federal law and regulations.
CONVICTED		A judgment of conviction has been entered by a federal, state or local court, regardless of whether an appeal from that judgment is pending.
COPAYMENT		A monetary amount specified by the Director that the member pays directly to a Contractor or provider at the time covered services are rendered, as defined in R9-22-701.
COVERED SERVICES		Health care services to be delivered by a Contractor, which are designated in Section D of this contract; AHCCCS Rules R9-22, Article 2, and R9-31, Article 2, and the AMPM [42 CFR 438.210(a)(4)].
CRS		The Children’s Rehabilitative Services administered by ADHS, as defined in R9-22-1401.
CRS-ELIGIBLE		An individual who has completed the CRS application process, as delineated in the CRS Policy and Procedure Manual, and has met all applicable criteria to be eligible to receive CRS-related services.
CY		See “CONTRACT YEAR”.
CYE		Contract Year Ending; same as “CONTRACT YEAR”.
DAYS		Calendar days, unless otherwise specified as defined in the text, as defined in R9-22-101.
DELEGATED AGREEMENT		A type of subcontract with a qualified organization or person to perform one or more functions required to be provided by the Contractor pursuant to this contract.
DIRECTOR		The Director of AHCCCS.
DISENROLLMENT		The discontinuance of a member’s ability to receive covered services through a Contractor.
DME		Durable medical equipment, which is an item or appliance that can withstand repeated use, is designated to serve a medical purpose, and is not generally useful to a person in the absence of a medical condition, illness or injury as defined in R9-22-101.
DUAL ELIGIBLE		A member who is eligible for both Medicare and Medicaid.
ELIGIBILITY DETERMINATION		A process of determining, through a written application and required documentation, whether an applicant meets the qualifications for Title XIX or Title XXI.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

EMERGENCY MEDICAL CONDITION		A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part [42 CFR 438.114(a)].
EMERGENCY MEDICAL SERVICE		Covered inpatient and outpatient services provided after the sudden onset of an emergency medical condition as defined above. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize the emergency medical condition [42 CFR 438.114(a)].
ENCOUNTER		A record of a health care-related service rendered by a provider or providers registered with AHCCCS to a member who is enrolled with a Contractor on the date of service.
ENROLLEE		An eligible person who is enrolled in AHCCCS, as defined in A.R.S. § 36-2901, A.R.S. § 36-2981, A.R.S. § 36-2901.01, and 42 CFR 438.10(a).
ENROLLMENT		The process by which an eligible person becomes a member of a Contractor’s plan.
EPSDT		Early and Periodic Screening, Diagnosis and Treatment; services for persons under 21 years of age, as described in AHCCCS Rules R9-22, Article 2.
FAMILY PLANNING SERVICES EXTENSION PROGRAM		A program that provides only family planning services for a maximum of two consecutive 12-month periods to a SOBRA woman whose pregnancy has ended and who is not otherwise eligible for full Title XIX services.
FEDERALLY QUALIFIED HEALTH CENTER (FQHC)		An entity that meets the requirements and receives a grant and funding pursuant to Section 330 of the Public Health Service Act. An FQHC includes an outpatient health program or facility operated by a tribe or tribal organization under the Indian Self-Determination and Education Assistance Act (P.L. 93-638) or an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act (P.L. 94-437).
FEE-FOR-SERVICE (FFS)		A method of payment to registered providers on an amount per-service basis.
FES		Federal Emergency Services program covered under R9-22-217, to treat an emergency medical condition for a member who is determined eligible under A.R.S. § 36-2903.03 (D).
FFP		Federal financial participation (FFP) refers to the contribution that the federal government makes to the Title XIX and Title XXI program portions of AHCCCS, as defined in 42 CFR 400.203.
FISCAL YEAR (FY)		The budget year — federal fiscal year: October 1 through September 30; State fiscal year: July 1 through June 30.
FREEDOM OF CHOICE (FC)		The opportunity given to each member who does not specify a Contractor preference at the time of enrollment to choose between the Contractors available within the Geographic Service Area in which the member is enrolled.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

FREEDOM TO WORK (TICKET TO WORK)		Eligible individuals under the Title XIX expansion program that extends eligibility to individuals 16 through 64 years old who meet SSI disability criteria; whose earned income, after allowable deduction, is at or below 250% of the FPL and who are not eligible for any other Medicaid program.
GEOGRAPHIC SERVICE AREA (GSA)		A specific county or defined grouping of counties designated by AHCCCS within which a Contractor provides, directly or through subcontract, covered health care to members enrolled with that Contractor.
GRIEVANCE SYSTEM		A system that includes a process for enrollee grievances, enrollee appeals, provider claim disputes, and access to the state fair hearing system.
HEALTHCARE GROUP OF ARIZONA (HCG)		A prepaid medical coverage plan marketed to small, uninsured businesses and political subdivisions within the state.
HEALTH PLAN		See “CONTRACTOR”.
HIPAA		The Health Insurance Portability and Accountability Act (P.L. 104-191); also known as the Kennedy-Kassebaum Act, signed August 21, 1996.
IBNR		Incurred but not reported: liability for services rendered for which claims have not been received.
IHS		Indian Health Service authorized as a federal agency pursuant to 25 U.S.C. 1661.
KIDSCARE		A program for individuals under the age of 19 years, who are eligible under the SCHIP program, in households with income at or below 200% FPL. All members, except Native American members, are required to pay a premium amount based on the number of children in the family and the gross family income. Also referred to as “Title XXI”.
LIABLE PARTY		A person or entity that is or may be, by agreement, circumstance or otherwise, liable to pay all or part of the medical expenses incurred by an AHCCCS applicant or member.
LIEN		A legal claim, filed with the County Recorder’s office in the county in which a member resides and/or in the county an injury was sustained, for the purpose of ensuring that AHCCCS receives reimbursement for medical services paid. The lien is attached to any settlement the member may receive as a result of an injury.
MANAGED CARE		Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality, utilization management and the coordination of care.
MANAGEMENT SERVICES AGREEMENT		A type of subcontract with an entity in which the owner of the Contractor delegates some or all of the comprehensive management and administrative services necessary for the operation of the Contractor.
MANAGEMENT SERVICES SUBCONTRACTOR		An entity to which the Contractor delegates the comprehensive management and administrative services necessary for the operation of the Contractor.
MANAGING EMPLOYEE		A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

MATERIAL OMISSION		Facts, data or other information excluded from a report, contract, etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, contract, etc.
MAJOR UPGRADE		Any upgrade or changes that may result in a disruption to the following: loading of contracts, providers or members, issuing prior authorizations or the adjudication of claims.
MEDICAID		A federal/state program authorized by Title XIX of the Social Security Act, as amended.
MEDICAL EXPENSE DEDUCTION (MED)		Title XIX waiver member whose family income exceeds the limits of all other Title XIX categories (except ALTCS) and has family medical expenses that reduce income to or below 40% of the FPL. MED members may or may not have a categorical link to Title XIX.
MEDICAL MANAGEMENT		An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the continuum of care (from prevention to end of life care).
MEDICARE		A federal program authorized by Title XVIII of the Social Security Act, as amended.
MEDICARE MANAGED CARE PLAN		A managed care entity that has a Medicare contract with CMS to provide services to Medicare beneficiaries, including Medicare Advantage Plan (MAP), Medicare Advantage Prescription Drug Plan (MAPDP), MAPDP Special Needs Plan, or Medicare Prescription Drug Plan.
MEDICARE PART D EXCLUDED DRUGS		Medicare Part D is the prescription drug coverage option available to Medicare beneficiaries, including those also eligible for Medicaid. Medications that are available under this benefit are not covered by AHCCCS for dual eligible members. Certain drugs that are excluded from coverage by Medicare continue to be covered by AHCCCS. Those medications are barbiturates, benzodiazepines, and over-the-counter medication as defined in the AMPM. Prescription medications that are covered under Medicare, but are not on a Part D health plan’s formulary are not considered excluded drugs, and are not covered by AHCCCS.
MEMBER		See “ENROLLEE”.
NON-CONTRACTING PROVIDER		A person or entity that provides services as prescribed in A.R.S. § 36-2901, but does not have a subcontract with an AHCCCS Contractor.
NON-MEDICAL EXPENSE DEDUCTION (NON MED) MEMBER		See “AHCCCS CARE”.
NPI		National Provider Identifier assigned by the CMS contracted national enumerator.
OFFEROR		An organization or other entity that submits a proposal to the Administration in response to this RFP, as defined in R9-22-101.
PERFORMANCE STANDARDS		A set of standardized measures designed to assist AHCCCS in evaluating, comparing and improving the performance of its Contractors.
PMMIS		AHCCCS’s Prepaid Medical Management Information System.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

POST STABILIZATION SERVICES		Medically necessary services, related to an emergency medical condition, provided after the member’s condition is sufficiently stabilized in order to maintain, improve or resolve the member’s condition so that the member could be safely discharged or transferred to another location [42 CFR 438-114(a)].
POTENTIAL ENROLLEE		A Medicaid-eligible recipient who is not yet enrolled with a Contractor [42 CFR 438.10(a)].
PRIMARY CARE PROVIDER (PCP)		An individual who meets the requirements of A.R.S. § 36-2901, and who is responsible for the management of a member’s health care. A PCP may be a physician defined as a person licensed as an allopathic or osteopathic physician according to A.R.S. Title 32, Chapter 13 or Chapter 17, or a practitioner defined as a physician assistant licensed under A.R.S. Title 32, Chapter 25, or a certified nurse practitioner licensed under A.R.S. Title 32, Chapter 15.
PRIOR PERIOD		The period of time, prior to a member’s enrollment, during which the member is eligible for covered services. The time frame is from the effective date of eligibility to the day a member is enrolled with a Contractor.
PROVIDER		Any person or entity that contracts with AHCCCS or a Contractor for the provision of covered services to members according to the provisions A.R.S. § 36-2901 or any subcontractor of a provider delivering services pursuant to A.R.S. § 36-2901.
QUALIFIED MEDICARE BENEFICIARY DUAL ELIGIBLE (QMB DUAL)		A person, eligible under A.R.S. § 36-2971(6), who is entitled to Medicare Part A insurance and meets certain income and residency requirements of the Qualified Medicare Beneficiary program. A QMB who is also eligible for Medicaid, is commonly referred to as a QMB dual eligible.
RATE CODE		Eligibility classification for capitation payment purposes.
REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA)		An organization under contract with ADHS, that administers covered behavioral health services in a geographically specific area of the state. Tribal governments, through an agreement with ADHS, may operate a tribal regional behavioral health authority (TRBHA) for the provision of behavioral health services to Native American members living on-reservation.
REINSURANCE		A risk-sharing program provided by AHCCCS to Contractors for the reimbursement of certain contract service costs incurred for a member beyond a predetermined monetary threshold.
RELATED PARTY		A party that has, or may have, the ability to control or significantly influence a Contractor, or a party that is, or may be, controlled or significantly influenced by a Contractor. “Related parties” include, but are not limited to, agents, managing employees, persons with an ownership or controlling interest in the Offeror and their immediate families, subcontractors, wholly-owned subsidiaries or suppliers, parent companies, sister companies, holding companies, and other entities controlled or managed by any such entities or persons.
RISK GROUP		Grouping of rate codes that are paid at the same capitation rate.
RFP		Request For Proposal is a document prepared by AHCCCS, which describes the services required and instructs prospective Offerors about how to prepare a response (proposal), as defined in R9-22-101.
RURAL HEALTH CLINIC (RHC)		A clinic located in an area designated by the Bureau of Census as rural, and by the Secretary of the DHHS as medically underserved or having an insufficient number of physicians, which meets the requirements under 42 CFR 491.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

SCHIP		State Children’s Health Insurance Program under Title XXI of the Social Security Act. The Arizona version of SCHIP is referred to as “KidsCare”. See “KIDSCARE”.
SCOPE OF SERVICES		See “COVERED SERVICES”.
SERVICE LEVEL AGREEMENT		A type of subcontract with a corporate owner or any of its divisions or subsidiaries that requires specific levels of service for administrative functions or services for the Contractor, specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this contract.
SOBRA		Eligible pregnant women under Section 9401 of the Sixth Omnibus Budget and Reconciliation Act of 1986, amended by the Medicare Catastrophic Coverage Act of 1988, 42 U.S.C. 1396a(a)(10)(A)(ii)(IX), November 5, 1990, with individually budgeted incomes at or below 150% of the FPL, and children in families with individually budgeted incomes ranging from below 100% to 140% of the FPL, depending on the age of the child.
SOBRA FAMILY PLANNING		Female members eligible for family planning services only, for a maximum of two consecutive 12-month periods following the loss of SOBRA eligibility.
SPECIAL HEALTH CARE NEEDS		Members with special health care needs are those members who have serious and chronic physical, developmental or behavioral conditions, and who also require medically necessary health and related services of a type or amount beyond that generally required by members.
STATE		The State of Arizona.
STATE ONLY TRANSPLANT MEMBERS		Individuals who are eligible under one of the Title XIX eligibility categories and found eligible for a transplant, but subsequently lose Title XIX eligibility due to excess income become eligible for one of two extended eligibility options as specified in A.R.S. 36-2907.10 and A.R.S. 36-2907.11.
STATE PLAN		The written agreements between the State and CMS, which describe how the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children’s Health Insurance Program.
SUBCONTRACT		An agreement entered into by the Contractor with a provider of health care services, who agrees to furnish covered services to members or with any other organization or person who agrees to perform any administrative function or service for the Contractor specifically related to fulfilling the Contractor’s obligations to AHCCCS under the terms of this contract, as defined in R9-22-101.
SUBCONTRACTOR		(1) A provider of health care who agrees to furnish covered services to members.
		(2) A person, agency or organization with which the Contractor has contracted or delegated some of its management/administrative functions or responsibilities.
		(3) A person, agency or organization with which a fiscal agent has entered into a contract, agreement, purchase order or lease (or leases of real property) to obtain space, supplies, equipment or services provided under the AHCCCS agreement.
SUPPLEMENTAL SECURITY INCOME (SSI) AND SSI RELATED GROUPS		Eligible individuals receiving income through federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or disabled and have household income levels at or below 100% of the FPL.

SECTION C: DEFINITIONS		Contract/RFP No. YH09-0001

TEMPORARY ASSISTANCE TO NEEDY FAMILIES (TANF)		A federal cash assistance program under Title IV of the Social Security Act established by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-193). It replaced Aid To Families With Dependent Children (AFDC).
THIRD PARTY LIABILITY (TPL)		See “LIABLE PARTY”.
TITLE XIX MEMBER		A member eligible for federally funded Medicaid programs under Title XIX of the Social Security Act including those eligible under 1931 provisions of the Social Security Act, Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), SSI-related groups, Title XIX Waiver groups, Medicare Cost Sharing groups, Breast and Cervical Cancer Treatment program and Freedom to Work program.
TITLE XIX WAIVER GROUP (TWG) MEMBER		All AHCCCS Care (Non-MED) and MED members who do not meet the requirements of a categorically linked Medicaid program.
TITLE XXI MEMBER		A member eligible for acute care services under Title XXI of the Social Security Act, referred to in Federal legislation as the “State Children’s Health Insurance Program” (SCHIP). The Arizona version of SCHIP is referred to as “KidsCare.”
WWHP		Well Woman Health-Check Program, administered by the Arizona Department of Health Services and funded by the Centers for Disease Control and Prevention. (See AMPM Chapter 300, Section 320)
YEAR		See “CONTRACT YEAR”.
YOUNG ADULT TRANSITIONAL INSURANCE (YATI)		Eligible individuals, between 18 and 21 years of age who were formerly enrolled through the foster care program.

[END OF DEFINITIONS]

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

SECTION D: PROGRAM REQUIREMENTS

INTRODUCTION

The Arizona Health Care Cost Containment System (AHCCCS) Administration is the single state agency for the Medicaid and SCHIP programs. AHCCCS has operated under an 1115 Research and Demonstration Waiver since 1982 when it became the first statewide Medicaid managed care system in the nation. The program is a model public-private collaboration that includes the state and its counties, the federal government, and managed care contractors and providers from both the public and private sectors. AHCCCS has remained a leader in Medicaid Managed Care through the diligent pursuit of excellence and cost effectiveness by Managed Care Contractors (MCOs) in collaboration with the AHCCCS Administration.

In order to continue this collaboration, Contractors must continue to add value to the program. A Contractor adds value when it:

•

Recognizes that Medicaid members are entitled to care and assistance navigating the service delivery system and demonstrates special effort to assure members receive necessary services, including prevention and screening services.

•

Recognizes that Medicaid members with special health care needs or chronic health conditions require care coordination, and provides that coordination. This is particularly true if a member must receive services from other AHCCCS Contractors in addition to the Contractor.

•

Recognizes that Medicaid members have the right to contact their elected officials in an effort to secure necessary services and assist members in order to reduce their need to contact elected officials. The Contractor provides information to elected officials to help them respond to the member.

•

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

•

Avoids administrative practices that place unnecessary burdens on providers with little or no impact on quality of care or cost containment.

•

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

•

Recognizes that the program is publicly funded, and as such is subject to public scrutiny and behaves in a manner that is supported by the general public.

•

Recognizes that the program is subject to significant regulation and operates in compliance with those regulations.

AHCCCS encourages Contractor innovation and application of best practices. The AHCCCS administration is always looking for ways to reduce administrative costs and improve program efficiency. Over the term of the contract, AHCCCS will work collaboratively with contractors to evaluate ways to reduce program complexity, improve chronic disease management, reduce administrative burdens, leverage joint purchasing power, and reduce unnecessary Medicaid/SCHIP administrative and medical costs.

1. TERM OF CONTRACT AND OPTION TO RENEW

The initial term of this contract shall be 10/1/08 through 9/30/11, with two additional one-year options to renew. All contract renewals shall be through contract amendment. AHCCCS shall issue amendments prior to the end date of the contract when there is an adjustment to capitation rates and/or changes to the scope of services contained herein. Changes to the scope of services include, but are not limited, to changes in the enrolled population, changes in covered services and changes in GSAs.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

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 addition, if the Contractor has had significant problems of non-compliance in one GSA, it may result in the capping of the Contractor’s enrollment in all 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.

When AHCCCS issues an amendment to the contract, the provisions of such renewal will be deemed to have been accepted 60 days after the date of mailing by AHCCCS, 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 renewal amendment. If the Contractor provides such notification, AHCCCS will initiate contract termination proceedings.

Contractor’s Notice of Intent Not To Renew: 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. If the Contractor provides AHCCCS 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 AHCCCS.

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, and shall abide by standards and protocols set forth in Paragraph 9, Transition of Members. 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. The Contractor shall make provision 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 be responsible for providing all reports set forth in this contract and necessary for the transition process, and shall be responsible for the following:

a.		Notification of subcontractors and members.
b.		Payment of 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 the following reports to AHCCCS on a monthly basis (due the 15th day of the month, for the preceding month):

	(1)		A monthly claims aging report by provider/creditor including IBNR amounts;
	(2)		A monthly summary of cash disbursements and provider/creditor settlements;
	(3)		A monthly accounting of Member Grievances and Provider Claim Disputes and their disposition;
	(4)		Additional reporting as requested in the termination letter issued by AHCCCS.

c.

Quarterly and Audited Financial Statements up to the date of contract termination. The financial statement requirement will not be absolved without an official release from AHCCCS.

d.

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

e.

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

f.

Cooperation with any open reconciliation activities including, but not limited to, PPC, or MED Prospective until release has been granted by AHCCCS.

g.

Quarterly Quality Management and Medical Management reports will be submitted as required by Section D, Paragraphs 23, Quality Management, and 24, Medical Management, as appropriate to provide AHCCCS with information on services rendered up to the date of Contract termination. This will include quality of care (QOC) concern reporting based on the date of service, as opposed to the date of reporting, for a period of 3 months after contract termination.

h.

Performance Bond will be required until remaining AHCCCS liabilities are less than $50,000.

i.

In the event of termination or suspension of the contract by AHCCCS, such termination or suspension shall not affect the obligation of the Contractor to indemnify 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.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

j.

Any dispute by the Contractor, with respect to termination or suspension of this contract by AHCCCS, shall be exclusively governed by the provisions of Section E, Paragraph 26, Disputes.

k.

Any funds advanced to the Contractor for coverage of members for periods after the date of termination shall be returned to AHCCCS within 30 days of termination of the contract.

l.

Record retention requirements, as described in Section D Paragraph 63; Section E, Paragraph 40 and Attachment A, Paragraph 20, will apply.

2. ELIGIBILITY CATEGORIES

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

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

Title XIX

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

SSI and SSI Related Groups: Eligible individuals receiving income through federal cash assistance programs under Title XVI of the Social Security Act who are aged, blind or disabled and have household income levels at or below 100% of the FPL.

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

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

SOBRA Family Planning: Family planning extension program that covers the costs for family planning services only, for a maximum of two consecutive 12-month periods following the loss of SOBRA eligibility.

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

Young Adult Transitional Insurance (YATI): Former foster care children between 18 and 21 years of age.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Title XIX Waiver Group

AHCCCS Care (Non-MED): Eligible individuals and couples whose income is at or below 100% of the FPL, and who are not categorically linked to another Title XIX program. Also known as Non-MED members.

MED: Title XIX waiver member whose family income exceeds the limits of all other Title XIX categories (except ALTCS) and has family medical expenses that reduce income to at or below 40% of the FPL. MED members may or may not have a categorical link to Title XIX.

Title XXI

KidsCare: Individuals under the age of 19 years, eligible under the SCHIP program, who are in households with incomes at or below 200% FPL. All members except Native American members are required to pay a premium amount based on the number of children in the family and the gross family income. Also referred to as Title XXI.

State-Only

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

1.

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

2.

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

3.

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

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

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

Option 2: As long as medical eligibility for a transplant (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 his/her previous Contractor to receive all covered transplant services. Option 2-eligible individuals are not eligible for any non-transplant related health care services from AHCCCS.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

3. ENROLLMENT AND DISENROLLMENT

AHCCCS has the exclusive authority to enroll and disenroll members. The Contractor shall not disenroll any member for any reason unless directed to do so by AHCCCS. The Contractor may request AHCCCS to change the member’s enrollment in accordance with the ACOM Enrollment Choice and Change of Contractor Policy. The Contractor may not request disenrollment because of an adverse change in the member’s health status nor because of the member’s utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs. An AHCCCS member may request disenrollment from the Contractor for cause at any time. Requests due to situations defined in Section A (1) of the ACOM Change of Plan Policy should be referred to AHCCCS Member Services via mail or at (602) 417-4000 or (800) 962-6690. For medical continuity requests, the Contractor shall follow the procedures outlined in the ACOM Change of Plan Policy, before notifying AHCCCS. AHCCCS will disenroll the member through the ACOM Change of Plan Policy when the member:

	1.		Becomes ineligible for the AHCCCS program;
	2.		Moves out of the Contractor’s service areas;

3.

Changes contractors during the member’s open enrollment/annual enrollment choice period;

4.

The Contractor does not, because of moral or religious objections, cover the service the member seeks; or

5.

When approved for a Contractor change [42 CFR 438.56].

Members may submit plan change requests to the Contractor or the AHCCCS Administration. A denial of any plan change request must include a description of the member’s right to appeal the denial.

Eligibility for the various AHCCCS coverage groups is determined by one of the following agencies:

Social Security Administration (SSA)		SSA determines eligibility for the Supplemental Security Income (SSI) cash program. SSI cash recipients are automatically eligible for AHCCCS coverage.
Department of Economic Security (DES)		DES determines eligibility for families with children under section 1931 of the Social Security Act, pregnant women and children under SOBRA, 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.
AHCCCS		AHCCCS determines eligibility for the SSI/Medical Assistance Only groups, including the FES program for this population (aged, disabled, blind), the Arizona Long Term Care System (ALTCS), the Qualified Medicare Beneficiary program and other Medicare cost sharing programs, BCCTP, the Freedom to Work program, the Title XXI KidsCare program and the State-Only Transplant program.

AHCCCS Acute Care members are enrolled with Contractors in accordance with the rules set forth in A.A.C R9-22, Article 17, A.A.C. R9-31, Articles 3 and 17.

Member Choice of Contractor

All AHCCCS members eligible for services covered under this contract have a choice of available Contractors. Information about these Contractors will be given to each applicant during the application process for AHCCCS benefits. If there is only one Contractor available for the applicant’s Geographic Service Area, no choice is offered as long as the Contractor offers the member a choice of PCPs. Members who do not choose a Contractor prior to AHCCCS being notified of their eligibility are automatically assigned to a Contractor based on family continuity or the auto-assignment algorithm. Once assigned, AHCCCS sends a Freedom of Choice notice to the member and gives them 30 days to choose a different Contractor from the auto-assigned Contractor. See Section D, Paragraph 6, Auto-Assignment Algorithm, for further explanation.

The Contractor will share with AHCCCS the cost of providing information about the Acute Care Contractors to potential members and to those eligible for annual enrollment choice.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Exceptions to the above enrollment policies for Title XIX members include previously enrolled members who have been disenrolled for less than 90 days. These members will be automatically enrolled with the same Contractor, if still available. Women who become eligible for the Family Planning Services Extension Program, will remain assigned to their current Contractor.

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

KidsCare Title XXI members must select a Contractor prior to being determined eligible, and therefore will not be auto-assigned.

When a member is transferred from Title XIX to Title XXI and has not made a Contractor choice for Title XXI, the member will remain with his/her current Contractor and a Freedom of Choice notice will be sent to the member. The member may then change plans no later than 30 days from the date the Freedom of Choice notice is sent.

The effective date of enrollment for a Title XXI member will be the first day of the month following notification to the Contractor. In the event that eligibility is determined on or after the 25^th day of the month, eligibility will begin on the 1^st day of the second month following the determination.

Prior Period Coverage: AHCCCS provides prior period coverage for the period of time prior to the Title XIX member’s enrollment during which the member is eligible for covered services. The time frame is from the effective date of eligibility to the day the member is enrolled with the Contractor. The Contractor receives notification from the Administration of the member’s enrollment. The Contractor is responsible for payment of all claims for medically necessary covered services, excluding most behavioral health services, provided to members during prior period coverage. This may include services provided prior to the contract year (See Section D, Paragraph 53, Compensation, for a description of the Contractor’s reimbursement from AHCCCS for this eligibility time period).

For behavioral health services, the Contractor is responsible for the same services as outlined in Section D, Paragraph 12, Behavioral Health Services, for the prospective period.

Newborns: Newborns born to AHCCCS eligible mothers enrolled at the time of the child’s birth will be enrolled with the mother’s Contractor, when newborn notification is received by AHCCCS. The Contractor is responsible for notifying AHCCCS of a child’s birth to an enrolled member. Capitation for the newborn will begin on the date notification is received by AHCCCS. The effective date of AHCCCS eligibility will be the newborn’s date of birth, and the Contractor is responsible for all covered services to the newborn, whether or not AHCCCS has received notification of the child’s birth. AHCCCS is currently available to receive notification 24 hours a day, 7 days a week via phone or the AHCCCS website. Each eligible mother of a newborn is sent a letter advising her of her right to choose a different Contractor for her child; the date of the change will be the date of processing the request from the mother. If the mother does not request a change, the child will remain with the mother’s Contractor.

Newborns of FES mothers are auto-assigned to a Contractor and mothers of these newborns sent letters advising them of their right to choose a different Contractor for their children. In the event the FES mother chooses a different Contractor, AHCCCS will recoup all capitation paid to the originally assigned Contractor and the baby will be enrolled retroactive to the date of birth with the second Contractor. The second Contractor will receive prior period capitation from the date of birth to the day before assignment and prospective capitation from the date of assignment forward. The second Contractor will be responsible for all covered services to the newborn from date of birth.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Enrollment Guarantees: Upon initial capitated enrollment as a Title XIX-eligible member, the member is guaranteed a minimum of five full months of continuous enrollment. Upon initial capitated enrollment as a Title XXI-eligible member, the member is guaranteed a minimum of 12 full months of continuous enrollment. The enrollment guarantee is a one-time benefit. If a member changes from one Contractor to another within the enrollment guarantee period, the remainder of the guarantee period applies to the new Contractor. The enrollment guarantee may not be granted or may be terminated if the member is incarcerated, or if a minor child is adopted. AHCCCS Rules R9-22, Article 17, and R9-31, Article 3, describes other reasons for which the enrollment guarantee may not apply.

Native Americans: Native Americans, on- or off-reservation, may choose to receive services from Indian Health Service (IHS), a P.L. 93-638 tribal facility or any available Contractor. If a choice is not made within the specified time limit, Native American Title XIX members living on-reservation will be assigned to the AHCCCS American Indian Health Program (AIHP) as FFS members. The designation of a zip code as a ‘reservation zip code’, not the physical location of the residence, is the factor that determines whether a member is considered on or off-reservation for these purposes. Further, if the member resides in a zip code that contains land on both sides of a reservation boundary and the zip code is assigned as off-reservation, the physical location of the residence does not change the off-reservation designation for the member. Native American Title XIX members living off-reservation who do not make a Contractor choice will be assigned to an available Contractor using the AHCCCS protocol for family continuity and the auto-assignment algorithm. Native American Title XXI members must make a choice prior to being determined eligible. Native Americans may change from AHCCCS AIHP FFS to a Contractor or from a Contractor to AHCCCS AIHP FFS at any time.

4. ANNUAL ENROLLMENT CHOICE

AHCCCS conducts an Annual Enrollment Choice (AEC) for members on their annual anniversary date [42 CFR 438.56(c)(2)(ii)]. AHCCCS may hold an open enrollment in any GSA or combination of GSAs, as deemed necessary. During AEC, members may change Contractors subject to the availability of other Contractors within their Geographic Service Area. A member is mailed a printed enrollment form and other information required by the Balanced Budget Act of 1997 (BBA) 60 days prior to his/her AEC date and may choose a new Contractor by contacting AHCCCS to complete the enrollment process. If the member does not participate in the AEC, no change of Contractor will be made (except for approved changes under the ACOM Change of Plan Policy) during the new anniversary year. This holds true if a Contractor’s contract is renewed and the member continues to live in a Contractor’s service area. The Contractor shall comply with the ACOM Member Transition for Annual Enrollment Choice Policy, Open Enrollment and Other Plan Changes Policy, and the AMPM.

5. ENROLLMENT AFTER CONTRACT AWARD

In the event that AHCCCS does not award a CYE ‘09 contract to an incumbent contractor, AHCCCS will direct enrollment effective October 1, 2008, for those members enrolled with an exiting Contractor. Members will be auto assigned to all or select Contractors utilizing the auto assignment algorithm found in the Conversion Group Assignment section of Attachment G, Auto-Assignment Algorithm. The members in the Conversion Group will have the opportunity to choose an alternate Contractor, according to the details in Attachment G, Auto-Assignment Algorithm.

AHCCCS will also use an enhanced auto-assignment algorithm in certain GSAs for new Contractors or those incumbent Contractors defined as small Contractors. This enhanced algorithm may be in effect beginning October 1, 2008, for a period of no less than three months and no more than six months. Those Contractors not defined as new or small Contractors in a GSA may not receive auto-assigned members during the enhanced algorithm period. See Attachment G, Auto-Assignment Algorithm, for details.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

In addition to auto-assignment, AHCCCS will make changes to both annual enrollment choice materials and new enrollee materials prior to October 1, 2008, to reflect the change in available contractors. The auto assignment algorithm will be adjusted to exclude auto assignment of new enrollees to exiting Contractor(s) effective August 1, 2008.

6. AUTO-ASSIGNMENT ALGORITHM

Members who do not exercise their right to choose and do not have family continuity are assigned to a Contractor through an auto-assignment algorithm. Once auto-assigned, AHCCCS sends a Freedom of Choice notice to the member and gives him/her 30 days to choose a different Contractor from the auto-assigned Contractor. The algorithm is a mathematical formula used to distribute members to the various Contractors in a manner that is predictable and consistent with AHCCCS goals. For CYE 09 through CYE 12, the algorithm favors those Contractors with lower capitation rates and higher Program scores in this procurement and as described below. AHCCCS may change the algorithm at any time during the term of the contract in response to Contractor-specific issues (e.g. imposition of an enrollment cap).

In future contract years, AHCCCS may adjust the auto-assignment algorithm in consideration of Contractors’ clinical performance measure results when calculating target percentages. Ranking in the algorithm may be weighted, based on the number of Performance Measures for which a Contractor is meeting the current AHCCCS Minimum Performance Standard (MPS) as a percentage of the total number of measures utilized in the calculation. AHCCCS will determine and communicate the adjusted auto-assignment algorithm to be used prior to the beginning of the contract year to be measured. For further details on the AHCCCS Auto-Assignment Algorithm for CYE 13, refer to Attachment G.

7. AHCCCS MEMBER IDENTIFICATION CARDS

The Contractor is responsible for paying the costs of producing AHCCCS member identification cards. The Contractor will receive an invoice the month following the issue date of the identification card.

8. MAINSTREAMING OF AHCCCS MEMBERS

To ensure mainstreaming of AHCCCS members, the Contractor shall take affirmative action so that members are provided covered services without regard to payer source, race, color, creed, gender, religion, age, national origin (to include those with limited English proficiency), ancestry, marital status, sexual preference, genetic information, or physical or mental handicap, except where medically indicated. The Contractor must take into account a member’s literacy and culture when addressing members and their concerns, and must take reasonable steps to encourage subcontractors to do the same. The Contractor must make interpreters, including assistance for the vision- or hearing- impaired, available free of charge for all members to ensure appropriate delivery of covered services. The Contractor must provide members with information instructing them how to access these services.

Prohibited practices include, but are not limited to, the following, in accordance with Title VI of the US Civil Rights Act of 1964, 42 USC, Section 2001, Executive Order 13166, and rules and regulation promulgated according to, or as otherwise provided by law:

a.

Denying or not providing a member any covered service or access to an available facility.

b.

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

c.

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

d.

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

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

If the Contractor identifies a problem involving discrimination by one of its providers, it shall promptly intervene and implement a corrective action plan. Failure to take prompt corrective measures may place the Contractor in default of its contract.

9. TRANSITION OF MEMBERS

The Contractor shall comply with the AMPM and the ACOM Member Transition for Annual Enrollment Choice, Open Enrollment and Other Plan Changes Policy standards for member transitions between Contractors or GSAs, participation in or discharge from CRS or CMDP, to or from an ALTCS Contractor, and upon termination or expiration of a contract. AHCCCS may discontinue enrollment of members with the Contractor three months prior to the contract termination date. The Contractor shall develop and implement policies and procedures which comply with these policies to address transition of:

a.

Members with significant medical conditions such as a high-risk pregnancy or pregnancy within the last 30 days, the need for organ or tissue transplantation, chronic illness resulting in hospitalization or nursing facility placement, etc.;

b.

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

c.

Members who have conditions requiring ongoing monitoring or screening such as elevated blood lead levels and members who were in the NICU after birth;

d.

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

e.

Members who have received prior authorization for services such as scheduled surgeries, out-of-area specialty services, or nursing home admission;

f.

Prescriptions, DME and medically necessary transportation ordered for the transitioning member by the relinquishing Contractor; and

g.

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

h.

Any members transitioning to CMDP.

When relinquishing members, the Contractor is responsible for timely notification to the receiving Contractor regarding pertinent information related to any special needs of transitioning members. The Contractor, when receiving a transitioning member with special needs, is responsible for coordinating care with the relinquishing Contractor in order that services are not interrupted, and for providing the new member with Contractor and service information, emergency numbers and instructions about how to obtain services.

10. SCOPE OF SERVICES

The Contractor shall provide covered services to AHCCCS members in accordance with all applicable federal and state laws regulations and policies, including those listed by reference in attachments and this contract. The services are described in detail in AHCCCS Rules R9-22, Article 2, the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor Operations Manual (ACOM), all of which are incorporated herein by reference, except for provisions specific to the Fee-for-Service program, and may be found on the AHCCCS website (http://www.azahcccs.gov/) [42 CFR 438.210(a)(1)]. To be covered, services must be medically necessary and cost effective. The covered services are briefly described below. Except for annual well woman exams, behavioral health and children’s dental services, covered services must be provided by or coordinated with a primary care provider.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

The Contractor shall coordinate all services it provides to a member with any services the member receives from other entities, including behavioral health services the member receives through an ADHS/RBHA provider and Children’s Rehabilitative Services (CRS) provided through ADHS/CRSA. The Contractor shall ensure that, in the process of coordinating care, each member’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164, Subparts A and E, to the extent that they are applicable [42 CFR 438.208(b)(4) and 438.224].

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

If the Contractor does not, because of a moral or religious objection, cover one or more of the services listed in this contract, it must notify AHCCCS of the objection. The Contractor must arrange for those services to be provided by another entity. Any alternative arrangement must be approved in advance by AHCCCS. Requests for approval must be submitted to the Division of Health Care Management, Acute Care Operations Unit, 90 days prior to implementation.

Authorization of Services: For the processing of requests for initial and continuing authorizations of services, the Contractor shall have in place and follow written policies and procedures. The Contractor shall have mechanisms in place to ensure consistent application of review criteria for authorization decisions. Any decision to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested, shall be made by a health care professional who has appropriate clinical expertise in treating the member’s condition or disease [42 CFR 438.210(b)].

Notice of Action: The Contractor shall notify the requesting provider and give the member written notice of any decision by the Contractor to deny, reduce, suspend or terminate a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice shall meet the requirements of 42 CFR 438.404, AHCCCS Rules and ACOM Notice of Action Policy. The notice to the provider must also be in writing as specified in Attachment H(1) of this contract. See Attachment F, Periodic Report Requirements, for information regarding the reporting of service provision and grievance tracking for specific items covered under this paragraph.

The Contractor shall ensure that its providers are not restricted or inhibited in any way from communicating freely with members regarding their health care, medical needs and treatment options, even if needed services are not covered by the Contractor.

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

American Indian Health Program (AIHP): AHCCCS will reimburse claims on a FFS basis for acute care services that are medically necessary, eligible for 100% Federal reimbursement, and are provided to Title XIX members enrolled with the Contractor in an IHS or a 638 tribal facility. Encounters for Title XIX services in IHS or tribal facilities will not be accepted by AHCCCS or considered in capitation rate development.

The Contractor is responsible for reimbursement to IHS or tribal facilities for services provided to Title XXI Native American members enrolled with the Contractor. The Contractor may choose to subcontract with an IHS or 638 tribal facility as part of its provider network for the delivery of Title XXI covered services. Expenses incurred by the Contractor for Title XXI services delivered in an IHS or 638 tribal facility shall be encountered and considered in capitation rate development.

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

Audiology: The Contractor shall provide audiology services to members under the age of 21 years, including the identification and evaluation of hearing loss and rehabilitation of the hearing loss through medical or surgical means. Only the identification and evaluation of hearing loss are covered for members 21 years of age and older unless the hearing loss is due to an accident or injury-related emergent condition. Pursuant to A.A.C. R9-22-212, hearing aids are not covered for members 21 and older.

Behavioral Health: The Contractor shall provide behavioral health services as described in Section D, Paragraph 12, Behavioral Health Services. Also refer to Prior Period Coverage in Section D, Paragraph 3, Enrollment and Disenrollment.

Children’s Rehabilitative Services (CRS): The program for children with CRS-covered conditions is administered by the Arizona Department of Health Services (ADHS) for children who meet CRS eligibility criteria. The Contractor shall refer children to the CRS program who are potentially eligible for services related to CRS-covered conditions, as specified in R9-22, Article 2, and A.R.S. Title 36, Chapter 2, Article 3. The Contractor is responsible for care of members until Children’s Rehabilitative Services Administration (CRSA) determines those members eligible. In addition, the Contractor is responsible for covered services for CRS-eligible members unless and until the Contractor has received written confirmation from CRSA that CRSA will provide the requested service. The Contractor shall require the member’s Primary Care Provider (PCP) to coordinate the member’s care with the CRS Program. For more detailed information regarding eligibility criteria, referral practices, and Contractor-CRS coordination issues, refer to the CRS Policy and Procedures Manual located on the Arizona Department of Health Services website at http://www.azdhs.gov/ and the related ACOM policy.

The Contractor shall respond to requests for services potentially covered by CRSA in accordance with the related ACOM policy. The Contractor is responsible for addressing prior authorization requests if CRSA fails to comply with the timeframes specified in the related ACOM policy. The Contractor remains ultimately responsible for the provision of all covered services to its members, including all emergency services (in or out of network), and AHCCCS-covered services denied by CRSA for the reason that it is not a service related to a CRS condition.

Referral to CRSA does not relieve the Contractor of the responsibility for providing timely medically necessary AHCCCS services not covered by CRSA. In the event that CRSA denies a medically necessary AHCCCS service for the reason that it is not related to a CRS condition, the Contractor must promptly respond to the service authorization request and authorize the provision of medically necessary services. CRSA cannot contest the Contractor prior authorization determination if CRSA fails to timely respond to a service authorization request. The Contractor, through its Medical Director, may request review from the CRS Regional Medical Director when it denies a service for the reason that it is not covered by the CRS Program. The Contractor may also request a hearing with the Administration if it is dissatisfied with the CRSA determination. If the AHCCCS Hearing Decision determines that the service should have been provided by CRSA, CRSA shall be financially responsible for the costs incurred by the Contractor in providing the service.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

A member with private insurance is not required to utilize CRSA. This includes members with Medicare whether they are enrolled in Medicare FFS or a Medicare Managed Care plan. If a member uses the private insurance network or Medicare for a CRS-covered condition, the Contractor is responsible for all applicable deductibles and copayments. If the member is on Medicare, the ACOM Medicare Cost Sharing for Members in Traditional Fee for Service Medicare Policy and Medicare Cost Sharing for Members in Medicare Managed Care Plans Policy shall apply. When the private insurance or Medicare is exhausted, or certain annual or lifetime limits are reached with respect to CRS-covered conditions, the Contractor shall refer the member to CRSA for determination of eligibility for CRS services. If the member with private insurance or Medicare chooses to enroll with CRS, CRS becomes the secondary payer responsible for all applicable deductibles and copayments. The Contractor is not responsible to provide services in instances when the CRS-eligible member who has no primary insurance or Medicare refuses to receive CRS-covered services through the CRS program. If the Contractor becomes aware that a member with a CRS-covered condition refuses to participate in the CRS application process or refuses to receive services through the CRS Program, the member may be billed by the provider in accordance with AHCCCS regulations regarding billing for unauthorized services.

Chiropractic Services: The Contractor shall provide chiropractic services to members under age 21 when prescribed by the member’s PCP and approved by the Contractor in order to ameliorate the member’s medical condition. Medicare approved chiropractic services for any member shall also be covered, subject to limitations specified in 42 CFR 410.22, for Qualified Medicare Beneficiaries if prescribed by the member’s PCP and approved by the Contractor.

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

Early and Periodic Screening, Diagnosis 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 illness discovered by the screenings for members under age 21. The Contractor shall ensure that these members receive required health screenings, including those for developmental/behavioral health, in compliance with the AHCCCS periodicity schedule. The Contractor shall submit all EPSDT reports to the AHCCCS Division of Health Care Management, as required by the AMPM. The Contractor is required to meet specific participation/utilization rates for members as described in Section D, Paragraph 23, Quality Management.

The Contractor shall ensure the initiation and coordination of a referral to the ADHS/RBHA system for members in need of behavioral health services. The Contractor shall follow up with the RBHA to monitor whether members have received these health services. The Contractor will ensure the Health Plan coordinates referrals and follow-up collaboration, as necessary, for members identified by the ADHS as needing acute care services.

The Contractor is encouraged to assign EPSDT-aged members to providers that are trained on and who use AHCCCS-approved developmental screening tools.

Early Detection Health Risk Assessment, Screening, Treatment and Primary Prevention: The Contractor shall provide primary prevention education to adult members. The Contractor shall provide health care services through screening, diagnosis 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 nutritional needs of members who may have a chronic debilitating disease. Physical examinations, diagnostic work-ups and medically necessary immunizations are also covered as found in Arizona Administrative Code Section R9-22-205. Required assessment and screening services for members under age 21 are specified in the AHCCCS EPSDT periodicity schedule.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Emergency Services: The Contractor shall have and/or provide the following as a minimum:

a.

Emergency services facilities adequately staffed by qualified medical professionals to provide pre-hospital, emergency care on a 24-hour-a-day, 7-day-a-week basis, for the sudden onset of a medically emergent condition. Emergency medical services are covered without prior authorization. The Contractor is encouraged to contract with emergency service facilities for the provision of emergency services. The Contractor shall be responsible for educating members and providers regarding appropriate utilization of emergency room services including behavioral health emergencies. The Contractor shall monitor emergency service utilization (by both provider and member) and shall have guidelines for implementing corrective action for inappropriate utilization;

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

Per the Balanced Budget Act of 1997, 42 CFR 438.114, the following conditions apply with respect to coverage and payment of emergency services:

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

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

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.

2.

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

Additionally, the Contractor may not:

1.

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

2.

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 stipulation is only related to the provision of emergency services.

3.

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

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

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

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

Family Planning: The Contractor shall provide family planning services in accordance with the AMPM, for all members who choose to delay or prevent pregnancy. These include medical, surgical, pharmacological and laboratory services, as well as contraceptive devices. Information and counseling, which allow members to make informed decisions regarding family planning methods, shall also be included. If the Contractor does not provide family planning services, it must contract for these services through another health care delivery system.

The Contractor shall provide services to members enrolled in the Family Planning Services Extension Program, a program that provides family planning services only, for a maximum of two consecutive 12-month periods, to women whose SOBRA eligibility has terminated. The Contractor is also responsible for notifying AHCCCS when a SOBRA woman is sterilized to prevent inappropriate enrollment in the SOBRA Family Planning Services Extension Program. Notification should be made at the time the newborn is reported or after the sterilization procedure is completed.

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

Foot and Ankle Services Adults: The Contractor shall provide foot care services to include bunionectomies, and medically necessary routine foot care for patients with a severe systemic disease that prohibits care by a nonprofessional person as described in the AMPM. Services are not covered for members 21 years of age and older, when provided by a podiatrist or podiatric surgeon.

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

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

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

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Immunizations: The Contractor shall provide immunizations for adults (21 years of age and older) to include but not limited to: diphtheria-tetanus, influenza, pneumococcus, rubella, measles and hepatitis-B and others as medically indicated. For all members under the age of 21, immunization requirements include but are not limited to: diphtheria, tetanus, pertussis vaccine (DTaP), inactivated polio vaccine (IPV), measles, mumps, rubella (MMR) vaccine, H. influenza, type B (HIB) vaccine, hepatitis B (Hep B) vaccine, varicella zoster virus (VZV) vaccine and pneumococcal conjugate vaccine (PCV) (see Section D, Paragraph 15, Pediatric Immunizations and the Vaccines for Children Program). The Contractor is required to meet specific immunization rates for members under the age of 21, which are described in Section D, Paragraph 23, Quality Management. (Please refer to the AMPM for current immunization requirements.)

Incontinence Supplies: The Contractor shall cover incontinence supplies as specified in AHCCCS Rule A.A.C. R9-22-212 and the AMPM.

Laboratory: Laboratory services for diagnostic, screening and monitoring purposes are covered when provided by a CLIA (Clinical Laboratory Improvement Act) approved free-standing laboratory, hospital, clinic, physician office or other health care facility laboratory.

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

Maternity: The Contractor shall provide 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. Members may select or be assigned to a PCP specializing in obstetrics. All members, anticipated to have a low-risk delivery, may elect to receive labor and delivery services in their home, if this setting is included in the allowable settings of the Contractor and the Contractor has providers in its network that offer home labor and delivery services. All members anticipated to have a low-risk prenatal course and delivery may elect to receive prenatal care, labor and delivery and postpartum care provided by certified nurse midwives or licensed midwives, if these providers are in the Contractor’s network. Members receiving maternity services from a certified nurse midwife or a licensed midwife must also be assigned to a PCP for other health care and medical services. A certified nurse midwife may provide those primary care services that s/he 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 is not within their scope of practice. The Contractor shall allow women and their newborns to receive up to 48 hours of inpatient hospital care after a routine vaginal delivery and up to 96 hours of inpatient care after a cesarean delivery. The attending health care provider, in consultation with the mother, may discharge the mother or newborn prior to the minimum length of stay. A normal newborn may be granted an extended stay in the hospital of birth when the mother’s continued stay in the hospital is beyond the 48 or 96 hour stay.

The Contractor shall inform all assigned AHCCCS pregnant women of voluntary prenatal HIV 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, which encourages pregnant women to be tested and provides instructions about where testing is available. Semi-annually, the Contractor shall report to AHCCCS the number of pregnant women who have been identified as HIV/AIDS-positive. This report is due no later than 30 days after the end of the second and fourth quarters of the contract year.

Medical Foods: Medical foods are covered within limitations defined in the AMPM for members diagnosed with a metabolic condition included under the ADHS Newborn Screening Program and 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.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Medical Supplies, Durable Medical Equipment (DME), and Prosthetic Devices: These services are covered when prescribed by the member’s PCP, attending physician, practitioner, or by a dentist as described in the AMPM. 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 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit.

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

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

The Contractor shall notify the Assistant Director of the Division of Member Services, by Email, when a member has been residing in a nursing facility for 75 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 HealthPlan75DayNotice@azahcccs.gov.

Notifications must include:

	1.		Member Name
	2.		AHCCCS ID
	3.		Date of Birth
	4.		Name of Facility
	5.		Admission Date to the Facility
	6.		Date they reach the 75 days
	7.		Name of Contractor of enrollment

Nutrition: Nutritional assessments may be conducted as a part of the EPSDT screenings for members under age 21, and to assist members 21 years of age and older whose health status may improve with nutritional intervention. Assessment of nutritional status on a periodic basis may be provided as determined necessary, and as a part of the health risk assessment and screening services provided by the member’s PCP. AHCCCS covers 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 and when AHCCCS criteria specified in the AMPM are met.

Oral Health: The Contractor shall provide all members under the age of 21 years with all medically necessary dental services including emergency dental services, dental screening and preventive services in accordance with the AHCCCS periodicity schedule, as well as therapeutic dental services, dentures, and pre-transplantation dental services. The Contractor shall monitor compliance with the EPSDT periodicity schedule for dental screening services. The Contractor is required to meet specific utilization rates for members as described in Section D, Paragraph 23, Quality Management. The Contractor shall ensure that members are notified 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 notice must be sent. Members under the age of 21 may request dental services without referral and may choose a dental provider from the Contractor’s provider network. For members who are 21 years of age and older, the Contractor shall provide dental services for transplantation services as specified in the AMPM.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Orthotics: These services are covered for members under the age of 21 when prescribed by the member’s PCP, attending physician, practitioner, or by a dentist as described in the AMPM. 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 members over and under the age of 21 to make the equipment serviceable and/or when the repair cost is less than renting or purchasing another unit.

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

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

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

	1.		Post-stabilization care services that were pre-approved by the Contractor; or
	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 being requested to approve such care or could not be contacted for pre-approval.
	3.		The Contractor representative and the treating physician cannot reach agreement concerning the member’s care and a Contractor physician is not available for consultation. In this situation, the Contractor must give the treating physician the opportunity to consult with a Contractor physician and the treating physician may continue with care of the patient until a Contractor physician is reached or one of the criteria in 42 CFR 422.113(c)(3) is met.

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

	1.		A Contractor physician with privileges at the treating hospital assumes responsibility for the member’s care;
	2.		A Contractor physician assumes responsibility for the member’s care through transfer;
	3.		A Contractor representative and the treating physician reach an agreement concerning the member’s care; or
	4.		The member is discharged.

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

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

Prescription Drugs: 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. The Contractor may include over-the-counter medications in the formulary, as defined in the AMPM. An appropriate over-the-counter medication may be prescribed, when it is determined to be a lower-cost alternative to prescription drugs.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

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 that are enrolled in Medicare Part D or are eligible for Medicare Part D.

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

Radiology and Medical Imaging: These services are covered when ordered by the member’s PCP, attending physician or dentist and are provided for diagnosis, prevention, treatment or assessment of a medical condition. Services are generally provided in hospitals, clinics, physician offices and other health care facilities.

Rehabilitation Therapy: The Contractor shall provide occupational, physical and speech therapies. Therapies must be prescribed by the member’s PCP or attending physician for an acute condition and the member must have the potential for improvement due to the rehabilitation. Physical therapy for all members, and occupational and speech therapies for members under the age of 21, are covered in both inpatient and outpatient settings. For those members who are 21 and over, occupational and speech therapies are covered in inpatient settings only.

Respiratory Therapy: This therapy is 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.

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

Transportation: These services include emergency and non-emergency medically necessary transportation. Emergency transportation, including transportation initiated by an emergency response system such as 911, may be provided by ground, air or water ambulance to manage an AHCCCS member’s emergency medical condition at an emergency scene and transport the member to the nearest appropriate medical facility. Non-emergency transportation shall be provided for members who are unable to provide their own transportation for medically necessary 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.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Triage/Screening and Evaluation: These are covered services when provided by acute care hospitals, IHS facilities, a PL 93-638 tribal facility and after-hours settings to determine whether or not an emergency exists, assess the severity of the member’s medical condition and determine what services are necessary to alleviate or stabilize the emergent condition. Triage/screening services must be reasonable, cost effective and meet the criteria for severity of illness and intensity of service.

Vision Services/Ophthalmology/Optometry: The Contractor shall provide all medically necessary emergency eye care, vision examinations, prescriptive lenses, and treatments for conditions of the eye for all members under the age of 21. For members who are 21 years of age and older, the Contractor shall provide emergency care for eye conditions which meet the definition of an emergency medical condition. Also covered for this population are cataract removal, and medically necessary vision examinations and prescriptive lenses, if required, following cataract removal and other eye conditions as specified in the AMPM.

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.

11. SPECIAL HEALTH CARE NEEDS

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

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

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

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

•

Accessible

•

Continuous

•

Coordinated

•

Family-centered

•

Comprehensive

•

Compassionate

•

Culturally effective

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

12. BEHAVIORAL HEALTH SERVICES

AHCCCS members, except for SOBRA Family Planning members, are eligible for comprehensive behavioral health services. For SOBRA Family Planning members, there is no behavioral health coverage. With the exception of the Contractor’s providers’ medical management of certain behavioral health conditions as described under “Medication Management Services”, the behavioral health benefit for these members is provided through the ADHS — Regional Behavioral Health Authority (RBHA) system. The Contractor shall be responsible for member education regarding these benefits; provision of limited emergency inpatient services; and screening and referral to the RBHA system of members identified as requiring behavioral health services.

Member Education: The Contractor shall be responsible for educating members in the member handbook and other printed documents about covered behavioral health services and where and how to access services. Covered services include:

a.		Behavior Management (behavioral health personal care, family support/home care training, self-help/peer support)
b.		Behavioral Health Case Management Services (limited)
c.		Behavioral Health Nursing Services
d.		Emergency Behavioral Health Care
e.		Emergency and Non-Emergency Transportation
f.		Evaluation and Assessment
g.		Individual, Group and Family Therapy and Counseling
h.		Inpatient Hospital Services (the Contractor may provide services in alternative inpatient settings that are licensed by the Arizona Department of Health Services, Division of Assurance and Licensure, the Office of Behavioral Health Licensure, in lieu of services in an inpatient hospital. These alternative settings must be lower cost than traditional inpatient settings. The cost of the alternative settings will be considered in capitation rate development)
i.		Non-Hospital Inpatient Psychiatric Facilities Services (Level I residential treatment centers and sub-acute facilities)
j.		Laboratory and Radiology Services for Psychotropic Medication Regulation and Diagnosis
k.		Opioid Agonist Treatment
l.		Partial Care (Supervised day program, therapeutic day program and medical day program)
m.		Psychosocial Rehabilitation (living skills training; health promotion; supportive employment services)
n.		Psychotropic Medication
o.		Psychotropic Medication Adjustment and Monitoring
p.		Respite Care (with limitations)
q.		Rural Substance Abuse Transitional Agency Services
r.		Screening
s.		Behavioral Health Therapeutic Home Care Services

Referrals: As specified in Section D, Paragraph 10, Scope of Services, EPSDT, the Contractor must provide developmental/behavioral health screenings for members up to 21 years of age in compliance with the AHCCCS periodicity schedule. The Contractor shall ensure the initiation and coordination of behavioral health referrals of these members to the RBHA when determined necessary through the screening process.

The Contractor will ensure the RBHA coordinates referrals and follow-up collaboration, as necessary, for other members identified by the AHCCCS Contractor as needing behavioral health evaluation and treatment. Members may also access the RBHA system for evaluation by self-referral or be referred by schools, State agencies or other service providers. The Contractor is responsible for providing transportation to a member’s first RBHA evaluation appointment if a member is unable to provide his/her own transportation. The Contractor will ensure coordination of referrals and follow-up collaboration, as necessary, for members identified by ADHS as needing acute care services.

Emergency Services: When members present in an emergency room setting, the Contractor is responsible for all emergency medical services including triage, physician assessment and diagnostic tests. ADHS is responsible for medically necessary psychiatric consultations in emergency room settings.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Reimbursement for court ordered screening and evaluation services is not the responsibility of the Contractor and instead falls to the county pursuant to A.R.S. 36-545. For additional information regarding behavioral health services refer to Title 9 Chapter 22 Articles 2 and 12. It is expected that the Contractor initiate a referral to the T/RBHA for evaluation and behavioral health recipient eligibility as soon as possible after admission.

Comorbidities: The Contractor must ensure that members with diabetes who are being discharged from the Arizona State Hospital (AzSH) are issued the same brand and model of both glucometer and supplies they were trained to use while in the facility. Care must be coordinated with the AzSH prior to discharge to ensure that all supplies are authorized and available to the member upon discharge.

In the event that a member’s mental health status renders them incapable or unwilling to manage their medical condition and the member has a skilled medical need, the Contractor must arrange ongoing medically necessary nursing services. The Contractor shall also have a mechanism in place for tracking members for whom ongoing medically necessary services are required.

Coordination of Care: The Contractor is responsible for ensuring that a medical record is established by the PCP when behavioral health information is received from the RBHA or provider about an assigned member even if the PCP has not yet seen the assigned member. In lieu of actually establishing a medical record, such information may be kept in an appropriately labeled file but must be associated with the member’s medical record as soon as one is established. The Contractor shall require the PCP to respond to RBHA/provider information requests pertaining to ADHS behavioral health recipient members within 10 business days of receiving the request. The response should include all pertinent information, including, but not limited to, current diagnoses, medications, laboratory results, last PCP visit, and recent hospitalizations. The Contractor shall require the PCP to document or initial signifying review of member behavioral health information received from a RBHA behavioral health provider who is also treating the member.

Medication Management Services: The Contractor shall allow PCPs to provide medication management services (prescriptions, medication monitoring visits, laboratory and other diagnostic tests necessary for diagnosis and treatment of behavioral disorders) to members with diagnoses of depression, anxiety and attention deficit hyperactivity disorder. The Contractor shall make available, on the Contractor’s formulary, medications for the treatment of these disorders. AHCCCS has facilitated the development of Clinical tool kits for the treatment of anxiety, depression, and ADHD. These tool kits are a resource only and may not apply to all patients and all clinical situations. They are not intended to replace clinical judgment. The Contractor shall ensure that PCPs and Pediatricians who have an interest or are actively treating members with these disorders are aware of these resources and/or are utilizing other recognized 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.

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 RBHA/behavioral health provider provides documentation to the Contractor that step therapy has already been completed, or is medically contraindicated, the Contractor shall continue to provide the medication at the dosage at which the member has been stabilized, unless there is subsequently a change in medical condition of the member. The Contractor shall monitor PCPs to ensure that they prescribe medication at the dosage at which the member has been stabilized.

The Contractor shall ensure that training and education are available to PCPs regarding behavioral health referral and consultation procedures. The Contractor shall establish policies and procedures for referral and consultation and shall describe them in its provider manual. Policies for referral must include, at a minimum, criteria, processes, responsible parties and minimum requirements no less stringent than those specified in this contract for the forwarding of member medical information.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

Transfer of Care: When a PCP has initiated medication management services for a member to treat a behavioral health disorder, and it is subsequently determined by the PCP or Contractor that the member should be transferred to a RBHA prescriber for evaluation and/or continued medication management services, the Contractor will require and ensure that the PCP or Contractor coordinates the transfer of care. All affected subcontracts shall include this provision. The Contractor shall establish policies and procedures for the transition of members who are referred to the RBHA for ongoing treatment. The Contractor shall ensure that PCPs maintain continuity of care for these members. The policies and procedures must address, at a minimum, the following:

1.

Guidelines for when a transition of the member to the RBHA for ongoing treatment is indicated.

2.

Protocols for notifying the RBHA of the member’s transfer, including reason for transfer, diagnostic information, and medication history.

3.

Protocols and guidelines for the transfer of medical records, including but not limited to which parts of the medical record are to be copied, timeline for making the medical record available to the RBHA, observance of confidentiality of the member’s medical record, and protocols for responding to RBHA requests for additional medical record information.

4.

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

5.

Contractor activities to monitor to ensure that members are appropriately transitioned to the RBHA for care.

The Contractor shall ensure that its quality management program incorporates monitoring of the PCP’s management of behavioral health disorders and referral to, coordination of care with and transfer of care to RBHA providers as required under this contract.

13. AHCCCS GUIDELINES, POLICIES AND MANUALS

All AHCCCS guidelines, policies and manuals are hereby incorporated by reference into this contract. All guidelines, policies and manuals are available on the AHCCCS internet website, located at www.azahcccs.gov. The Contractor is responsible for complying with the requirements set forth within. In addition, linkages to AHCCCS Rules (Arizona Administrative Code), Statutes and other resources are also available to all interested parties through the AHCCCS website. Upon adoption by AHCCCS, updates will be made available to the Contractor. The Contractor shall be responsible for implementing these requirements and maintaining current copies of updates.

14. 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.

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 approved alternative setting. Currently, services include audiology, therapies (OT, PT and speech/language); behavioral health evaluation and counseling; nursing and attendant care (health aid services provided in the classroom); and specialized transportation to and from school on days when the child receives an AHCCCS-covered 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.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

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

15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM

Through the Vaccines for Children Program, the Federal and State governments purchase, and make available to providers free of charge, vaccines for AHCCCS children under age 19. The Contractor shall not utilize AHCCCS funding to purchase vaccines for members under the age of 19. If vaccines are not available through the VFC Program, the Contractor shall contact the AHCCCS Division of Health Care Management, Clinical Quality Management Unit. Any provider, licensed by the State to administer immunizations, may register with ADHS as a “VFC provider” and receive free vaccines. The Contractor shall not reimburse providers for the administration of the vaccines in excess of the maximum allowable as set by CMS, found in the AHCCCS fee schedule. The Contractor shall comply with all VFC requirements and monitor its providers to ensure that, a physician if acting as primary care physician (PCP) to AHCCCS members under the age of 19 is registered with ADHS/VFC.

In some GSAs, providers may choose not to provide vaccinations due to low numbers of children in their panels, etc. The Contractor must develop processes to ensure that vaccinations are available through a VFC enrolled provider or through the county Health Department. In all instances, the antigens are to be provided through the VFC program. The Contractor must develop processes to pay the administration fee to whoever administers the vaccine regardless of their contract status with the Contractor.

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

16. STAFF REQUIREMENTS AND SUPPORT SERVICES

The Contractor shall have in place the organizational, operational, managerial and administrative systems capable of fulfilling all contract requirements. For the purposes of this contract, the Contractor shall not employ or contract with any individual who has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order 12549 [42 CFR 438.610 (a) & (b), 42 CFR §1001.1901(b), 42 CFR §1003.102(a)(2)]. The Contractor is obligated to screen all employees and contractors to determine whether any of them have been excluded from participation in Federal health care programs. You can search the HHS-OIG website by the names of any indivuduals. The database can be accessed at http://www.oig.hhs.gov/fraud/exclusions.asp.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

The Contractor is responsible for maintaining a significant local (within the State of Arizona) presence. This presence includes staff designated below with an asterisk (*). All staff or functions designated with an asterisk must be located within the State of Arizona at all times throughout the term of the Contract. The Contractor must obtain approval from AHCCCS prior to moving any functions not designated with an asterisk outside the State of Arizona after Contract initiation. Such a request for approval must be submitted to the Division of Health Care Management at least 60 days prior to the proposed change in operations and must include a description of the processes in place that assure rapid responsiveness to effect changes for contract compliance. The Contractor shall be responsible for any additional costs associated with on-site audits or other oversight activities of required functions located outside of the State of Arizona. At the beginning of each contract year the Contractor must provide, to the Division of Health Care Management, a listing of all functions and their locations.

The Contractor must employ sufficient staffing and utilize appropriate resources to achieve contractual compliance. The Contractor’s resource allocation must be adequate to achieve outcomes in all functional areas within the organization. Adequacy will be evaluated based on outcomes and compliance with contractual and AHCCCS policy requirements, including the requirement for providing culturally competent services. If the Contractor does not achieve the desired outcomes or maintain compliance with contractual obligations, additional monitoring and regulatory action may be employed by AHCCCS, up to and including actions specified in Section D, Paragraph 72, Sanctions, of the Contract.

An individual staff member shall be limited to occupying a maximum of two of the Key Staff positions listed below. The Contractor shall inform AHCCCS, Division of Health Care Management, in writing within seven days, when an employee leaves one of the Key Staff positions listed below (this requirement does not apply to Additional Required Staff, also listed below). The name of the interim contact person should be included with the notification. The name and resume of the permanent employee should be submitted as soon as the new hire has taken place. Each year on October 15^th, the Contractor must provide the name, Social Security Number and date of birth of the staff members performing the duties of the Key Staff listed as a, b and c below. AHCCCS will compare this information against federal databases to confirm that those individuals have not been banned or debarred from participating in Federal programs [42 CFR 455.104]. At a minimum, the following staff is required:

Key Staff

a.

*Administrator/CEO/COO or designee must be available, full time, to fulfill the responsibilities of the position and to oversee the entire operation of the Contractor. The Administrator shall devote sufficient time to the Contractor’s operations to ensure adherence to program requirements and timely responses to AHCCCS Administration.

b.

*Medical Director/CMO who shall be an Arizona-licensed physician. The Medical Director shall be actively involved in all-major clinical programs and QM and MM components of the Contractor. The Medical Director shall devote sufficient time to the Contractor to ensure timely medical decisions, including after-hours consultation as needed.

c.

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

d.

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

e.

Dental Director/Coordinator who is responsible for coordinating dental activities of the health plan and providing required communication between the plan and AHCCCS. The Dental Director/Coordinator may be an employee or Contractor of the plan and must be licensed in Arizona if they are required to review or deny dental services.

f.

*Compliance Officer who will implement and oversee the Contractor’s compliance program. The compliance officer shall be an on-site management official, available to all employees, with designated and recognized authority to access records and make independent referrals to the AHCCCS Office of Program Integrity. See Section D, Paragraph 62, Corporate Compliance.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

g.

*Dispute and Appeal Manager who will manage and adjudicate member and provider disputes arising under the Grievance System including member grievances, appeals, and requests for hearing and provider claim disputes.

h.

Business Continuity Planning Coordinator as noted in the ACOM Business Continuity and Recovery Plan Policy.

i.

*Contract Compliance Officer who will serve as the primary point-of-contact for all Contractor operational issues.

The primary functions of the Contract Compliance Officer are:

•

Coordinate the tracking and submission of all contract deliverables

•

Field and coordinate responses to AHCCCS inquiries

•

Coordinate the preparation and execution of contract requirements such as OFRS, random and periodic audits and ad hoc visits

j.

*Quality Management Coordinator who is an Arizona-licensed registered nurse, physician or physician’s assistant or a Certified Professional in Healthcare Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The QM Coordinator must have experience in quality management and quality improvement.

The primary functions of the Quality Management Coordinator position are:

•

Ensure individual and systemic quality of care

•

Integrate quality throughout the organization

•

Implement process improvement

•

Resolve, track and trend quality of care grievances

•

Ensure a credentialed provider network

k.

Performance/Quality Improvement Coordinator The Performance/Quality Improvement Coordinator will have a minimum qualification as a CPHQ or CHCQM or comparable education and experience in data and outcomes measurement.

The primary functions of the Performance/Quality Improvement Coordinator are:

•

Focus organizational efforts on improving clinical quality performance measures

•

Develop and implement performance improvement projects

•

Utilize data to develop intervention strategies to improve outcomes

•

Report quality improvement/performance outcomes

l.

*Maternal Health/EPSDT (child health) Coordinator who shall be an Arizona licensed nurse, physician or physician’s assistant; or have a Master’s degree in health services, public health, health care administration or other related field, and/or a CPHQ or CHCQM. Staffing under this position should be sufficient to meet quality and performance measure goals.

The primary functions of the MCH/EPSDT Coordinator are:

•

Ensuring receipt of EPSDT services

•

Ensuring receipt of maternal and postpartum care

•

Promoting family planning services

•

Promoting preventive health strategies

•

Identification and coordination assistance for identified member needs

•

Interface with community partners

m.

*Medical Management Coordinator who is an Arizona licensed registered nurse, physician or physician’s assistant if required to make medical necessity determinations; or have a Master’s degree in health services, health care administration, or business administration if not required to make medical necessity determination.

The primary functions of the Medical Management Coordinator are:

•

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

•

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

•

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

•

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

n.

*Behavioral Health Coordinator who shall be a behavioral health professional as described in Health Services Rule R9-20. The Behavioral Health Coordinator shall devote sufficient time to ensure that the Contractor’s behavioral health referral and coordination activities are implemented per AHCCCS requirements.

The primary functions of the Behavioral Health Coordinator are:

•

Coordinate member behavioral care needs with the RBHA system

•

Develop processes to coordinate behavioral health care between PCPs and RBHAs

•

Participate in the identification of best practices for behavioral health in a primary care setting

•

Coordinate behavioral care with medically necessary services

o.

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

p.

*Provider Services Manager who shall coordinate communications between the Contractor, its subcontractors, IHS and tribally-operated health programs under P.L. 93-638 (Indian Self-Determination and Education Assistance Act); provide assistance to providers in resolving problems; respond to provider inquiries; educate providers about participation in the AHCCCS program and maintain a sufficient provider network.

q.

Claims Administrator

The primary functions of the Claims Administrator are:

•

Develop and implement claims processing systems capable of paying claims in accordance with state and federal requirements

•

Develop processes for cost avoidance

•

Ensure minimization of claims recoupments

•

Meet claims processing timelines

•

Meet AHCCCS encounter reporting requirements

r.

*Provider Claims Educator (full-time equivalent employee for a Contractor with over 100,000 members) The position is fully integrated with the Contractor’s grievance, claims processing, and provider relations systems and facilitates the exchange of information between these systems and providers.

The primary functions of the Provider Claims Educator are:

•

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

•

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

•

identifies trends and guides the development and implementation of strategies to improve provider satisfaction

•

Frequently communicates (i.e.: telephonic and on-site) with providers to assure the effective exchange of information and gain feedback regarding the extent to which providers are informed about appropriate claims submission practices

Additional Required Staff

s.

Prior Authorization staff to authorize health care 24 hours per day, 7 days per week. This staff shall include an Arizona-licensed nurse, physician or physician’s assistant. The staff will work under the direction of an Arizona-licensed registered nurse, physician, or physician’s assistant.

t.

*Concurrent Review staff to conduct inpatient concurrent review. This staff shall consist of an Arizona-licensed nurse, physician, or physician’s assistant. The staff will work under the direction of an Arizona-licensed nurse.

u.

*Clerical and Support staff to ensure appropriate functioning of the Contractor’s operation.

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

v.

Member Services staff There shall be sufficient Member Service staff to enable members to receive prompt resolution of their inquiries/problems.

w.

*Provider Services staff There shall be sufficient Provider Services staff to enable providers to receive prompt responses and assistance (See Section D, Paragraph 29, Network Management, for more information).

x.

Claims Processing staff There shall be sufficient, appropriately trained, Claim Processing staff to ensure the timely and accurate processing of original claims, resubmissions and overall adjudication of claims.

y.

Encounter Processing staff There shall be sufficient, appropriately trained, Encounter Processing staff to ensure the timely and accurate processing and submission to AHCCCS of encounter data and reports.

Staff Training and Meeting Attendance

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

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

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

The Contractor shall provide the appropriate staff representation for attendance and participation in meetings and/or events scheduled by AHCCCS. All meetings shall be considered mandatory unless otherwise indicated.

17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS

The Contractor shall develop and maintain written policies, procedures and job descriptions for each functional area of its plan, consistent in format and style. The Contractor shall maintain written guidelines for developing, reviewing and approving all policies, procedures and job descriptions. All policies and procedures shall be reviewed at least annually to ensure that the Contractor’s written policies reflect current practices. Reviewed policies shall be dated and signed by the Contractor’s appropriate manager, coordinator, director or administrator. Minutes reflecting the review and approval of the policies by an appropriate committee are also acceptable documentation. All medical and quality management policies must be approved and signed by the Contractor’s Medical Director. Job descriptions shall be reviewed at least annually to ensure that current duties performed by the employee reflect written requirements.

Based on provider or member feedback, if AHCCCS deems a Contractor policy or process to be inefficient and/or place unnecessary burden on the members or providers, the Contractor will be required to work with AHCCCS to change the policy or procedure within a time period specified by AHCCCS.

18. MEMBER INFORMATION

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

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

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

All vital materials shall be translated when the Contractor is aware that a language is spoken by 1,000 or 5%, whichever is less, of the Contractor’s members, who also have LEP. Vital materials must include, at a minimum, Notices of Action, vital information from the member handbooks and consent forms.

All written notices informing members of their right to interpretation and translation services in a language shall be translated when the Contractor is aware that 1,000 or 5%, whichever is less, of the Contractor’s members speak that language and have LEP [42 CFR 438.10(c)(3)].

Oral interpretation services must be available and free of charge to all members regardless of the prevalence of the language. The Contractor must notify all members of their right to access oral interpretation services and how to access them. Refer to the ACOM Member Information Policy [42 CFR 438.10(c)(4) and (5)].

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

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

The Contractor shall produce and provide the following printed information to each member or family within 10 days of receipt of notification of the enrollment date [42 CFR 438.10(f)(3)]:

I.

A member handbook which, at a minimum, shall include the items listed in the ACOM Member Information Policy.

The Contractor shall review and update the Member Handbook at least once a year. The handbook must be submitted to AHCCCS, Division of Health Care Management for approval within four weeks of receiving the annual renewal amendment and upon any changes prior to distribution.

II.

A description of the Contractor’s provider network, which at a minimum, includes those items listed in the ACOM Member Information Policy.

The Contractor must give written notice about termination of a contracted provider, within 15 days after receipt or issuance of the termination notice, to each member who received their primary care from, or is seen on a regular basis by, the terminated provider. Affected members must be informed of any other changes in the network 30 days prior to the implementation date of the change [42 CFR 438.10(f)(4) and (5)]. The Contractor shall have information available for potential enrollees as described in the ACOM Member Information Policy.

The Contractor must develop and distribute, at a minimum, semi-annual newsletters during the contract year. The following types of information are to be contained in the newsletter:

	•		Educational information on chronic illnesses and ways to self-manage care
	•		Reminders of flu shots and other prevention measures at appropriate times

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

	•		Medicare Part D issues
	•		Cultural Competency, other than translation services
	•		Contractor specific issues
	•		Tobacco cessation information
	•		HIV/AIDS testing for pregnant women
	•		Other information as required by the Administration

The Contractor will, on an annual basis, inform all members of their right to request the following information [42 CFR 438.10(f)(6) and 42 CFR 438.100(a)(1) and (2)]:

	a.		An updated member handbook at no cost to the member
	b.		The network description as described in the ACOM Member Information Policy

This information may be sent in a separate written communication or included with other written information such as in a member newsletter.

19. SURVEYS

The Contractor may be required to perform its own annual general or focused member survey. All such Contractor surveys, along with a timeline for the project, shall be approved in advance by AHCCCS DHCM. The results and the analysis of the results shall be submitted to the Acute Care Operations Unit within 45 days of the completion of the project. AHCCCS may require inclusion of certain questions.

For non AHCCCS required surveys, the Contractor shall provide AHCCCS notification 15 days prior to conducting any Contractor initiated member or provider survey. The notification must include a project scope statement, project timeline and a copy of the survey. The results and the analysis of the results of any Contractor initiated surveys shall be submitted to the Acute Care Operations Unit within 45 days of the completion of the project.

AHCCCS may periodically conduct surveys of a representative sample of the Contractor’s membership and providers. AHCCCS will consider suggestions from the Contractor for questions to be included in each survey. The results of these surveys, conducted by AHCCCS, will become public information and available to all interested parties upon request. The draft reports from the surveys will be shared with the Contractor prior to finalization. The Contractor will be responsible for the cost of these surveys based on its share of AHCCCS enrollment.

At least quarterly, the Contractor is required to survey a sample of its membership that have received services to verify that services the Contractor paid for were delivered as outlined in the ACOM Policy 424 (Verification of Receipt of Services) [42 CFR 455.201].

20. CULTURAL COMPETENCY

The Contractor shall have a Cultural Competency Plan that meets the requirements of the ACOM Cultural Competency Policy. An annual assessment of the effectiveness of the plan, along with any modifications to the plan, must be submitted to the Division of Health Care Management, no later than 45 days after the start of each contract year. This plan should address all services and settings [42 CFR 438.206(c)(2)].

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

21. MEDICAL RECORDS

The member’s medical record is the property of the provider who generates the record. Each member is entitled to one copy of his or her medical record free of charge. The Contractor shall have written policies and procedures to maintain the confidentiality of all medical records.

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

The Contractor shall have written policies and procedures for the maintenance of medical records so that those records are documented accurately and in a timely manner, are readily accessible, and permit prompt and systematic retrieval of information.

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

The Contractor shall have written plans for providing training and evaluating providers’ compliance with the Contractor’s medical records standards. Medical records shall be maintained in a detailed and comprehensive manner, which conforms to good professional medical practice, permits effective professional medical review and medical audit processes, and which facilitates an adequate system for follow-up treatment. Medical records must be legible, signed and dated.

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

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

Information related to fraud and abuse may be released so long as protected HIV-related information is not disclosed (A.R.S. §36-664(I)).

22. ADVANCE DIRECTIVES

In accordance with 42 CFR 422.128, the Contractor shall maintain policies and procedures addressing advanced directives for adult members that specify:

1.

Each contract or agreement with a hospital, nursing facility, home health agency, hospice or organization responsible for providing personal care, must comply with Federal and State law regarding advance directives for adult members [42 CFR 438.6(i)(1)]. Requirements include:

a)

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

b)

Provide written information to adult members regarding each individual’s rights under State law to make decisions regarding medical care, and the health care provider’s written policies concerning advance directives (including any conscientious objections) [42 CFR 438.6(i)(3)].

SECTION D: PROGRAM REQUIREMENTS		Contract/RFP No. YH09-0001

c)

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

d)

Not discriminating against a member because of his or her decision to execute or not execute an advance directive, and not making it a condition for the provision of care.

e)

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

2.

The Contractor shall require subcontracted PCPs, which have agreements with the entities described in paragraph 1 above, to comply with the requirements of subparagraphs 1 (a) through (e) above. The Contractor shall also encourage health care providers specified in subparagraph a. to provide a copy of the member’s executed advanced directive, or documentation of refusal, to the member’s PCP for inclusion in the member’s medical record.

3.

The Contractor shall provide written information to adult members that describe the following:

	a)		A member’s rights under State law, including a description of the applicable State law.
	b)		The organization’s policies respecting the implementation of those rights, including a statement of any limitation regarding the implementation of advance directives as a matter of conscience.
	c)		The member’s right to file complaints directly with AHCCCS.
	d)		Changes to State law as soon as possible, but no later than 90 days after the effective date of the change [42 CFR 438.6(i)(4)].

23. QUALITY MANAGEMENT (QM)

The Contractor shall provide quality medical care and services to members, regardless of payer source or eligibility category. The Contractor shall promote improvement in the quality of care provided to enrolled members through established quality management and performance improvement processes. The Contractor shall execute processes to assess, plan, implement and evaluate quality management and performance improvement activities, as specified in the AMPM [42 CFR 438.240(a)(1) and (e)(2)].

The Contractor quality assessment and performance improvement programs, at a minimum, shall comply with the requirements outlined in the AMPM and this Paragraph.

A. Quality Management Program:
The Contractor shall have an ongoing quality management program for the services it furnishes to members that includes the requirements listed in AMPM Chapter 900 and the following:

1.

A written Quality Assessment and Performance Improvement (QA/PI) plan, an evaluation of the previous year’s QA/PI program, and Quarterly QA/PI reports that address its strategies for performance improvement and conducting the quality management activities.

2.

QM/PI Program monitoring and evaluation activities that includes Peer Review and Quality Management Committees chaired by the Contractor’s Chief Medical Officer.