HEALTH CHOICE ARIZONAaq.co.yavapai.az.us/docs/2015/BOS/20150706_570/8272_2015 Contrac… · HEALTH...

Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) of 29 County of Yavapai dba Yavapai County Community Health Services

HEALTH CHOICE ARIZONA FEE-FOR-SERVICE PRIMARY/SPECIALTY PHYSICIAN, DENTIST

SUBCONTRACTOR AGREEMENT

This Agreement is entered into between HEALTH CHOICE ARIZONA, Inc, a Delaware Corporation (hereinafter referred to as HCA or CONTRACTOR), and County of Yavapai dba Yavapai County Community Health Services (hereinafter referred to as SUBCONTRACTOR), who will provide services to HCA MEMBERS.

County of Yavapai dba Yavapai County Community Health Services

Participating Health Professional 1090 Commerce Drive

Business Street Address Prescott, Arizona 86305-3700

City, State, Zip Code

RECITALS WHEREAS, HCA has entered into a contract with Arizona Health Care Cost Containment System (AHCCCS), A.R.S. 36-2901, et. seq. to provide and/or arrange for the provision of COVERED SERVICES to MEMBERS. WHEREAS, HCA dba Health Choice Generations (HC Generations) has entered into a contract with Centers for Medicare and Medicaid Services (CMS) to provide and/or arrange for or administer the provisions of health care services to Medicare beneficiaries; and WHEREAS, SUBCONTRACTOR is a physician, hospital, pharmacy, skilled nursing facility or other health care provider properly licensed, certified and/or accredited, as applicable, within the State of Arizona, that desires to enter into this Agreement to provide COVERED SERVICES to MEMBERS. WHEREAS, the Parties desire to enter into this Agreement in order to facilitate the provision of cost effective, covered health care services to MEMBERS. NOW THEREFORE, HCA and SUBCONTRACTOR agree to abide by all terms and conditions set forth in this Agreement, including Attachments, if any, to this Agreement. IN WITNESS WHEREOF, this Agreement having been duly executed by the authorized representatives of HCA and SUBCONTRACTOR will become effective the first of the month following the execution of the agreement by both parties.

Agreement effective date is: ___________

FOR AND ON BEHALF OF HCA FOR AND ON BEHALF OF SUBCONTRACTOR

Signature Signature

Typed Name Typed Name

Title Title 86-6000561 Date Subcontractor Federal Tax Number

AHCCCS Identification Number / Group NPI

Date

c08366

Typewritten Text

See attached roster


SECTION 1 - DEFINITIONS 1.1 638 TRIBAL FACILITY – A facility that is operated by an Indian tribe and that is authorized to

provide services pursuant to Public Law (PL.) 93-638, as amended. 1.2 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).

1.3 ABUSE (of MEMBER) - Intentional affliction of physical harm injury caused by negligent acts or omissions, unreasonable, confinement, sexual or emotional abuse or sexual assault. [A.R.S. Section 46-451 and 13-3623]

1.4 ABUSE (BY SUBCONTRACTOR) - Provider practices that are inconsistent with sound fiscal, business or medical practice and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the AHCCCS program. [42 CFR 455.2]

1.5 ACOM - AHCCCS Contractor Operations Manual, available on the AHCCCS website at www.azahcccs.gov.

1.6 ADHS - Arizona Department of Health Services, the state agency mandated to serve the

public health needs of all Arizona residents. 1.7 ADHS BEHAVIORAL HEALTH RECIPIENT - A Title XIX or Title XXI acute care member who

is -receiving behavioral health services through ADHS and its subcontractors. 1.8 ADJUDICATED CLAIMS - Claims that have been received and processed by the Contractor

which resulted in a payment or denial of payment.

1.9 ADVERSE ACTION - Any action for which a Provider may file a Claim Dispute. 1.10 ANCILLARY CARE - All COVERED SERVICES other than physician and hospital inpatient

services which are ordered or approved by a physician, including but not limited to, radiology, laboratory, ambulance transportation, home health, skilled nursing and pharmacy services.

1.11 AGENT - Any person who has been delegated the authority to obligate or act on behalf of another person or entity.

1.12 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.

1.13 AHCCCS BENEFITS - See "COVERED SERVICES". 1.14 AHCCCS CARE - Eligible individuals and childless adults whose income is less than or equal

to 100% of the FPL, and who are not categorically linked to another Title XIX program. (Formerly Non-MED)

1.15 AHCCCS MEMBER - See "MEMBER".

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1.16 ALTCS - The Arizona Long Term Care System, a program under AHCCCS that delivers long-term, acute, behavioral health and case management services to eligible members, as authorized by A.R.S. § 36-2932.

1.17 AMBULATORY CARE - Preventive, diagnostic and treatment services provided on an

outpatient basis by physicians, nurse practitioners, physician assistants and other health care providers.

1.18 AMERICAN INDIAN HEALTH PROGRAM (AIHP) - AIHP is an acute care FFS program

administered by AHCCCS for eligible American Indians which reimburses for services provided by and through the Indian Health Service (IHS), tribal health programs operated under PL 93-638 or any other AHCCCS registered provider. AIHP was formerly known as AHCCCS IHS.

1.19 AMPM - AHCCCS Medical Policy Manual, available on the AHCCCS website at www.azahcccs.gov.

1.20 ANNUAL ENROLLMENT CHOICE (AEC) - The opportunity for a person to change

contractors every 12 months, effective on their anniversary date. 1.21 ANNIVERSARY DATE - The anniversary date is 12 months from the date enrolled with the

Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date the member was given an opportunity to change,

1.22 APPEAL RESOLUTION - The written determination by the Contractor concerning an appeal. 1.23 ARIZONA ADMINISTRATIVE CODE (A.A.C.) - Arizona Administrative Code. State

regulations established pursuant to relevant statutes. Referred to in Contract as "AHCCCS Rules".

1.24 AT RISK - Refers to the period of time that a member is enrolled with a Contractor during

which time the Contractor is responsible to provide AHCCCS covered services under capitation.

1.25 A.R.S. - Arizona Revised Statutes. 1.26 BBA - The Balanced Budget Act of 1997. 1.27 BIDDER'S LIBRARY – A repository of manuals, statutes, rules and other reference material

located on the AHCCCS website at www.azahcccs.gov. 1.28 BOARD CERTIFIED - An individual who has successfully completed all prerequisites of the

respective specialty board and successfully passed the required examination for certification. 1.29 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)

1.30 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.

1.31 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.

1.32 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.

1.33 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. 1.34 CLEAN CLAIM - A claim that may be processed without obtaining additional information from

the provider of service or from a third party; but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by A.R.S. § 36-2904.

1.35 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.

1.36 COMPENSATION - The payment as set forth in Attachment B herein to be paid by HCA to SUBCONTRACTOR in exchange for the provision of COVERED SERVICES to MEMBERS. CONTRACTOR or HCA shall mean Health Choice Arizona, Inc. (HCA).

1.37 COMPETITIVE BID PROCESS - A state procurement system used to select Contractors to provide covered services on a geographic basis.

1.38 CONTINUING OFFEROR - An AHCCCS Contractor during the CYE 08 that submits a

proposal pursuant to this solicitation. 1.39 CONTRACT SERVICES - See "COVERED SERVICES". 1.40 CONTRACT YEAR (CY) - Corresponds to the federal fiscal year (October 1 through

September 30). 1.41 CONTRACTOR - A person, 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 as defined in A.R.S. § 36-2901.

1.42 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. 1.43 COORDINATION OF BENEFITS - Those provisions by which SUBCONTRACTOR or HCA,

either together or separately, seek to recover costs of COVERED SERVICES provided for an incident of sickness or accident on the part of MEMBER which are covered by another insurer, service plan, government, third party payor or other organization.


1.44 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 9 A.A.C. 22, Article 7.

1.45 COST AVOIDANCE - The process of identifying and utilizing all sources of first or third-party

benefits before services are rendered by the Contractor or before payment is made by the Contractor. (This assumes the Contractor can avoid costs by not paying until the first or third party has paid what it covers first, or having the first or third party render the service so that the Contractor is only liable for coinsurance and/or deductibles.)

1.46 COVERED SERVICES - The health and medical services to be delivered by the Contractor as

defined in 9 A.A.C. 22, Article 2 and 9 A.A.C. 31, Article 2, the AMPM and Section D of this contract. [42 CFR 438.210(a)(4)]

1.47 CRS - Children's Rehabilitation Services - A program administered by the AHCCCS CRS

Contractor. The CRS Contractor provides services to Title XIX and Title XXI members who have completed the CRS application and have met the eligibility criteria to receive CRS related services as specified in 9 A.A.C. 7.

1.48 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.

1.49 CRS RECIPIENT - An individual who has completed the CRS application process, and has

met all applicable criteria to be eligible to receive CRS related Services. 1.50 DAYS - Calendar days, unless otherwise specified as defined in the text, as defined in A.A.C.

22, Article 1. 1.51 DELEGATED AGREEMENT - A type of subcontract agreement with a qualified organization

or person to perform one or more functions required to be performed by the Contractor pursuant to this contract.

1.52 DIRECTOR - The Director of AHCCCS. 1.53 DISENROLLMENT - The discontinuance of a member's ability to receive covered services

through a Contractor. 1.54 DME - Durable medical equipment is an item or appliance that can withstand repeated use, is

designated to serve a medical purpose, and are not generally useful to a person in the absence of a medical condition, illness or injury as defined in A.A.C. 22, Article 1.

1.55 DUAL ELIGIBLE - A member who is eligible for both Medicare and Medicaid. 1.56 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.

1.57 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 438.1 14(a)].

1.58 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)].

1.59 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. 1.60 ENROLLEE - A Medicaid recipient who is currently enrolled with a Contractor. [42 CFR

438.10(a)] 1.61 ENROLLMENT - The process by which an eligible person becomes a member of a

Contractor's plan. 1.62 EPSDT - Early and Periodic Screening, Diagnostic and Treatment services for eligible persons

or members less than 21 years of age as, defined in 9 A.A.C. 22, Article 2. 1.63 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.

1.64 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 (PL. 93-638) or an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act (PL. 94-437).

1.65 FEDERALLY QUALIFIED HEALTH CENTER Look-Alike - An organization that meets all of

the eligibility requirements of an organization that receives a Public Health Service Section 330 Grant CFQHC), but does not receive grant funding. AHCCCS requires Contractors to credential providers employed by an FQHC Look-Alike through the temporary or provisional credentialing process.

1.66 FEE-FOR-SERVICE (FFS) - Fee-For-Service, a method of payment to registered providers on

an amount-per-service basis. 1.67 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). 1.68 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.

1.69 FIRST PARTY LIABILITY - The resources available from any insurance or other coverage

obtained directly or indirectly by a member or eligible person that provides benefits directly to the member or eligible person and is liable to pay all or part of the expenses for medical services incurred by an AHCCCS, contractor, or member.


1.70 FISCAL YEAR (FY) - Federal Fiscal Year, October 1 through September 30. 1.71 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.

1.72 FRAUD - An intentional deception or misrepresentation made by a person with the knowledge

that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable state or federal law, a<; defined in 42 CFR 455.2.

1.73 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.

1.74 GEOGRAPHIC SERVICE AREA (GSA) - An area designated by AHCCCS within which a

Contractor of record provides, directly or through subcontract, covered health care service to a member enrolled with that contractor of record, as defined in 9 A.A.C. 22, Article 1.

1.75 GRIEVANCE SYSTEM - A system that includes a process for enrollee grievances, enrollee

appeals, provider claim disputes, and access to the state fair hearing system. 1.76 HEALTHCARE GROUP OF ARIZONA (RCG) - A prepaid medical coverage plan marketed to

small, uninsured businesses and political subdivisions within the state. 1.77 HEARING - A State Fair Hearing or administrative hearing under Title 41, Chapter 6, Article

10. [R9-34-402] 1.78 HEALTH PLAN - See "CONTRACTOR". 1.79 HIPAA - The Health Insurance Portability and Accountability Act (P.L. 104-191); also known

as the Kennedy-Kassebaum Act, signed August 21, 1996. 1.80 IBNR - Incurred but not reported: liability for services rendered for which claims have not been

received. 1.81 IHS - Indian Health Service authorized as a federal agency pursuant to 25 U.S.C. 166l. 1.82 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 American Indian 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".

1.83 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.

1.84 LIEN - A legal claim, filed with the County Recorder's office in which a member resides and in

the county an injury was sustained, for the purpose of ensuring that AHCCCS receives reimbursement for medical services paid. The lien is attached to any settlement the member may receive as a result of an injury.


1.85 MANAGED CARE - Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality medical management and the coordination of care.

1.86 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.

1.87 MANAGEMENT SERVICES SUBCONTRACTOR - An entity to which the Contractor

delegates the comprehensive management and administrative services necessary for the operation of the Contractor.

1.88 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.

1.89 MATERIAL OMISSION – A fact, data, or other information excluded from a report, contract,

etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, contract, etc.

1.90 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.

1.91 MEDICAID - A federal/state program authorized by Title XIX of the Social Security Act, as

amended. 1.92 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.

1.93 MEDICAL MANAGEMENT - Is 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).

1.94 MEDICARE - A federal program authorized by Title XVIII of the Social Security Act, as

amended. 1.95 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.

1.96 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 will not be covered by AHCCCS for dual eligible members. There are certain drugs that are excluded from coverage by Medicare, and will 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.

1.97 MEMBER - An eligible person who is enrolled in AHCCCS, as defined in A.R.S. §§ 36-2931,

36-2901, 36-2901.01 and A.R.S. §36-2981. 1.98 NON-CONTRACTING PROVIDER - A person or entity that provides services as prescribed in

A.R.S. § 36-2901 who does not have a subcontract with an AHCCCS Contractor.

1.99 NON-COVERED SERVICES - Those health care services which are not benefits under the AHCCCS program and are therefore the financial responsibility of MEMBER.

1.100 NON-MEDICAL EXPENSE DEDUCTION (Formerly NON MED) MEMBER - See "AHCCCS

CARE". 1.101 NPI - National Provider Identifier assigned by the CMS contracted national enumerator. 1.102 OFFEROR - An organization or other entity that submits a proposal to AHCCCS in response

to a Request For Proposal, as defined in 9 A.A.C. 22, Article 1. 1.103 PAY AND CHASE - Recovery method used by the Contractor to collect from legally liable first

or third parties after the Contractor pays the member's medical bills. The service may be provided by a contracted or non-contracted provider. Regardless of who provides the service, pay and chase assumes that the Contractor will pay the provider, then seek reimbursement from the first or third party.

1.104 PERFORMANCE STANDARDS - A set of standardized measures designed to assist

AHCCCS in evaluating, comparing and improving the performance of its Contractors. 1.105 PIP - Performance Improvement Project (PIP), formerly referred to as Quality Improvement

Projects (QIP). 1.106 PMMIS - AHCCCS's Prepaid Medical Management Information System. 1.107 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 alternatively be safely discharged or transferred to another location [42 CFR 438-114(a)].

1.108 POTENTIAL ENROLLEE - A Medicaid-eligible recipient who is not yet enrolled with a

Contractor [42 CFR 438.10(a)]. 1.109 PRIMARY CARE PROVIDER (PCP) – Primary Care Provider/Practitioner, an individual who

meets the requirements of A.R.S. § 36-2901, and who is responsible for the management of the member's or eligible person'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.

1.110 PRIOR PERIOD COVERAGE (PPC) - The period prior to a member's enrollment, during

which a 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.


1.111 PROPER REFERRAL - An occasion upon which a PRIMARY CARE PHYSICIAN directs

MEMBER to seek and obtain COVERED SERVICES from a health care professional in accordance with the terms of HCA referral policies and procedures as provided in the HCA Provider Manuals.

1.112 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.

1.113 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.

1.114 RATE CODE - Eligibility classification for capitation payment purposes. 1.115 REGIONAL BEHAVIORAL HEALTH AUTHORITY (RBHA) - An organization under contract

with ADHS, to administer 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 American Indians.

1.116 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.

1.117 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.

1.118 RISK GROUP - Grouping of rate codes that are paid at the same capitation rate. 1.119 RFP - Request For Proposal, a document prepared by AHCCCS, that describes the services

required and instructs prospective Offerors about how to prepare a response (proposal), as defined in 9 A.A.C. 22, Article 1.

1.120 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.

1.121 SCHIP - State Children's Health Insurance Program under Title XXI of the Social Security Act

(Also known as CHIP). The Arizona version of CHIP is referred to as "KidsCare". See "KIDSCARE".

1.122 SCOPE OF SERVICES - See "COVERED SERVICES". 1.123 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.

1.124 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.

1.125 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. 1.126 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.

1.127 SPECIALTY CARE PHYSICIAN - A physician to whom MEMBER has been referred for specialty services and who limits his/her practice to a certain branch of medicine related to specific services or procedures, certain categories of patients, certain body systems or certain types of diseases.

1.128 STATE - The State of Arizona. 1.129 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.

1.130 STATE PLAN - The written agreements between the State and CMS, which describes how

the AHCCCS program meets CMS requirements for participation in the Medicaid program and the State Children's Health Insurance Program.

1.131 SUBCONTRACT - An agreement entered into by the Contractor with any of the following: a

provider of health care services, who agrees to furnish covered services to 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 9 A.A.C. 22, Article 1.

1.132 SUBCONTRACTOR -

1.132.1 A provider of health care who agrees to furnish covered services to members. 1.132.2 A person, agency or organization with which the Contractor has contracted or

delegated some of its management/administrative functions or responsibilities. 1.132.3 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.

1.133 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.

1.134 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 (PL. 104-193). It replaced Aid to Families with Dependent Children (AFDC).

1.135 THIRD PARTY LIABILITY (TPL) - See "LIABLE PARTY". 1.136 TIMELY CLAIM SUBMISSION - Claims for AHCCCS covered services that are initially

submitted within six months of the date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later, or that are submitted as clean claims within twelve months of the date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later. HCA shall deny claims received outside of these timeframes.

1.137 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 (previously AFDC), Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), or SSI-related groups, Medicare Cost Sharing groups, Title XIX Waiver groups, Breast and Cervical Cancer Treatment program and Freedom to Work.

1.138 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 or CHIP). The Arizona version of CHIP is referred to as "KidsCare."

1.139 TRIBAL/REGIONAL BEHAVIORAL HEALTH AUTHORITY (T/RBHA) - An organization

under contract with ADHS/DBHS 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 for the provision of behavioral health services to American Indian members.

1.140 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)

1.141 YOUNG ADULT TRANSITIONAL INSURANCE (YATI) - Eligible individuals, between 18 and

21 years of age who were formerly enrolled through the foster care program. SECTION 2 - RELATIONSHIP OF PARTIES 2.1 BASIC RELATIONSHIP HCA and SUBCONTRACTOR are separate and independent

entities. In the performance of this Agreement, it is mutually understood and agreed that SUBCONTRACTOR is at all times acting and performing as an independent contractor with, and not an employee of, HCA. SUBCONTRACTOR shall not have any claim under this Agreement or otherwise against HCA for Workers' Compensation, unemployment compensation, sick leave, vacation pay, or retirement benefits. HCA shall not withhold on behalf of SUBCONTRACTOR pursuant to this Agreement any sums for income tax, unemployment insurance, Social Security or otherwise pursuant to any law or requirement of any governmental agency. SUBCONTRACTOR shall indemnify and hold harmless HCA from any and all loss or liability, if any, arising out of or with respect to any of the foregoing benefits or withholding requirements, which amounts of loss or liability may, at HCA's discretion, be


offset against compensation otherwise due SUBCONTRACTOR under this Agreement. 2.2 ASSIGNMENT This Agreement is entered into because of the personal qualifications of

SUBCONTRACTOR. SUBCONTRACTOR may not assign payment to be received under this Agreement, nor may any of the duties of SUBCONTRACTOR be delegated, without advance written consent of HCA. Upon receiving consent of Health Choice Arizona, functions delegated by SUBCONTRACTOR shall be subject to the terms of the Subcontractor Agreement between Health Choice Arizona and SUBCONTRACTOR and in accordance with the most current applicable URAC Standards.

2.3 PRIMARY CARE MANAGEMENT SYSTEM The Parties recognize that the efficient, cost-

effective operation of HCA is dependent in large part on the success of the Primary Care Management System under which a PRIMARY CARE PHYSICIAN is responsible for coordinating the provision of health care services to MEMBER and initiating all referrals to health care professionals and facilities. This Primary Care Management System involves multiple categories of subcontractors and nonparticipating providers, each with specific rights and responsibilities. This Agreement sets forth the rights and responsibilities of SUBCONTRACTOR.

SECTION 3 - DUTIES OF THE PARTIES 3.1 RIGHTS AND OBLIGATIONS OF HCA. HCA agrees to:

(a) Process claims of, and transmits payments to, SUBCONTRACTOR in accordance with the terms and conditions set forth in the Fiscal Relationships section herein.

(b) Operate, at its own expense, quality management, utilization review, peer review and Grievance System programs, to complement and coordinate with any similar programs established by AHCCCS and CMS.

(c) Appoint administrative, clinical and support staff to support and coordinate the activities of HCA as they affect SUBCONTRACTOR and to ensure that SUBCONTRACTOR understands and complies with HCA policies and procedures.

(d) Be responsible for the successful management and administration of the relationships between SUBCONTRACTOR, HCA, AHCCCS and CMS.

(e) Maintain a listing of subcontractors where appropriate. (f) Notify SUBCONTRACTOR of changes in HCA and HC Generations policies and

procedures. (g) Establish and enforce policies and procedures designed to ensure the compliance of

HCA with state and federal regulations. (h) Report all cases of suspected fraud and abuse by SUBCONTRACTOR, MEMBERS or

HCA employees to AHCCCS and CMS. 3.2 RIGHTS AND OBLIGATIONS OF SUBCONTRACTOR. SUBCONTRACTOR agrees

to:

3.2.1 Provision of COVERED SERVICES SUBCONTRACTOR agrees to provide and/or arrange for COVERED SERVICES as needed by MEMBERS who are assigned or referred to SUBCONTRACTOR. SUBCONTRACTOR further agrees to arrange for the provision of all other COVERED SERVICES in accordance with the terms and conditions of this Agreement, to obtain authorization in advance for all hospitalizations and, when applicable, to obtain authorization in advance for all care rendered by SPECIALTY CARE PHYSICIANS, except in the case of emergencies and to follow all policies and procedures set-forth by HCA.


3.2.1.1 Physician/Patient Relationship SUBCONTRACTOR recognizes that the physician/patient relationship is initiated when MEMBER selects or is assigned a PRIMARY CARE PHYSICIAN. The PRIMARY CARE PHYSICIAN selected by each MEMBER shall provide primary health care and shall serve as a gatekeeper and coordinator in referring the member for specialty medical services. The PCP is responsible for maintaining the members 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. Behavioral Health Services Primary Care Physician shall be responsible to respond to the Regional Behavioral Health Authority (RBHA)/provider or other provider as approved by HCA and CMS, for information requests pertaining to members receiving behavioral health services within 10 business days of receiving the request. The response must include all pertinent information, including but not limited to:

current diagnosis

medications

laboratory results

last PCP visit

hospitalization

PCP is also required to initial documentation received by the RBHA, or other designated provider as approved by HCA and CMS, provider signifying medical records have been reviewed. PCPs who have initiated medication treatment management services for members to treat a behavioral health disorder and it is subsequently determined by the PCP or HCA that the member should be transferred to a RBHA provider for evaluation and/or continued medication services, the PCP shall assist HCA to coordinate the transfer of care. HCA will ensure that the PCP maintains continuity of care for member assigned.

3.2.1.2 Continuation of Services after Termination SUBCONTRACTOR agrees

that if SUBCONTRACTOR or HCA terminates this Agreement, all COVERED SERVICES, as enumerated in Attachment B herein, shall continue to be provided for those MEMBERS hospitalized on or before the date of termination, and SUBCONTRACTOR shall be reimbursed in accordance with Attachment B herein, until the discharge of MEMBER or alternative coverage is obtained by MEMBER. If AHCCCS terminates the coverage of MEMBER, the responsibility of SUBCONTRACTOR to provide services under this Agreement to that MEMBER shall also terminate effective on the date of termination. SUBCONTRACTOR may bill the patient for all services provided subsequent to the termination date.

3.2.1.3 Staff Training SUBCONTRACTOR agrees to train staff on the following

aspects of the Federal False Claims Act provisions:

administrative remedies for false claims and statements;

any state law relating to civil or criminal penalties for false claims and statements;

whistle blower protections under such laws


3.2.2 Health Plan’s Policies and Procedures SUBCONTRACTOR agrees to abide by the policies and procedures during the term of this Agreement including the HCA Prior Authorization and Referral Policies as incorporated within the current Provider Manuals. Failure to comply with the HCA Prior Authorization and Referral Policies may result in claim denial. SUBCONTRACTOR agrees to participate in, cooperate with, and submit reports consistent with state, federal and independent accrediting agencies' requirements for HCA utilization review, quality management, peer review, disciplinary action and Grievance System policies and procedures. Copies of policies and procedures relating to these programs are available upon request.

3.2.3 Marketing and Outreach SUBCONTRACTOR shall support and contribute to HCA marketing and outreach activities. SUBCONTRACTOR shall adhere to the most current AHCCCS and CMS Marketing Policy and Procedure regarding the marketing and outreach activities of SUBCONTRACTOR related to the AHCCCS and CMS population.

3.2.4 Fraud and Abuse SUBCONTRACTOR shall report all cases of suspected AHCCCS

and CMS fraud and abuse by MEMBERS, employees of SUBCONTRACTOR or employees of HCA to AHCCCS, CMS and HCA.

3.2.5 SUBCONTRACTOR Qualifications

3.2.5.1 SUBCONTRACTOR Credentialing SUBCONTRACTOR shall comply

with, and shall ensure that the practice or employment of SUBCONTRACTOR comply with, credentialing and recertification standards, as well as all federal and state laws and regulations regarding licensure, certification and credentialing and use of DEA number(s) in prescribing. SUBCONTRACTOR shall give immediate written notice to HCA if the license or certificate of SUBCONTRACTOR, or that of a health care provider in the practice or employment of SUBCONTRACTOR, is revoked, suspended or limited in any way.

3.2.5.2 Maintenance of Licensure and Certification SUBCONTRACTOR agrees

to maintain in good standing all licenses, accreditations and certifications as applicable and required by law and under Titles XVIII and XIX of the Social Security Act. SUBCONTRACTOR shall maintain a valid AHCCCS provider identification number.

3.2.5.3 Notice of Change of Condition SUBCONTRACTOR shall immediately

notify HCA, writing, of any change in or loss of general and professional liability insurance as applicable, or action against any licenses, accreditation or certifications including, but not limited to, those under Titles XVIII or XIX; or any other situation that might interfere with the duties and obligations of HCA under its contract with AHCCCS.

3.2.5.4 SUBCONTRACTOR Information SUBCONTRACTOR agrees to

complete Attachment A, Subcontractor Information Sheet, and agrees to notify HCA promptly, but in any event, at least thirty (30) days prior to any change in the information submitted. All changes and/or additions to the practice locations of SUBCONTRACTOR are subject to the approval of HCA.


3.2.6 Practice Standards

3.2.6.1 Standard of Care SUBCONTRACTOR agrees to provide and/or arrange for the provision of COVERED SERVICES, in order to provide a quality standard of care in conformity with generally accepted medical practices in effect at the time of service.

3.2.6.2 Access to Care SUBCONTRACTOR shall make COVERED SERVICES

available and accessible to MEMBERS twenty-four (24) hours per day, seven (7) days per week. This includes normal business hours at the usual place of business of SUBCONTRACTOR, telephone access and emergency services. SUBCONTRACTOR shall make arrangements for the assumption of responsibility by another HCA subcontractor when necessary, subject to HCA approval.

3.2.6.3 Appointment Standards. SUBCONTRACTOR shall establish office

procedures such that, except in the case of an emergency or unforeseen circumstances, MEMBERS experience a waiting time no longer than forty-five (45) minutes from the time of the scheduled appointment. SUBCONTRACTOR shall ensure that the following appointment availability standards are met for MEMBERS.

Primary Care Appointments a) Emergency appointments: Same day of request or

within 24 hours of the member’s phone call or other notification

b) Urgent care appointments: Within 2 days of request c) Routine care appointments: Within 21 days of request Specialty Referrals a) Emergency appointments: Within 24 hours of referral b) Urgent care appointments: Within 3 days of referral c) Routine care appointments: Within 45 days of referral Dental Appointments a) Emergency appointments: Within 24 hours of referral b) Urgent care appointments: Within 3 days of referral c) Routine care appointments: Within 45 days of referral Maternity Care a) First Trimester: Within 14 days of request b) Second Trimester: Within 7 days of request c) Third Trimester: Within 3 days of request d) High Risk Pregnancies: Within 3 days of the identification

of high-risk by the contractor or maternity care provider, or immediately if any emergency exists.

3.2.6.4 Responsibility for Care SUBCONTRACTOR has the ultimate

responsibility for the care provided to MEMBERS and shall make decisions for the provision of care according to the best medical judgment of SUBCONTRACTOR and in sole consideration of the health


of MEMBER, notwithstanding financial consideration or HCA policies and procedures.

3.2.6.5 Confidentiality of Care and Information SUBCONTRACTOR shall

provide or arrange for all COVERED SERVICES and maintain all medical records of MEMBERS with due attention to confidentiality. SUBCONTRACTOR is not required to violate the physician/patient relationship by revealing to anyone, other than AHCCCS or the HCA Medical Director or designee, any confidential information concerning MEMBER that would be construed to be in violation of those medical ethics governing the receipt by SUBCONTRACTOR of information from MEMBER.

3.2.6.6 Drug Formulary SUBCONTRACTOR shall prescribe medications as

listed in the current HCA and HC Generations Drug Formularies. If the medication is not available or listed in the current HCA Drug Formulary, SUBCONTRACTOR shall consider appropriate formulary substitution or request prior authorization from HCA prior to prescribing the medication.

3.2.6.7 Advance Directives Hospitals, Nursing Facilities, Home Health

Agencies, Hospice, or organizations responsible for providing personal care must comply with CMS, AHCCCS or Federal and State law regarding advance directives for adult members. These requirements include:

(1) Maintaining written policies that address the rights of adult

members to make decisions about medical care, and the right to execute an advance directive. If SUBCONTRACTOR has a conscientious objection to carrying out an advance directive, it must be explained in SUBCONTRACTOR’s policies. (SUBCONTRACTOR is not prohibited from making such objection when made pursuant to A.R.S.§ 36-3205.C.1.)

(2) SUBCONTRACTOR must 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).

(3) SUBCONTRACTOR must document in the member’s medical record whether or not the adult member has been provided the information and whether the advance directive has been executed.

(4) SUBCONTRACTOR may not discriminate against a member because of his or her decision to execute or not execute an advance directive, and SUBCONTRACTOR may not make the execution of an advance directive a condition of care.

(5) SUBCONTRACTOR must be able to show proof that SUBCONTRACTOR provides or has provided education to SUBCONTRACTOR’s staff on issues concerning advance directives including notification of SUBCONTRACTOR’s direct care providers of services of any advanced directives executed by members to whom SUBCONTRACTOR’s direct care providers provide services.


3.2.6.8 Advance Directives and Primary Care Providers. If SUBCONTRACTOR is a primary care physician and has agreements with hospitals, nursing facilities, home health agencies, hospice or any organization responsible for providing personal care to HCA members, SUBCONTRACTOR must comply with AHCCCS, CMS and Federal and State law regarding advance directives for adult members. In addition PCP must comply with Section One, subparagraph 3.2.6.7, 2 through 5 above. SUBCONTRACTOR is further encouraged to include a copy of the member’s executed advance directive, or documented refusal, into the member’s medical record both at the primary care physician’s office and the facility, entity or organization with which the primary care physician has an agreement.

3.2.7 Records

3.2.7.1 Content of Medical Records SUBCONTRACTOR agrees to maintain a

medical record for each MEMBER, including, at a minimum, a record of outpatient and emergency care, specialty care, ancillary care, laboratory and x-ray tests and findings, prescriptions for medications, inpatient discharge summaries, physical examinations and history including any smoking and chemical dependencies. All medical records shall be maintained according to the standards specified in the HCA Provider Manual.

3.2.7.2 Maintenance of Medical Records SUBCONTRACTOR agrees that

medical records are to be maintained in a detailed and comprehensive manner which conforms to community standards, and which facilitates an adequate system for follow-up treatment. Medical records must be legible, signed and dated. Confidentiality of medical records must be maintained except as otherwise provided by law. SUBCONTRACTOR shall retain all MEMBER medical records for a minimum of five (5) years post date of last service.

3.2.7.3 Access to Records All records, books and papers of

SUBCONTRACTOR pertaining to MEMBERS shall be open for copying and inspection by HCA and authorized state, federal and independent accrediting authorities during normal business hours. Medical records must be provided within seven (7) days of request. Failure of SUBCONTRACTOR to provide AHCCCS with medical records necessary for data validation which results in a sanction to HCA by AHCCCS shall result in such sanction being deducted in full from future payments to SUBCONTRACTOR. HCA will issue a written notification to SUBCONTRACTOR seven (7) days prior to the sanction being imposed.

3.2.7.4 Requests for Medical Records by Other HCA Subcontractors

SUBCONTRACTOR agrees that medical records or copies of medical records of any MEMBER requested by other subcontractors of HCA shall be forwarded to the requesting subcontractor within five (5) working days of a request thereof.


3.2.8 Referrals and Prior Authorization

3.2.8.1 Referral/Authorization Services. SUBCONTRACTOR agrees to refer MEMBERS only to other subcontractors of HCA in accordance with HCA authorization policies and procedures as provided in the HCA Provider Manual and understands and agrees that if all COVERED SERVICES are not available from SUBCONTRACTOR and other subcontractors currently retained under contract with HCA, MEMBERS shall be referred for medical specialty services, or other services, only at the direction and with prior approval of HCA. Except in situations requiring EMERGENCY MEDICAL SERVICES, care provided by a nonparticipating provider that has not been authorized by HCA and/or one of its subcontractors, may result in denial of payment.

3.2.8.2 Referral/Prior Authorization Standards SUBCONTRACTOR shall

establish office procedures to ensure that urgent and emergent referrals are processed on the same day as the date of service to MEMBER, and routine referrals are processed within four (4) days from the date of service.

3.2.8.3 Verification of MEMBER Eligibility and Authorization Prior to admitting

MEMBER to an HCA or HC Generations participating hospital or rendering any service other than EMERGENCY MEDICAL SERVICES, SUBCONTRACTOR agrees to obtain: (a) Verification of eligibility by calling HCA to verify eligibility and (b) Verification of identity by asking MEMBER to produce his/her

AHCCCS or HC Generations membership card and another form of photo identification, or if no membership card has yet been issued, two other forms of identification, at least one a photo identification. If MEMBER is a minor, the identification of a parent will be acceptable if the eligibility of MEMBER is verified with HCA as set forth in (a) hereinabove.

(c) An authorization number for the admission from HCA or HC Generations, unless the service does not require pre-authorization in accordance with currently established HCA and HC Generations policies and procedures.

3.2.8.4 Good Faith Treatment Should SUBCONTRACTOR be unable to

ascertain the eligibility of a patient who holds himself/herself as a MEMBER, SUBCONTRACTOR shall render immediate, necessary care on a good faith basis. At the first available opportunity, eligibility shall be verified by SUBCONTRACTOR. If the patient proves not to be an eligible MEMBER, SUBCONTRACTOR shall collect such payment due from the patient.

3.2.8.5 Authorization for Inpatient Service Except in the case of EMERGENCY

MEDICAL SERVICES, MEMBERS may not be admitted to any hospital without the prior approval of the appropriate PRIMARY CARE PHYSICIAN and prior authorization by HCA. Hospitals are required to notify HCA (via phone call or HCA web site when operational), on the day of the admission.

3.2.8.6 EMERGENCY MEDICAL SERVICES Admissions: In cases in which


emergency admissions are required, SUBCONTRACTOR agrees to notify HCA of the admission. If due to the severity of the emergency, prior notification cannot be obtained, SUBCONTRACTOR must provide notification, via phone call or HCA web site (when operational) to HCA of the emergency within twenty-four hours after admission.

3.2.9 Quality Management Subcontractor agrees to comply with HCA quality management

policies and procedures as dictated by AHCCCS and CMS for both hospital based care and office based care. Policies and procedures relating to these programs are provided in the HCA Provider Manuals or available upon request. Failure to comply with the decisions of HCA and the Quality Management Committee shall result in termination of this Agreement.

3.2.9.1 Quality Improvement SUBCONTRACTOR shall participate in HCA

quality improvement activities as determined by HCA, including compliance with recommendations regarding the practice standards of SUBCONTRACTOR.

3.2.9.2 State Site Evaluations, Medical Record Audits and Inspections In

accordance with the terms and conditions of this Agreement, the HCA contract with AHCCCS and CMS, and current state and federal laws and regulations, SUBCONTRACTOR agrees to permit HCA, the State Departments of Health Services and Insurance, the U.S. Department of Health and Human Services, and AHCCCSA to conduct periodic site evaluations and medical record audits of the facilities, offices and equipment of SUBCONTRACTOR, medical records of MEMBERS, and all phases of professional and ancillary medical care provided to MEMBERS by SUBCONTRACTOR. SUBCONTRACTOR further agrees to comply with the State of Arizona and/or federal regulations, if any.

3.2.9.3 Medical Record Audit Standard SUBCONTRACTOR shall meet or

exceed the HCA medical record audit standard of eighty five percent (85%) compliance with HCA specified goals and within acceptable standards as determined by AHCCCS and CMS specified goals. In the event SUBCONTRACTOR fails to meet this standard, SUBCONTRACTOR shall comply with HCA corrective recommendations until such time as the medical record audit standard is met. Repeated failure to achieve compliance shall be considered cause for termination of this Agreement. Failure of SUBCONTRACTOR to provide medical record audit information which results in a sanction to HCA by AHCCCS shall result in such sanction being deducted in full from future payments to SUBCONTRACTOR.

3.2.10 Encounter Data and Statement of Charges Each year the Arizona Health Care Cost

Containment System Administration (AHCCCSA) performs a data validation study. In support of this study, HCA is required to collect from SUBCONTRACTOR copies of Medical Records necessary to substantiate that a service provided and billed by SUBCONTRACTOR and paid by HCA with the subsequent submission of an encounter, was in fact provided. SUBCONTRACTOR agrees to cooperate with HCA in the completion of this study by providing copies of such Medical Records. All information must be handled in accordance with HIPAA requirements.


SECTION 4 - FISCAL RELATIONSHIPS

4.1 MEMBERS COVERED UNDER AHCCCS CONTRACT SUBCONTRACTOR agrees to provide

and/or arrange for COVERED SERVICES in accordance with the terms and conditions set forth in this Agreement.

4.1.1 Payment and Billing In exchange for COVERED SERVICES provided to and/or

arranged and paid for on behalf of eligible MEMBERS, HCA agrees to pay SUBCONTRACTOR in accordance with the payment terms set forth in Attachment B-1 herein. SUBCONTRACTOR agrees to accept these amounts as payment in full for COVERED SERVICES, except for authorized COPAYMENTS and amounts recovered by SUBCONTRACTOR or HCA through COORDINATION OF BENEFITS. In any case, reimbursement made to SUBCONTRACTOR shall not exceed the total amount billed after collection of COPAYMENTS and COORDINATION OF BENEFITS. Bills shall be submitted and payments made on a timely basis as outlined in the HCA Provider Manual.

4.1.2 COPAYMENTS Collected from MEMBERS COPAYMENTS, to the extent specified in

the HCA Provider Manual, shall be collected from MEMBER at the time of service; however, the inability of MEMBER to pay shall not impede nor prevent MEMBER from receiving MEDICALLY NECESSARY COVERED SERVICES.

4.1.3 Loss of Eligibility Except as provided in the Continuation of Services after Termination

subsection herein, if MEMBER loses AHCCCS eligibility during hospitalization, SUBCONTRACTOR may collect from patient or any other eligible primary payer any amounts due subsequent to loss of AHCCCS eligibility.

4.2 COORDINATION OF BENEFITS HCA has been designed to help MEMBER meet the cost of

receiving health care services. AHCCCS, CMS and HCA will arrange benefits as specified in Attachment B-1 for Health Choice Arizona and Attachment B-2 for Health Choice Generations herein but may coordinate the costs of providing these benefits with any other health plan under which MEMBER is covered. SUBCONTRACTOR agrees to be bound by the HCA COORDINATION OF BENEFITS policies and procedures as provided in the HCA Provider Manual.

4.2.1 Third Party Liability SUBCONTRACTOR agrees to coordinate benefits so that costs for

services otherwise payable by HCA are avoided or recovered from a third party payor. SUBCONTRACTOR shall collect or allow HCA to collect any monies available from third party payors for services provided to its MEMBERS except for uninsured and underinsured motorists insurance, first and third party liability insurance and tort fees or unless referred by AHCCCS for collection. Both Parties shall provide such information as is necessary to facilitate COORDINATION OF BENEFITS. Such third party payors include, but are not limited to, Medicare and any individual, entity or program that is or may be liable to pay all or part of the medical expenses incurred by MEMBER. Additionally, SUBCONTRACTOR shall perform any activities related to third party liability required by AHCCCS Rules and Policies and Procedures. SUBCONTRACTOR shall report to HCA the amounts of third party collections in the format and frequency as may be required by AHCCCS. AHCCCS may assume responsibility for the coordination of certain types of third party liability. The distribution of funds collected from third parties shall be in accordance with AHCCCS Rules and Policies and Procedures.


4.2.2 MEMBER Responsibility for NON-COVERED SERVICES It is recognized that MEMBERS might request services of SUBCONTRACTOR that are not authorized or covered and are, therefore, payable by MEMBERS. In such cases, SUBCONTRACTOR agrees to advise MEMBERS of their payment responsibility prior to rendering any such services.

SECTION 5 - INSURANCE

5.1 INDEMNIFICATION CLAUSE:

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

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

5.2 INSURANCE REQUIREMENTS:

Subcontractors shall procure and maintain until all of their obligations have been discharged, including any warranty periods under this contract, are satisfied, insurance against claims for injury to persons or damage to property which may arise from or in connection with the performance of the work hereunder by the Contractor, his agents, representatives, employees or Subcontractors.

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

5.3 MINIMUM SCOPE AND LIMITS OF INSURANCE: Subcontractor shall provide coverage with limits of liability not less than those stated below as applicable in accordance with the services provided by the Subcontractor.


1. Commercial General Liability – Occurrence Form Policy shall include bodily injury, property damage, personal injury and broad form contractual liability coverage.

General Aggregate $3,000,000

Products – Completed Operations Aggregate $1,000,000

Personal and Advertising Injury $1,000,000

Blanket Contractual Liability – Written and Oral $1,000,000

Fire Legal Liability $ 50,000

Each Occurrence $1,000,000

a. The policy shall be endorsed (Blanket Endorsements are not acceptable) to include the following additional insured language: “The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor." Such additional insured shall be covered to the full limits of liability purchased by the Subcontractor, even if those limits of liability are in excess of those required by this contract.

b. Policy shall contain a waiver of subrogation endorsement (Blanket

Endorsements are not acceptable) in favor of the “State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees” for losses arising from work performed by or on behalf of the Subcontractor.

2. Business Automobile Liability

Bodily Injury and Property Damage for any owned, hired, and/or non-owned vehicles

used in the performance of this contract.

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

a. The policy shall be endorsed (Blanket Endorsements are not

acceptable) to include the following additional insured language: “The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees shall be named as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor, involving automobiles owned, leased, hired or borrowed by the Contractor." Such additional insured shall be covered to the full limits of liability purchased by the Subcontractor even if those limits of liability are in excess of those required by this contract.

b. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements

are not acceptable) in favor of the “State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees” for losses arising from work performed by or on behalf of the Subcontractor.


3. Worker's Compensation and Employers' Liability

Workers' Compensation Statutory

Employers' Liability Each Accident $ 500,000 Disease – Each Employee $ 500,000 Disease – Policy Limit $1,000,000

a. Policy shall contain a waiver of subrogation endorsement (Blanket Endorsements are not acceptable) in favor of the “State of Arizona, and departments, agencies, boards, commissions, universities, officers, officials, agents, and employees” for losses arising from work performed by or on behalf of the Subcontractor.

b. This requirement shall not apply to: Separately, EACH Contractor or Subcontractor exempt under A.R.S. §23-901, AND when such Contractor or Subcontractor executes the appropriate waiver (Sole Proprietor/Independent Contractor) form.

4. Professional Liability (Errors and Omissions Liability)

Each Claim $1,000,000 Annual Aggregate $3,000,000

a. In the event that the professional liability insurance required by this contract is

written on a claims-made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this contract; and that either continuous coverage will be maintained or an extended discovery period will be exercised for a period of two (2) years beginning at the time work under this contract is completed.

b. The policy shall cover professional misconduct or lack of ordinary skill for those positions defined in the Scope of Work of this contract.

5.4 ADDITIONAL INSURANCE REQUIREMENTS: The policies shall include, or be endorsed (Blanket Endorsements are not acceptable) to include, the following provisions. Subcontractors not currently having these provisions in place shall do so upon insurance policy renewal:

1. The Subcontractor’s policies shall stipulate that the insurance afforded the Subcontractor

shall be primary insurance and that any insurance carried by the Department, and its agents, officials, employees or the State of Arizona shall be excess and not contributory insurance, as provided by A.R.S. §41-621 (E).

2. Coverage provided by the Subcontractor shall not be limited to the liability assumed under

the indemnification provisions of this contract.

5.5 NOTICE OF CANCELLATION: With the exception of (10) day notice of cancellation for non-

payment of premium, any changes material to compliance with this contract in the insurance policies above shall require (30) days written notice to the State of Arizona. Such notice shall be sent directly to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034 and shall be sent by certified mail, return receipt requested.


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

5.7 VERIFICATION OF COVERAGE: Subcontractor shall furnish the State of Arizona with

certificates of insurance (ACORD form or equivalent approved by the State of Arizona) as required by this contract. The certificates for each insurance policy are to be signed by an authorized representative.

Upon request, all certificates and endorsements (Blanket Endorsements are not acceptable) are to be received and approved by the State of Arizona before work commences. Each insurance policy required by this contract must be in effect at or prior to commencement of work under this contract and remain in effect for the duration of the project. Failure to maintain the insurance policies as required by this contract, or to provide evidence of renewal, is a material breach of contract. All certificates required by this contract shall be sent directly to AHCCCS Contracts Unit, Mail Drop 5700, Division of Business and Finance, 701 E. Jefferson St., Phoenix, AZ 85034. All subcontractors are required to maintain insurance and to provide verification upon request. The State of Arizona project/contract number and project description shall be noted on the certificate of insurance. The State of Arizona reserves the right to require complete, copies of all insurance policies required by this contract at any time.

5.8 SUBCONTRACTORS: Contractors’ certificate(s) shall include all Subcontractors as insureds

under its policies or upon request, the Contractor shall furnish to the State of Arizona separate certificates and endorsements for each Subcontractor upon request. All coverages for Subcontractors shall be subject to the minimum requirements identified above. 5.9 APPROVAL: Any modification or variation from the insurance requirements in this contract shall be made by the contracting agency in consultation with the Department of Administration, Risk Management Division. Such action will not require a formal contract amendment, but may be made by administrative action. 5.10 EXCEPTIONS: In the event the Contractor or Subcontractor(s) is/are a public entity, then the

Insurance Requirements shall not apply. Such public entity shall provide a Certificate of Self- Insurance. If the Contractor or Subcontractor(s) is/are a State of Arizona agency, board, commission, or university, none of the above shall apply.

SECTION 6 - TERMINATION AND DEFAULT 6.1 MUTUAL CONSENT This Agreement may be terminated at any time upon the mutual written

consent of both Parties. 6.2 EVENTS OF DEFAULT This Agreement may be terminated by the non-defaulting Party upon

any of the following events of default and upon compliance with the notice provisions set forth below.

6.2.1 Failure to Meet Obligations Except as otherwise provided in the Duration of

Agreement and Renewal section herein, in the event that either Party defaults in the performance of any duties or obligations hereunder, including the inability or refusal to


provide COVERED SERVICES hereunder, and the default or breach has not been resolved within thirty (30) days of the non-defaulting Party giving written notice of default or breach, specifying the nature of the alleged default or breach, the non-defaulting Party may give notice of intent to terminate this Agreement, and this Agreement will terminate on the last day of the month in which the notice of intent to terminate is received.

6.2.2 Loss of Licensure or Insurance HCA may terminate this Agreement immediately upon

loss of licensure or insurance by SUBCONTRACTOR. 6.2.3 Danger to Health or Safety of MEMBERS HCA may terminate this Agreement

immediately, whenever HCA or the applicable state or federal regulatory agency reasonably believes the health or safety of MEMBERS is endangered by actions of SUBCONTRACTOR, its staff, contractors or subcontractors.

6.2.4 Insolvency and Change of Ownership HCA may terminate this Agreement should

SUBCONTRACTOR have a change in ownership or sell a significant percentage of the assets of SUBCONTRACTOR; voluntarily file a petition in or for bankruptcy, reorganization or an arrangement with creditors; make a general assignment for the benefit of creditors; be adjudged bankrupt; be unable to pay debts as they become due; have a trustee, receiver or other custodian appointed on the behalf of SUBCONTRACTOR; or, should any other case or proceeding under any bankruptcy or insolvency law, or any dissolution or liquidation proceeding be commenced against SUBCONTRACTOR.

6.2.5 Failure to Meet and/or Maintain Credentialing Standards. HCA may terminate this

Agreement immediately should SUBCONTRACTOR fail to meet and/or maintain HCA Credentialing/Recredentialing standards.

6.2.6 Notification of Default. HCA shall promptly inform CMS and AHCCCS, Division of

Health Care Management, in writing if Subcontractor is in significant non-compliance or default based on any one of the conditions listed in Section 6.2, that would affect Subcontractor’s abilities to perform the duties and responsibilities of this Agreement.

6.3 EFFECT OF TERMINATION Except as otherwise mutually agreed upon in writing by the

Parties termination of this Agreement shall be subject to the provisions of the Continuation of Services after Termination section herein.

6.4 RIGHTS UPON TERMINATION Upon termination of this Agreement, the rights and duties of

each Party hereunder shall terminate, provided, however, that such action shall not release either HCA or SUBCONTRACTOR from any obligations to the other which occurred prior to such termination.

SECTION 7 - DURATION OF AGREEMENT AND RENEWAL

7.1 TERM OF AGREEMENT AND RENEWAL This Agreement shall have an initial term of one year from the effective date of the Agreement. This Agreement shall thereafter be automatically renewed for successive one year periods unless terminated pursuant to the terms of this section or the Termination and Default section herein. This Agreement may be terminated without cause by either Party through the provision of at least a ninety (90) day prior written notice of intent to terminate to the other Party.


SECTION 8 - GENERAL PROVISIONS 8.1 ENTIRE AGREEMENT; MODIFICATION This Agreement constitutes the entire

understanding of the Parties and supersedes any and all written or oral agreements, representations or understandings. HCA may amend this Agreement by providing prior written notice to SUBCONTRACTOR. Failure of SUBCONTRACTOR to object in writing to any such proposed amendment within thirty (30) days following receipt of notice shall constitute SUBCONTRACTOR’s acceptance. Rejection of any proposed amendment within the thirty (30) days period means that this Agreement remains in force without the proposed amendment.

8.1.1 Regulatory Amendments In the event that federal or state laws, rules or

regulations, or CMS’ or any other governmental agency’s or authority’s rules, regulations or positions should change such that the terms, benefits and conditions of this Agreement may be affected, HCA may modify this Agreement accordingly and, upon notice of such amendment by HCA, SUBCONTRACTOR agrees to continue to perform services in the same manner under this Agreement as modified.

Except as provided above, amendments to this Agreement shall be agreed to in advance, in writing, by HCA and SUBCONTRACTOR.

In the event that any updates or revisions to the most current HCPCS, CPT or ICD-9 should occur during the term of this Agreement, SUBCONTRACTOR agrees to employ the most recent update or revision without notice by HCA.

8.2 SOLICITATION OF MEMBERS The business relationship between HCA and its MEMBERS,

and HCA and AHCCCS with which it contracts, shall be deemed the property of HCA. Similarly, all lists of MEMBERS referred to SUBCONTRACTOR under the provisions of this Agreement shall be deemed the property of HCA. During the term of this Agreement or any renewal thereof, and for a period of one (1) year from the date of termination, SUBCONTRACTOR agrees not to interfere with the contract and/or property rights of HCA; advise or counsel any MEMBER to disenroll from HCA; solicit such MEMBER to become enrolled with any other competing program; or disclose proprietary HCA information.

8.3 CIRCUMSTANCES BEYOND THE CONTROL OF HCA \To the extent that a natural

disaster, war, riot, civil insurrection, strike, epidemic or any other emergency or similar event not within the control of HCA results in the personnel or financial resources of HCA being unavailable to provide or arrange for the provision of the services called for in this Agreement, HCA shall make a good faith effort to provide or arrange for the provision of these services. In such circumstances, HCA shall fulfill duties required under this Agreement insofar as practicable and according to its best judgment.

8.4 MEETING TO DISCUSS AMENDMENTS Representatives of HCA and SUBCONTRACTOR,

upon mutual agreement, may meet at any time to discuss changes or amendments to this Agreement.

8.5 GOVERNING LAW This Agreement shall be governed by and construed in accordance with

the laws of the State of Arizona.

8.6 NONWAIVER No covenant, condition or undertaking contained in this Agreement may be waived except by written agreement of the Parties. Forbearance or indulgence in any other form by either Party in regard to any covenant, condition or undertaking to be kept or performed by the other Party shall not constitute a waiver thereof, and until complete


satisfaction or performance of all such covenants, conditions and undertakings have been satisfied, the other Party shall be entitled to invoke any remedy available under this Agreement, despite any such forbearance or indulgence.

8.7 CONFIDENTIALITY HCA and SUBCONTRACTOR each acknowledge a duty to maintain the confidentiality of payment terms of this Agreement, except where disclosure is required by law.

8.8 HEADINGS The section headings used herein are for reference and convenience only, and

shall not enter into the interpretation hereof. Any attachments, exhibits, tables or schedules referred to herein and/or attached or to be attached hereto are incorporated herein to the same extent as if set forth in full herein.

8.9 APPROVALS Where agreement, approval, acceptance or consent by either Party is

required by any provision of this Agreement, such action shall not be unreasonably delayed or withheld.

8.10 REPRESENTATIONS HCA warrants that all representations made regarding this Agreement

are truthful and complete to the best of the knowledge of HCA. 8.11 NO GUARANTEE SUBCONTRACTOR acknowledges that HCA cannot and does not

guarantee the number of MEMBERS, volume of referrals generated on behalf of SUBCONTRACTOR or amount of revenue that will be generated to SUBCONTRACTOR under this Agreement.

8.12 NOTICE Any notice, request, demand or other communication required or permitted

hereunder will be given in writing by certified mail, communication charges prepaid, to the Party to be notified. All communications will be deemed given upon delivery or attempted delivery to the addresses specified herein, as from time to time amended. The addresses of the Parties for the purposes of such communication are:

HEALTH CHOICE ARIZONA: HEALTH CHOICE GENERATIONS: Health Choice Arizona Health Choice Generations 410 N. 44th St., Ste. 900 410 N. 44th St., Ste. 510 Phoenix, AZ 85008 Phoenix, AZ 85008

SUBCONTRACTOR: County of Yavapai dba Yavapai County Community Health Services

1090 Commerce Drive

Prescott, Arizona 86305-3700

Either Party may at any time change or amend its address for notification purposes, by mailing a notice as required hereinabove, stating the change and setting forth the new address. The new address shall be effective on the date specified in such notice, or if no date is specified, on the tenth (10th) day following the date such notice is received.

SECTION 9 - ARBITRATION OF DISPUTES 9.1 ARBITRATION In the event any dispute shall arise with regard to the performance or

interpretation of any of the terms of this Agreement, all matters in controversy shall be


submitted to a Board of Arbitrators consisting of three (3) members (one selected by SUBCONTRACTOR, one selected by HCA, and a third selected by the two previously selected arbitrators), under the rules and regulations of the American Arbitration Association. Both Parties expressly covenant and agree to be bound by the decision of the arbitrators and accept any determination of the matter in dispute. Both Parties agree to pay fifty percent (50%) of the cost of arbitration regardless of the outcome.

9.1.1 MEMBER AND CONTRACT DISPUTE RESOLUTION HCA agrees to arbitrate

all MEMBER and contract disputes in accordance with the policies and procedures of AHCCCS and HCA.

Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) Page 1 of 1 County of Yavapai dba Yavapai County Community Health Services

Insert ATTACHMENT A Here


ATTACHMENT B-1

HEALTH CHOICE ARIZONA PLAN SCOPE OF SERVICES AND REIMBURSEMENT

FEE-FOR-SERVICE AGREEMENT

SECTION 1 - SCOPE OF SERVICES 1.1 SUBCONTRACTOR shall provide authorized Primary Care COVERED SERVICES under the

Health Choice Arizona, Inc (HCA) contract with AHCCCS. These services shall be paid for by HCA, when provided or arranged for by SUBCONTRACTOR in accordance with the terms and conditions of this Agreement and when such services are within the normal scope of practice of SUBCONTRACTOR.

SECTION 2 - VACCINES FOR CHILDREN (VFC) PROGRAM

2.1 SUBCONTRACTOR agrees to participate in the Vaccine for Children (VFC) Program

implemented by AHCCCS wherein all vaccines are acquired through the Arizona Department of Health Services (ADHS). HCA shall reimburse an administration fee of Eleven dollars and fifty cents ($11.50) per immunization. Subcontractor is also required to report all immunizations provided to the Arizona State Immunization Information System (ASIIS). This system will allow SUBCONTRACTOR to view MEMBER immunization history as well as assist SUBCONTRACTOR in providing any catch-up immunizations that need to be administered.

SECTION 3 – FEE-FOR-SERVICE REIMBURSEMENT

3.1 For authorized Primary Care, and Dental Care COVERED SERVICES provided to Health Choice Arizona MEMBERS, SUBCONTRACTOR shall be reimbursed at One hundred percent (100%) of the SUBCONTRACTOR specific Arizona Medicaid Program Per Visit rate for FQHC Covered Services in effect on the date of service. 3.1.1 In the event that AHCCCS or any other governmental agency or authority implements

changes or reforms affecting Medicaid Program payments or any other state or federal governmental healthcare payments, it is agreed by both parties that HCA may adjust the rates or reimbursement payable under this Agreement by a proportional amount to account for such governmental adjustment, and SUBCONTRACTOR agrees to continue to perform services in the same manner under this Agreement as modified.

3.2 For FQHC COVERED SERVICES rendered by SUBCONTRACTOR to a MEMBER that are not payable under the FQHC COVERED SERVICES Table, the contract rates will be One hundred percent (100%) of the prevailing AHCCCS Fee Schedule rate, whether Primary Care or Specialty Care. For non-FQHC COVERED SERVICES rendered by SUBCONTRACTOR to a MEMBER, the contract rates will be One hundred percent (100%) of the prevailing AHCCCS Fee Schedule, whether Primary Care or Specialty Care. For COVERED SERVICES provided under this subsection, Physician extenders employed

and/or contracted by SUBCONTRACTOR, reimbursement shall be Eighty percent (80%) of the applicable physician fee schedule.


SECTION 4 - BILLING AND REPORTING REQUIREMENTS

4.1 SUBCONTRACTOR shall file, regardless of reimbursement method, claims data on a valid claim form OR via electronic method as approved by HCA and in accordance with Policies and the applicable provisions of this Agreement, within six (6) months from the date of service. SUBCONTRACTOR shall utilize the most current diagnostic and procedure coding guidelines, including International Classification of Diseases (ICD), American Medical Association Current Procedural Terminology (AMA CPT), Health Care Financing Administration Common Procedural Coding System (HCPCS), National Drug Code (NDC), Diagnostic Statistical Manual (DSM), Current Dental Terminology (CDT), Uniform Billing Data Elements (UB-92) Specification Manual, and State identified CPT/HCPCS codes as directed by HCA.

Failure to submit claims and if applicable, Encounter data within the prescribed time period may result in payment delay and/or denial. All SUBCONTRACTORS billing must follow recognized national billing practices.

HCA will evaluate all claims and payments for Covered Services in light of claim information on the condition treated and services or items provided and AMA CPT-4 guidelines, national bundling edits including the Correct Coding Initiative, modifier usage, global surgery rules, multiple procedure reductions, unit limitations, age/gender appropriateness and other reimbursement or utilization criteria, and reimburse or adjust reimbursement for Covered Services in accordance with the information and guidelines and criteria.

PROVIDER shall use its best efforts to submit claims and if applicable, Encounter data electronically. If claims and/or Encounter data are submitted electronically, they shall be submitted in compliance with HCA requirements, Applicable Law, including HIPAA regulations and Policies.

4.2 HCA adjudicates ninety-five percent (95%) of authorized clean claims that include all

necessary information for processing (i.e., a “clean claim”) within thirty (30) days of receipt. A clean claim is a claim that may be processed without obtaining additional information from the provider of service or from a third party; but does not include claims under investigation for fraud or abuse or claims under review for medical necessity.

4.3 At a minimum, all claims shall provide the following information and data:

4.3.1 Members’ Name, Sex, and Date of Birth; 4.3.2 Member’s AHCCCS I.D. Number 4.3.3 Diagnosis Code (ICD-9 Codes); 4.3.4 Procedure Code (Current HCPC Codes including CPT); 4.3.5 Date(s) of Service 4.3.6 HCA Prior Authorization Number (if applicable); 4.3.7 SUBCONTRACTOR’ Name, Address and Authorized Signature 4.3.8 Subcontractor AHCCCS ID Number, or National Provider Identification Number (NPI)

as required by CMS on the appropriate claim form 4.3.9 Explanatory Benefits (refer to Section 5 of this attachment for more details); 4.3.10 Rates and Charges (usual and customary billing charges); 4.3.11 Failure to submit any of the above information and data within the prescribed time

period may result in payment delay and/or denial; 4.3.12 Claims are to be mailed and addressed to the HCA office at the following address:

Health Choice Arizona 410 N. 44th St., Ste. 500 Phoenix, AZ 85008


4.4 HCA shall be required to pay interest on late payments. Late claim payments are those that

are paid after 45 days of receipt of the clean claim. In grievance situations, interest shall be paid back to the date interest would have started to accrue beyond the applicable 45 day requirement. Interest shall be at the rate of 10 percent per annum.

4.5 HCA shall not recoup monies from a provider later than twelve (12) months after the date of

original payment on a clean claim, without prior approval from AHCCCSA, unless the recoupment is a result of fraud, reinsurance audit findings, data validation or audits conducted by the AHCCCSA Office of Program Integrity.

4.6 HCA shall reimburse providers who previously had recouped dollars if the following situations

apply:

4.6.1 Provider was subsequently denied payment by the primary insurer based on timely filing limits; or

4.6.2 Lack of prior authorization with the primary insurer; and 4.6.3 The member failed to disclose additional insurance coverage other than AHCCCS.

SECTION 5 - COORDINATION OF BENEFITS 5.1 HCA is the payor of last resort and SUBCONTRACTOR shall identify and bill other third-party

carriers or insurers first.

5.2 If a Member has third-party coverage, including but not limited to Part A or Part B Medicare, SUBCONTRACTOR agrees to identify and seek such payment before submitting claims to HCA.

5.3 Claims involving third parties shall be filed in accordance with the following:

5.3.1 SUBCONTRACTOR shall include a complete copy of the other third-party carrier’s explanation of benefits (EOB) or remittance advice (RA) when submitting a claim for the balance due under coordination of benefits. Such claim(s) for any balance due must be received by HCA within thirty (30) days from the date of remit from the primary carrier or six (6) months from date of service, whichever is less.

5.3.2 For services covered by Medicare and AHCCCS, HCA shall not have any cost sharing obligation if the Medicare or Medicare Managed Care Plan payment rate exceeds the HCA contracted rated. If the Medicare or Medicare Managed Care Plan payment rate is less than HCA contracted rate, then HCA’s payment will be based upon the HCA fee schedule, less the Medicare or Medicare Managed Care Plan payment amount. Or, HCA payment is the applicable member co-insurance and deductible, which will constitute payment in full to SUBCONTRACTOR.

5.3.3 For HCA non-Medicare Members, the allowed amount will be based upon the HCA fee

schedule, less the allowed amount of the other third-party carrier(s); the balance of which will be paid by HCA as coordination of benefits.

5.3.4 In situations where SUBCONTRACTOR has not received notification from the primary

payor, SUBCONTRACTOR may submit the claim without the EOB/EOMB and it must be received by HCA within the prescribed initial submission deadline of six (6) months. HCA will deny the claim for failure to submit the EOB/EOMB thereby allowing the


SUBCONTRACTOR to resubmit the claim with the EOB/EOMB within twelve (12) months from the date of service.

SECTION 6 - CLAIMS RESUBMISSION

6.1 SUBCONTRACTOR may resubmit claims that have been denied or adjudicated by HCA but they must be received by HCA within twelve (12) months from the date of service.

6.2 HCA will re-adjudicate claims re-submitted by SUBCONTRACTOR only if initial claim had

been filed within the prescribed submission timeframe. 6.3. Claims re-submissions shall be designated as such and shall consist of the following:

1. Copy of claim 2. Mode of submission 3. Copy of HCA remit 4. Supporting documentation; and 5. Written explanation as to reasons for resubmission

6.4 Resubmitted claims are to be addressed and mailed to the HCA address listed in Section 4 of

this Attachment. SECTION 7- CLAIM DISPUTE

7.1 The Claim Dispute Process: HCA processes Claim Disputes in accordance with established

laws, rules, and procedures set forth by AHCCCS (ARS §36-2903.01, A.A.C. R9-34-401 et. seq.).

7.2 Right to File a Claim Dispute: SUBCONTRACTOR has the right to file a written Claim Dispute

in response to any adverse action or decision made by HCA. The AHCCCS grievance process described as Arizona Administrative Code R9-34-401 et. seq. is the manner through which SUBCONTRACTOR may challenge an adverse decision, action or policy of HCA. The parties agree to attempt to resolve all disputes informally prior to initiating a formal grievance; however, all timeliness and other requirements to initiate a written Claim Dispute shall apply. HCA encourages SUBCONTRACTOR to exhaust all other means of resolution before using the Claim Dispute process. Towards this end, SUBCONTRACTOR may contact HCA to resolve claims reimbursement issues informally.

7. 3 Filing a Claim Dispute: If SUBCONTRACTOR is unable to resolve a claim issue, he/she may

file a written Claim Dispute. To file a Claim Dispute, SUBCONTRACTOR must notify HCA in writing. Per AHCCCS rules [ARS 36-2903.01/R9-34-405], HCA will entertain any Claim Dispute within twelve months after the date of service, within twelve months after the date that eligibility is posted or within sixty days after the date of the denial of a timely claim submission, whichever is later. HCA shall deny Claim Disputes received outside of these timeframes. A timely claim submission is defined as claims for system covered services that are initially submitted within six months of the date of the service for which payment is claimed or after the date that eligibility is posted, whichever date is later, or that are submitted as clean within twelve months of the date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later.

7.4 SUBCONTRACTOR must include a cover letter with the requester’s name, address and

telephone number. The cover letter must include the factual or legal basis for filing the Claim


Dispute and the relief requested, to include specifically why SUBCONTRACTOR disagrees with the action initiated by HCA. A copy of the claim and all supporting documentation to support the billed charges in question must be included if it is a billing issue. HCA shall deny a Claim Dispute if the factual or legal basis is not detailed. SUBCONTRACTOR agrees to submit all written Claim Disputes to the Compliance Department at the address listed below:

Health Choice Arizona Attention: Compliance Department 410 N. 44th St., Ste. 900 Phoenix, Arizona 85008

7.5 HCA agrees that once SUBCONTRACTOR has submitted a written Claim Dispute to HCA, HCA will send an acknowledgment letter by regular mail. HCA further agrees to respond to all Claim Dispute requests by SUBCONTRACTOR within thirty (30) days from the date that HCA received the written Claim Dispute. HCA agrees to mail a final written decision via Certified Mail. If an extension is necessary, HCA will forward notification.

7.6 SUBCONTRACTOR may file a request for State Fair Hearing if SUBCONTRACTOR is not satisfied with HCA’s decision. State Fair Hearing Requests must be received by HCA no later than thirty (30) calendar days from the date the SUBCONTRACTOR receives HCA’s Claim Dispute decision. The State Fair Hearing request only needs to state that the requester does not agree with the decision of HCA. HCA will forward a copy of SUBCONTRACTOR’s request the AHCCCS Office Legal Assistance within five (5) working days. AHCCCS may either issue an informal decision or schedule a hearing.


ATTACHMENT B-2

HEALTH CHOICE GENERATIONS PLAN SCOPE OF SERVICES AND REIMBURSEMENT

FEE-FOR-SERVICE AGREEMENT

SECTION 1 - SCOPE OF SERVICES 1.1 SUBCONTRACTOR shall provide authorized COVERED SERVICES under the Health Choice

Arizona, Inc (HCA) contract with CMS dba Health Choice Generations (HC Generations). These services shall be paid for by HC Generations, when provided or arranged for by SUBCONTRACTOR in accordance with the terms and conditions of this Agreement and when such services are within the normal scope of practice of SUBCONTRACTOR.

SECTION 2 - FEE-FOR-SERVICE REIMBURSEMENT

2.1 For COVERED SERVICES provided to HC Generations BENEFICIARIES, SUBCONTRACTOR shall be reimbursed less any applicable Co-payments, Deductibles, and Coinsurance, at One Hundred percent (100%) of the prevailing Participating Medicare Fee Schedule or billed charges, whichever is less. For Physician extenders employed and/or contracted by SUBCONTRACTOR, reimbursement shall be eighty percent (80%) of this fee schedule or in accordance to Medicare payment regulations and Correct Coding Initiative Rules. 2.1.1 In the event that CMS or any other governmental agency or authority implements

changes or reforms affecting Medicare Program payments or any other state or federal governmental healthcare payments, it is agreed by both parties that HCA may adjust the rates or reimbursement payable under this Agreement by a proportional amount to account for such governmental adjustment, and SUBCONTRACTOR agrees to continue to perform services in the same manner under this Agreement as modified.

2.2 For authorized Specialty Care COVERED SERVICES provided to Health Choice Generations

BENEFICIARIES, SUBCONTRACTOR shall be reimbursed less any applicable Co-payments, Deductibles, and Coinsurance, at ___________ percent (%) of the prevailing Medicare Fee Schedule. For Physician extenders employed and/or contracted by SUBCONTRACTOR, reimbursement shall be eighty percent (80%) of the Specialist fee schedule.

2.3 Certain services are excluded from the PLAN’s fee schedule and paid at the PLAN’s defined

reimbursement rate for that service, less Co-payments, Deductibles, and Coinsurance. Examples of these services include but are not limited to: immunizations, obstetrical pre/post/delivery services and certain HCPCS and injectable drugs codes as determined by PLAN. In the event CMS or any other applicable government authority implements sequestration relative to Medicare Program payments or any other governmental healthcare payments, it is agreed by both parties that the rates payable under this Agreement shall be adjusted by an amount proportionally equal to such governmental adjustment.

SECTION 3 - BILLING AND REPORTING REQUIREMENTS

3.1 SUBCONTRACTOR shall file, regardless of reimbursement method, claims data on a valid claim form OR via electronic method as approved by HCA and in accordance with Policies and the applicable provisions of this Agreement, within six (6) months from the date of service.


SUBCONTRACTOR shall utilize the most current diagnostic and procedure coding guidelines, including International Classification of Diseases (ICD), American Medical Association Current Procedural Terminology (AMA CPT), Health Care Financing Administration Common Procedural Coding System (HCPCS), National Drug Code (NDC), Diagnostic Statistical Manual (DSM), Current Dental Terminology (CDT), Uniform Billing Data Elements (UB-92) Specification Manual, and State identified CPT/HCPCS codes as directed by HC Generations.

Failure to submit claims and if applicable, Encounter data within the prescribed time period may result in payment delay and/or denial. All SUBCONTRACTORS billing must follow recognized national billing practices.

HC Generations will evaluate all claims and payments for Covered Services in light of claim information on the condition treated and services or items provided and AMA CPT-4 guidelines, national bundling edits including the Correct Coding Initiative, modifier usage, global surgery rules, multiple procedure reductions, unit limitations, age/gender appropriateness and other reimbursement or utilization criteria, and reimburse or adjust reimbursement for Covered Services in accordance with the information and guidelines and criteria.

PROVIDER shall use its best efforts to submit claims and if applicable, Encounter data electronically. If claims and/or Encounter data are submitted electronically, they shall be submitted in compliance with HC Generations requirements, Applicable Law, including HIPAA regulations and Policies.

3.2 At a minimum, all claims shall provide the following information and data:

3.2.1 Members’ Name, Sex, and Date of Birth; 3.2.2 Member’s Health Choice Generation I.D. Number 3.2.3 Diagnosis Code (ICD-9 Codes); 3.2.4 Procedure Code (Current HCPC Codes including CPT); 3.2.5 Date(s) of Service 3.2.6 HC Generations Prior Authorization Number (if applicable); 3.2.7 SUBCONTRACTOR’ Name, Address and Authorized Signature 3.2.8 Subcontractor’s Medicare UPIN number, or National Provider Identification Number

(NPI) as required by CMS on the appropriate claim form. 3.2.9 Explanatory Benefits; 3.2.10 Rates and Charges (usual and customary billing charges); 3.2.11 Failure to submit any of the above information and data within the prescribed time

period may result in payment delay and/or denial; 3.2.12 Claims are to be mailed and addressed to the HC Generations office at the following

address: Health Choice Generations 410 N. 44th St., Ste. 510 Phoenix, AZ 85008

3.3 HC Generations shall pay interest according to the Prompt Payment Act (42 CFR §422.520

(b)) on clean claims that are not paid within forty five (45) days of the claims receipt date by HC Generations. Interest shall be the “Prompt Payment Interest Rate” as of the date the claim is processed.

3.3.1 If SUBCONTRACTOR fails to repay overpayments on claims paid incorrectly by HC

Generations within 60 days of original payment, HC Generations may apply interest to the overpayment amount at the rate, as determined according to the Federal Prompt


Payment Act rate amount. Interest will be charged on the unpaid balance of the overpayment, beginning on the 31st day. Interest is calculated in 30 day periods and is assessed for each full 30-day period that the payment is not made. If payment is received 31 days from the date of a HC Generations notice, one 30-day period of interest will be charged. Each payment will be applied first to accrued interest and the remaining amount of the overpayment balance.

3.4 HC Generations shall not recoup monies from a provider later than eighteen (18) months after

the date of original payment on a clean claim, unless the recoupment is a result of fraud, audit findings, risk adjustment or audits conducted by CMS.

3.5 HC Generations shall maintain adequate records and procedures to record dates of

receipt, processing, and payment of claims from contracted, subcontracted, non-contracted or other health care providers for Covered Services provided to HC Generations Members. HC Generations shall process and pay or deny all claims submitted by non-contracted providers for covered services rendered to an HC Generations Member within the time limits specified by CMS, the state and Applicable Law. HC Generations is obligated to comply with the requirements of Prompt Payment Act (42 CFR §422.520 (b)) in respect to prompt payment of claims.

SECTION 4 - COORDINATION OF BENEFITS 4.1 Health Choice Generations is the primary payer for HC Generations Members and their

Covered Services. 4.2 Coordination of Benefits. SUBCONTRACTOR shall cooperate with and support coordination of

benefits activities by HC Generations. 4.2.1 HC Generations is Primary. If an HC Generations Member possesses health benefits

coverage through another policy which is secondary to the Health Choice Generations Member’s Plan under applicable coordination of benefits rules, including the Medicare secondary payer program, SUBCONTRACTOR shall accept payment from HC Generations for Covered Services as provided herein as full payment for such Services, except for applicable Co-payments, Coinsurance, or Deductibles. Other than for Co-payments, Coinsurance, or Deductibles under the applicable HC Generations Benefit Plan, Health Choice Generations Members shall have no obligation for any fees, regardless of whether secondary insurance is available. Nothing in this section is meant to prevent SUBCONTRACTOR from receiving payment from any secondary payer.

4.3 Claims involving third parties shall be filed in accordance with the following: 4.3.1 HC Generations is Secondary. If a Health Choice Generations Member possesses

health benefits coverage through another policy which is primary to HC Generations, for example a Group Health Plan and Retiree Coverage or if a Health Choice Generations Member is entitled to payment under a worker’s compensation policy or automobile insurance policy, SUBCONTRACTOR must pursue payment from the primary payer consistent with the applicable State and Federal Law. In such event, Health Choice Generations’ payment responsibility shall be the difference between the primary payer’s allowed reimbursement and the HC Generations allowed reimbursement.


4.3.2 SUBCONTRACTOR shall include a complete copy of the other third- party carrier’s explanation of benefits (EOB) or remittance advice (RA) when submitting a claim for the balance due under coordination of benefits. Such claim(s) for any balance due must be received by HC Generations within thirty (30) days from the date of remit from the primary carrier or six (6) months from date of service, whichever is less.

4.3.3 For HC Generations Members, payment will be based upon the prevailing Participating

Medicare fee schedule or billed charges, whichever is less; less the beneficiary co-insurance, co-payment, and applicable deductible. This will constitute payment in full to SUBCONTRACTOR.

4.3.4 In situations where SUBCONTRACTOR has not received notification from the primary

payer, SUBCONTRACTOR may submit the claim without the EOB/EOMB and it must be received by HC Generations within the prescribed initial submission deadline of six (6) months. HC Generations will deny the claim for failure to submit the EOB/EOMB thereby allowing the SUBCONTRACTOR to resubmit the claim with the EOB/EOMB within eighteen (18) months from the date of service.

SECTION 5 - CLAIMS RESUBMISSION

5.1 SUBCONTRACTOR may resubmit claims that have been previously adjudicated by HC Generations and must be received by HC Generations within eighteen (18) months from the date of service.

5.2 HC Generations will re-adjudicate claims re-submitted by SUBCONTRACTOR only if initial

claim had been filed within the prescribed submission timeframe. 5.3 Claims re-submissions shall be designated as such and shall consist of the following:

1. Copy of claim 2. Mode of Submission 3. Copy of HC Generations remittance advice

4. Supporting documentation; and 5. Written explanation as to reasons for resubmission 5.4 Resubmitted claims are to be addressed and mailed to:

Health Choice Generations Attention: Adjustments 410 N. 44th St., Ste. 510

Phoenix, Arizona 85008

SECTION 6 - HC GENERATIONS CLAIMS RECONSIDERATION 6.1 SUBCONTRACTOR requests for claims reconsideration must be received by HC Generations

within eighteen (18 months) from the date of service or from the date of discharge for an in-patient hospital stay. SUBCONTRACTOR must complete a claims reconsideration form and submit to Health Choice Generations Compliance Department. Included with this form should be a written explanation of the reason for the reconsideration, including a copy of the explanation of payment, documentation if appealing coding, or modifier use and medical records if needed.

The HC Generations Compliance staff shall provide an acknowledgment letter to the provider. HC Generations will make a determination within sixty (60) calendar days following receipt of


the completed claims reconsideration form. All decisions rendered by HC Generations are final.

All HC Generations claims for reconsideration must be mailed to the address below:

Health Choice Generations Attention: Compliance Department 410 N. 44

th St., Ste. 510

Phoenix, Arizona 85008


ATTACHMENT C

AHCCCS SUBCONTRACT PROVISIONS

The following represents the current version of the AHCCCS Subcontract Provisions. This provision is required by AHCCCS and cannot be altered by either SUBCONTRACTOR or HCA.

1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES No payment due the Subcontractor under this subcontract may be assigned without the prior approval of the Contractor. No assignment or delegation of the duties of this subcontract shall be valid unless prior written approval is received from the Contractor. (A.A.C. R2-7-305) 2. AWARDS OF OTHER SUBCONTRACTS AHCCCS and/or the Contractor may undertake or award other contracts for additional or related work to the work performed by the Subcontractor and the Subcontractor shall fully cooperate with such other contractors, subcontractors or state employees. The Subcontractor shall not commit or permit any act which will interfere with the performance of work by any other contractor, subcontractor or state employee. (A.A.C. R2-7-308) 3. CERTIFICATION OF COMPLIANCE – ANTI-KICKBACK AND LABORATORY TESTING By signing this subcontract, the Subcontractor certifies that it has not engaged in any violation of the Medicare Anti-Kickback statute (42 USC §§1320a-7b) or the “Stark I” and “Stark II” laws governing related-entity referrals (PL 101-239 and PL 101-432) and compensation there from. If the Subcontractor provides laboratory testing, it certifies that it has complied with 42 CFR §411.361 and has sent to AHCCCS simultaneous copies of the information required by that rule to be sent to the Centers for Medicare and Medicaid Services. (42 USC §§1320a-7b; PL 101-239 and PL 101-432; 42 CFR §411.361) 4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION By signing this subcontract, the Subcontractor certifies that all representations set forth herein are true to the best of its knowledge. 5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires laboratories and other facilities that test human specimens to obtain either a CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the requirements of 42 CFR 493, Subpart A. To comply with these requirements, AHCCCS requires all clinical laboratories to provide verification of CLIA Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in either a termination of an active provider ID number or denial of initial registration. These requirements apply to all clinical laboratories. Pass-through billing or other similar activities with the intent of avoiding the above requirements are prohibited. The Contractor may not reimburse providers who do not comply with the above requirements. (CLIA of 1988; 42 CFR 493, Subpart A)


6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide relating to the audit of the Subcontractor's records and the inspection of the Subcontractor's facilities. If the Subcontractor is an inpatient facility, the Subcontractor shall file uniform reports and Title XVIII and Title XIX cost reports with AHCCCS. A.R.S. 41-2548; 45 CFR 74.48 (d) 7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS The Subcontractor shall comply with all federal, State and local laws, rules, regulations, standards and executive orders governing performance of duties under this subcontract, without limitation to those designated within this subcontract. [42 CFR 434.70] [42 CFR 438.6(l)] 8. CONFIDENTIALITY REQUIREMENT The Subcontractor shall safeguard confidential information in accordance with Federal and State laws and regulations, including but not limited to, 42 CFR Part 431, Subpart F, A.R.S. §§36-107, 36-2903 (for Acute), 362932 (for ALTCS), 41-1959 and 46-135, the Health Insurance Portability and Accountability Act (Public Law 107-191 Statutes 1936), 45 CFR Parts 160 and 164, and AHCCCS Rules. 9. CONFLICT IN INTERPRETATION OF PROVISIONS In the event of any conflict in interpretation between provisions of this subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take precedence. 10. CONTRACT CLAIMS AND DISPUTES Contract claims and disputes arising under A.R.S. Title 36, Chapter 29 shall be adjudicated in accordance with AHCCCS Rules, A.R.S. §36-2901 et seq. (for Acute) and A.R.S. §36-2931 et seq. (for ALTCS). 11. ENCOUNTER DATA REQUIREMENT If the Subcontractor does not bill the Contractor (e.g., Subcontractor is capitated), the Subcontractor shall submit encounter data to the Contractor in a form acceptable to AHCCCS. 12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES AHCCCS or the U.S. Department of Health and Human Services may evaluate, through inspection or other means, the quality, appropriateness or timeliness of services performed under this subcontract. 13. FRAUD AND ABUSE If the Subcontractor discovers, or is made aware, that an incident of suspected fraud or abuse has occurred, the Subcontractor shall report the incident to the prime Contractor as well as to AHCCCS, Office of the Inspector General (OIG). All incidents of potential fraud should be reported to the OIG. 14. GENERAL INDEMNIFICATION The parties to this contract agree that AHCCCS shall be indemnified and held harmless by the Contractor and Subcontractor for the vicarious liability of AHCCCS as a result of entering into this


contract. However, the parties further agree that AHCCCS shall be responsible for its own negligence. Each party to this contract is responsible for its own negligence. 15. INSURANCE [This provision applies only if the Subcontractor provides services directly to AHCCCS members] The Subcontractor shall maintain for the duration of this subcontract a policy or policies of professional liability insurance, comprehensive general liability insurance and automobile liability insurance in amounts that meet Contractor’s requirements. The Subcontractor agrees that any insurance protection required by this subcontract, or otherwise obtained by the Subcontractor, shall not limit the responsibility of Subcontractor to indemnify, keep and save harmless and defend the State and AHCCCS, their agents, officers and employees as provided herein. Furthermore, the Subcontractor shall be fully responsible for all tax obligations, Worker's Compensation Insurance, and all other applicable insurance coverage, for itself and its employees, and AHCCCS shall have no responsibility or liability for any such taxes or insurance coverage. (45 CFR Part 74) The requirement for Worker’s Compensation Insurance doesn’t apply when a Subcontractor is exempt under A.R.S. 23-901, and when such Subcontractor executes the appropriate waiver (Sole Proprietor/Independent Contractor) form. 16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES Except as provided in federal and state law and regulations, the Subcontractor shall not bill, or attempt to collect payment from a person who was AHCCCS eligible at the time the covered service(s) were rendered, or from the financially responsible relative or representative for covered services that were paid or could have been paid by the System. 17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES The Subcontractor shall be registered with AHCCCS and shall obtain and maintain all licenses, permits and authority necessary to do business and render service under this subcontract and, where applicable, shall comply with all laws regarding safety, unemployment insurance, disability insurance and worker's compensation. 18. NON-DISCRIMINATION REQUIREMENTS The Subcontractor shall comply with State Executive Order No. 99-4, which mandates that all persons, regardless of race, color, religion, gender, national origin or political affiliation, shall have equal access to employment opportunities, and all other applicable Federal and state laws, rules and regulations, including the Americans with Disabilities Act and Title VI. The Subcontractor shall take positive action to ensure that applicants for employment, employees, and persons to whom it provides service are not discriminated against due to race, creed, color, religion, sex, national origin or disability. (Federal regulations, State Executive order # 99-4) 19. PRIOR AUTHORIZATION AND UTILIZATION MANAGEMENT The Contractor and Subcontractor shall develop, maintain and use a system for Prior Authorization and Utilization Review that is consistent with AHCCCS Rules and the Contractor’s policies. 20. RECORDS RETENTION

The Subcontractor shall maintain books and records relating to covered services and expenditures including reports to AHCCCS and working papers used in the preparation of reports to AHCCCS. The


Subcontractor shall comply with all specifications for record keeping established by AHCCCS. All books and records shall be maintained to the extent and in such detail as required by AHCCCS Rules and policies. Records shall include but not be limited to financial statements, records relating to the quality of care, medical records, prescription files and other records specified by AHCCCS. The Subcontractor agrees to make available at its office at all reasonable times during the term of this contract and the period set forth in the following paragraphs, any of its records for inspection, audit or reproduction by any authorized representative of AHCCCS, State or Federal government. The Subcontractor shall preserve and make available all records for a period of five years from the date of final payment under this contract unless a longer period of time is required by law. If this contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for a period of five years from the date of any such termination. Records which relate to grievances, disputes, litigation or the settlement of claims arising out of the performance of this contract, or costs and expenses of this contract to which exception has been taken by AHCCCS, shall be retained by the Subcontractor for a period of five years after the date of final disposition or resolution thereof unless a longer period of time is required by law. (45 CFR 74.53; 42 CFR 431.17; A.R.S. 41-2548) 21. SEVERABILITY If any provision of these standard subcontract terms and conditions is held invalid or unenforceable, the remaining provisions shall continue valid and enforceable to the full extent permitted by law. 22. SUBJECTION OF SUBCONTRACT The terms of this subcontract shall be subject to the applicable material terms and conditions of the contract existing between the Contractor and AHCCCS for the provision of covered services. 23. TERMINATION OF SUBCONTRACT AHCCCS may, by written notice to the Subcontractor, terminate this subcontract if it is found, after notice and hearing by the State, that gratuities in the form of entertainment, gifts, or otherwise were offered or given by the Subcontractor, or any agent or representative of the Subcontractor, to any officer or employee of the State with a view towards securing a contract or securing favorable treatment with respect to the awarding, amending or the making of any determinations with respect to the performance of the Subcontractor; provided, that the existence of the facts upon which the state makes such findings shall be in issue and may be reviewed in any competent court. If the subcontract is terminated under this section, unless the Contractor is a governmental agency, instrumentality or subdivision thereof, AHCCCS shall be entitled to a penalty, in addition to any other damages to which it may be entitled by law, and to exemplary damages in the amount of three times the cost incurred by the Subcontractor in providing any such gratuities to any such officer or employee. [A.A.C. R2-5-501; A.R.S. 412616 C.; 42 CFR 434.6, a. (6)] 24. VOIDABILITY OF SUBCONTRACT This subcontract is voidable and subject to immediate termination by AHCCCS upon the Subcontractor becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States Code, or upon assignment or delegation of the subcontract without AHCCCS’ prior written approval.


25. WARRANTY OF SERVICES The Subcontractor, by execution of this subcontract, warrants that it has the ability, authority, skill, expertise and capacity to perform the services specified in this contract. 26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED Due to security and identity protection concerns, direct services under this contract shall be performed within the borders of the United States. Any services that are described in the specifications or scope of work that directly serve the State of Arizona or its clients and may involve access to secure or sensitive data or personal client data or development or modification of software for the State shall be performed within the borders of the United States. Unless specifically stated otherwise in specifications, this definition does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the performance of the contract. This provision applies to work performed by subcontractors at all tiers. 27. FEDERAL IMMIGRATION AND NATIONALITY ACT The Subcontractor shall comply with all federal, state and local immigration laws and regulations relating to the immigration status of their employees during the term of the contract. Further, the Subcontractor shall flow down this requirement to all subcontractors utilized during the term of the contract. The State shall retain the right to perform random audits of Contractor and subcontractor records or to inspect papers of any employee thereof to ensure compliance. Should the State determine that the Contractor and/or any subcontractors be found noncompliant, the State may pursue all remedies allowed by law, including, but not limited to; suspension of work, termination of the contract for default and suspension and/or debarment of the Contractor. Compliance with the Federal Immigration and Nationality Act (FINA) and All Other Federal Immigration Laws and Regulations related to Immigration Status of its Employees: By entering into the Contract, the subcontractor warrants compliance with the Federal Immigration and Nationality Act (FINA) and all other Federal immigration laws and regulations related to the immigration status of its employees. The subcontractor shall obtain statements from any of its subcontractors certifying compliance and shall furnish the statements to the Procurement Officer, upon request. These warranties shall remain in effect through the term of the Contract. The subcontractor and its subcontractors shall also maintain Employment Eligibility Verification forms (I-9) as required by the U.S. Department of Labor’s Immigration and Control Act, for all employees performing work under the Contract. I-9 forms are available for download at USACIS.GOV. The State may request verification of compliance for any subcontractor or its subcontractor performing work under the Contract. Should the Contractor suspect or find that the subcontractor or any of its subcontractors are not in compliance, the Contractor may pursue any and all remedies allowed by law, including, but not limited to: suspension of work, termination of the Contract for default, and suspension and/or debarment of the subcontractor. All costs necessary to verify compliance are the responsibility of the subcontractor. Compliance Requirements for A.R.S. 41-4401, Government Procurement: E-Verify Requirement: The subcontractor warrants compliance with all Federal immigration laws and regulations relating to employees and warrants its compliance with Section A.R.S. 23-214, Subsection A. (That subsection reads: “After December 31, 2007, every employer, after hiring an employee, shall verify the employment eligibility of the employee through the E-Verify program.”)


A breach of a warranty regarding compliance with immigration laws and regulations shall be deemed a material breach of the contract and the subcontractor may be subject to penalties up to and including termination of the contract. Failure to comply with a State or Contractor audit process to randomly verify the employment records of subcontractors and any of its subcontractors shall be deemed a material breach of the contract and the subcontractor may be subject to penalties up to and including termination of the contract. The State Agency and Contractor retains the legal right to inspect the papers of any employee who works on the contract to ensure that the contractor or subcontractor is complying with the warranty.


ATTACHMENT D HEALTH CHOICE GENERATIONS PLAN

This Attachment modifies the HEALTH CHOICE ARIZONA, Inc., AGREEMENT to include services under the Health Choice Generations Plan (PLAN). Health Choice Generations is a Medicare Advantage Special Needs Plan (SNP) which covers dual eligible members under Medicare and Medicaid; which HCA is directly contracted with the Centers for Medicare and Medicaid Services (CMS) to provide, arrange for or administer the provision of health care services to Medicare beneficiaries; and WHEREAS, the Contractor and Subcontractor desire to amend the Agreement to allow Subcontractor to provide covered health care services to Medicare beneficiaries enrolled with the PLAN and permit the PLAN to join the Agreement as a party; SECTION 1 DEFINITIONS The following terms shall be added to the Agreement: “Clean Claim” shall also mean, in addition to the definition set forth in Section 1 (1.34), a claim that has no material defect or impropriety including accurately containing all the data elements required by Federal Medicare provider manuals and/or program transmittals and any other data element(s) required by PLAN as specified in PLAN’s Provider Manual, unless otherwise defined by Federal law (including any lack of any reasonably required substantiating documentation) which substantially prevents timely payment from being made on the claim. “CMS” means the Centers for Medicare and Medicaid, a division of the United States Department of Health and Human Services, responsible for administering the Medicare Program.

“CMS Agreement” is the Medicare Advantage contract between CMS and PLAN.

“Coinsurance” means a payment that a Health Choice Generations Member is required to make to Subcontractor for Covered Services under a Medicare Benefit Contract, which is calculated as a percentage of the contracted reimbursement rate for such services.

“Contracted Providers” shall also mean in addition to the definition set forth in Section 1 (1.112, 1.132.1), with respect to Health Choice Generations Members those providers who have entered into an Agreement with PLAN for the purpose of providing Covered Services to PLAN’s Medicare Members with respect to the particular Program under which the Medicare Member is participating. “Covered Services” shall also mean, in addition to the definition set forth in Section 1 (1.46) with respect to Health Choice Generations Members those medically necessary health care services, supplies and benefits, which are required by a Medicare Health PLAN member in accordance with the CMS Agreement and as outlined in the Health Choice Generations Health PLAN Exhibit.

“Co-payment” or “Deductible” shall also mean, in addition to the definition set forth in Section 1 (1.44), with respect to Health Choice Generations Member a dollar amount which a Medicare Member is responsible to pay Subcontractor under a Service Agreement, which is calculated as a fixed dollar payment. “Cost-sharing” includes deductibles, coinsurance, and co-payments. “Coverage Description” Coverage Description means the document issued to a Health Choice Generations Member that describes the Member’s Covered Services under a Medicare Benefit Contract, which term may include the Evidence of Coverage, Certificate of Insurance, Schedule of Benefits or Summary Plan Description, as applicable to the Member's specific Benefit Contract.


“Government Agencies” are the Department of Health and Human Services (DHHS), the General Accounting Office (GAO), the Office of Inspector General (OIG) and their designees. “Health Choice Generations Member” means a person who is a Medicare beneficiary entitled to receive coverage for certain health care services under the terms of the PLAN’s Medicare Benefit Contract and who has elected to enroll in PLAN and whose enrollment with PLAN been confirmed by CMS. “Health Practitioner” means a person who holds a current, unrestricted license to practice as a Physician’s Assistant, Certified Nurse Practitioner, Certified Nurse Midwife, or Dental Hygienist under applicable federal and state laws and regulations. “Medicare” is the Hospital Insurance Plan (Part A) and the Supplementary Medicare Insurance Plan (Part B) provided under the Title XVIII of the Social Security Act, as amended. “Medicare Advantage (MA)” means health benefits coverage offered under a policy or contract by Health Choice Generations referred to as PLAN that includes a specific set of health benefits offered Health Choice Generations Members residing in the service area of the PLAN. “Medicare Advantage Plan Enrollee” is an eligible individual who has elected an MA plan offered by Health Choice Generations. “Medicare Benefit Program” means a Health Benefit Program which is designed to provide services to Medicare beneficiaries under a contract with CMS, authorized by the Balanced Budget Act of 1997 and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 including a Medicare Advantage program under which PLAN is the Payer for Covered Services provided to Health Choice Generations Members. “Non-Covered Services” shall mean, in addition to the definition set forth in Section 1(1.23) with respect to Non-Covered Services involving Health Choice Generations Members those health care services, which are not Covered Services under a Health Choice Generations or Original Medicare Member’s Benefit Contract. “Provider” means any individual who is engaged in the delivery of health care services in a State and is licensed or certified by the State to engage in that activity in the State; and any entity that is engaged in the delivery of health care services in a State and is licensed or certified to deliver those services if such licensing or certification is required by State law or regulation. “Provider Network” means providers with which Health Choice Generations contracts or makes arrangements to furnish covered health care services to Health Choice Generations Members. “Special Needs Individual” means an MA eligible individual who is entitled to medical assistance under a State Medicaid Plan (AHCCCS) under title XIX, or has a severe or disabling chronic condition(s) and would benefit from enrollment in a specialized MA plan. “Special Needs Plan” means a MA coordinated care plan that exclusively enrolls special needs individuals, beginning January 1, 2006, provides Part D benefits to all enrollees; and which has been designated by CMS as meeting the requirements of a Medicare Advantage Special Needs Plan. “Subscriber Agreement” An individual contract between a Health Choice Generations Member and PLAN or other entity and PLAN under which a Medicare Member is entitled to receive Covered Services under the terms of Plan’s Medicare Benefit Program as described in the Medicare Benefit


Program Evidence of Coverage. SECTION 2 TERM OF AGREEMENT, RENEWAL AND TERMINATION 2.1 Termination of CMS Agreement. In the event that CMS Agreement is not executed, or is

terminated or not renewed, the provisions of the Agreement relating to the Health Generations Members shall automatically terminate, unless otherwise specified by the “PLAN.”

2.2 Medicare Advantage Termination. The termination provisions contained in the Agreement

shall permit PLAN to terminate the Subcontractor with respect to Health Choice Generations Members in accordance with the terms contained in the applicable provision. In the event Subcontractor or PLAN terminates the Agreement with respect to Health Choice Generations Members, the Agreement shall not terminate with respect to non-Health Choice Generations Members. Termination of any provisions contained in the Health Choice Generations Exhibit shall not have the effect of terminating the entire Agreement and all remaining Sections, of the Agreement will remain in full force.

2.3 Continuation of Services after Termination. SUBCONTRACTOR agrees that if

SUBCONTRACTOR or HCG terminates this Agreement, all COVERED SERVICES, as enumerated in Attachment B-2 herein, shall continue to be provided for those MEMBERS hospitalized and/or institutionalized on or before the date of termination, and SUBCONTRACTOR shall be reimbursed in accordance with Attachment B-2 herein, until the discharge of MEMBER or through the disenrollment date of the member. [42 CFR §422.504(g)(2)(i); 422.504(g)(2)(ii); 422.504(g)(3)]

2.4 Termination Without Cause. This Agreement may be terminated at any time by either party

without cause upon ninety (90) days prior written notice to the other party, in accordance with Section 7.1.

2.5 Termination and Default. This Agreement may be terminated in accordance with Section 6

(6.1 through 6.4) of the Health Choice Arizona, Inc. Subcontractor Agreement. SECTION 3 MEDICARE ADVANTAGE REQUIREMENTS Subcontractor agrees to comply with the Requirements set forth in the Health Choice Generations Exhibit for Health Choice Generations Members. The requirements contained here within apply to Health Choice Generations Members and not to AHCCCS Members, unless such AHCCCS Member is also a Health Choice Generations Member. 3.1 Inspection and Audit of Records and Facilities. Subcontractor acknowledges that the

performance of the Subcontractor is monitored by the PLAN and shall provide access at reasonable times upon demand by the PLAN and Government Agencies to periodically audit or inspect the facilities, offices, equipment, books, documents and records of Subcontractor in regards to the performance of the Agreement and the Medicare Covered Services provided to Health Choice Generations Members, including without limitation, all phases of professional and ancillary medical care provided or arranged for Health Choice Generations Members by Subcontractor, Health Choice Generations Member medical records and financial records pertaining to the cost of operations and income received by Subcontractor for Medicare Covered Services rendered to Health Choice Generations Members. Such access shall be limited to that necessary to perform the audit. Subcontractor shall comply with any requirements or directives issued by the PLAN and Government Agencies as a result of such evaluation, inspection or audit of Subcontractor. Subcontractor shall retain the books and records described in this Section for at least ten (10) years and acknowledge that Government


Agencies may have the right to inspect and audit Subcontractor’s books and records for ten (10) years beyond termination of the Agreement or until the conclusion of any governmental audit that may be initiated that pertains to such records, whichever is latest unless: (i) the CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies the PLAN or Subcontractor at least thirty (30) days before the normal disposition date; (ii) there has been a termination, dispute, or fraud or similar fault by Subcontractor, in which case the retention may be extended to ten (10) years from the date of any resulting final resolution of the termination, dispute, or fraud or similar fault; or (iii) the CMS determines that there is a reasonable possibility of fraud, in which case it may inspect, evaluate, and audit Subcontractor at any time. Without limiting the foregoing, following the commencement of any audit by a Government Agency, Subcontractor shall retain its relevant books and records until completion of said audit. The provisions of this Section shall survive termination of the Agreement for the period of time required by State and Federal Law. [42 CFR §422.504(e)(2); 422.504(e)(3); 422.504(i)(2)(ii); 422.504(e)(4)] ; 422.504(i)(4)(iii)

3.1.1 Requests for Medical Records by Other HCA Subcontractors SUBCONTRACTOR

agree that medical records or copies of medical records of any MEMBER requested by other subcontractors of Health Choice Arizona, Inc (HCA) shall be forwarded to the requesting subcontractor within five (5) working days of a request thereof. Failure of SUBCONTRACTOR to provide Health Choice Arizona, Inc (HCA) dba Health Choice Generations (HC Generations) with medical records which results in a sanction to (HCA) by CMS, shall result in such sanction being deducted in full from future payments to SUBCONTRACTOR. HCA will issue a written notification to SUBCONTRACTOR seven (7) days prior to the sanction being imposed.

3.2 Compliance. Subcontractor agrees to comply with PLAN’s policies and procedures and all applicable Federal, CMS, State and local laws, rules and regulations, now or hereafter in effect, including but not limited to 42 CFR §422 regarding the performance of Subcontractor’s obligations hereunder, including without limitation, laws or regulations governing the record timeliness, adequacy and accuracy, Health Choice Generations Member and Beneficiary privacy and confidentiality along with the appeal and dispute resolution procedures related to Covered Services provided to a Health Choice Generations Member, to the extent that they directly or indirectly affect Subcontractor, Subcontractor’s facilities or PLAN and bear upon the subject matter of this Attachment. [42 CFR §422.504(a)(13); 422.118]

3.3 Applicable Federal Laws. The compensation payable to Subcontractor pursuant to the

Agreement consists of Federal funds; accordingly, Subcontractor acknowledges that Subcontractor shall be required to comply with certain laws applicable to entities and individuals receiving Federal funds. [42 CFR §422.502 (h)(1); 422.502 (i)(4)(v)]

3.3.1 Nondiscrimination. Subcontractor understands that CMS requires compliance with

the provision of this Section as a condition for participation in Medicare plans. Subcontractor and Subcontractor Representatives shall comply with Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. Section 200d et. seq.), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794) and the regulation there under, Title IX of the Education Attachments of 1972, as amended (20 U.S.C. Section 1681 et. seq.), the Age Discrimination Act of 1975, as amended (42 U.S.C. Section 6101 et. Seq.), Section 654 of the Omnibus Budget Reconciliation Act of 1981, as amended (42 U.S.C. Section 9849), the Americans With Disabilities Act (P.L. 101-365) and all implementing regulations, guidelines and standards as are now or may be lawfully adopted under the above statutes. [42 CFR § 422.110(a)]

3.3.2 Medicare Participation Standards. SUBCONTRACTOR and its Ancillary


Practitioners shall meet the standards for participation and all applicable requirements for providers of health care services under the Medicare Program. In addition, SUBCONTRACTOR shall require that its facilities and/or offices utilized by SUBCONTRACTOR for its Health Choice Generations Members shall comply with facility standards established by CMS.

3.3.3 Persons Excluded from Medicare Participation. SUBCONTRACTOR shall not

employ, or contract with, any person who has been excluded from participation in the Medicare Program under Sections 1128 or 1128A of the Social Security Act (42 USC Sections 1330a-7 and 1330a-7a) for the provision of any (1) health care services, (2) utilization review, 3) medical social work or (4) administrative services. SUBCONTRACTOR shall inform Health Choice Generations immediately upon exclusion from participation in the Medicare Program under section 1128 or 1128A of the Social Security Act and acknowledges that PLAN is prohibited, by federal law, from contracting with a provider excluded from participation in the Medicare Program under section 1128 or 1128A of the Social Security Act as amended. [42 CFR §422.752 (a)(8)]

3.3.4 Prompt Payment. Refer to Attachment B-2, Section 3.3 Billing and Reporting

Responsibilities

3.4 Referral/Prior Authorization. SUBCONTRACTOR agrees to refer MEMBERS only to other subcontractors of HC Generations in accordance with HC Generations authorization policies and procedures as provided in the HC Generations Provider Manual and understands and agrees that if all COVERED SERVICES are not available from SUBCONTRACTOR and other subcontractors currently retained under contract with HC Generations, MEMBERS shall be referred for medical specialty services, or other services, only at the direction and with prior approval of HC Generations. Except in situations requiring EMERGENCY MEDICAL SERVICES, care provided by a nonparticipating provider that has not been authorized by HC Generations and/or one of its subcontractors may result in a denial of payment. 3.4.1 Referral/Prior Authorization Standards. SUBCONTRACTOR shall establish office

procedures to ensure that urgent and emergent referrals are processed on the same day as the date of service to MEMBER, and routine referrals are processed within four (4) days from the date of service.

3.4.2 Verification of MEMBER Eligibility and Authorization. Prior to admitting MEMBER

to an HC Generations participating hospital or rendering any service other than EMERGENCY MEDICAL SERVICES, SUBCONTRACTOR agrees to obtain:

(a) Verification of eligibility by calling HC Generations to verify eligibility; or

accessing PLAN’s web site; and (b) Verification of identity by asking MEMBER to produce his/her Health Choice

Generations membership card and another form of photo identification, or if no membership card has yet been issued, two other forms of identification, at least one a photo identification. If MEMBER is a minor, the identification of a parent will be acceptable if the eligibility of MEMBER is verified with HC Generations as set forth in (a) herein above.

(c) An authorization number for the admission from HC Generations, unless the service does not require pre-authorization in accordance with currently established HC Generations policies and procedures.


3.4.3 Good Faith Treatment. Should SUBCONTRACTOR be unable to ascertain the eligibility of a patient who holds himself/herself as a MEMBER, SUBCONTRACTOR shall render immediate, necessary care on a good faith basis. At the first available opportunity, eligibility shall be verified by SUBCONTRACTOR. If the patient proves not to be an eligible MEMBER, SUBCONTRACTOR shall collect such payment due from the patient.

3.4.4 Authorization for Inpatient Service. Except in the case of EMERGENCY MEDICAL

SERVICES, MEMBERS may not be admitted to any hospital without the prior approval of the appropriate PRIMARY CARE PHYSICIAN and prior authorization by HCA. Hospitals are required to notify HCA (via phone call or HCA web site when operational), on the day of the admission.

3.4.5 EMERGENCY MEDICAL SERVICES Admissions. In cases in which emergency

admissions are required, SUBCONTRACTOR agrees to notify HCA of the admission. If due to the severity of the emergency, prior notification cannot be obtained, SUBCONTRACTOR must provide notification, via phone call or HCA web site (when operational) to HCA of the emergency within twenty-four hours after admission.

3.5 CMS Agreement Compliance, Accountability Provisions and Delegation Requirements.

Subcontractor shall comply with all requirements in the CMS Agreement, which are applicable to Subcontractor as a result of the Agreement. Subcontractor acknowledges and agrees that the PLAN shall remain accountable to CMS for complying with its obligations under the CMS Agreement. Subcontractor shall cooperate with the PLAN in CMS required oversight activities. Without limiting the foregoing, Subcontractor shall ensure that all provisions of this Agreement, which are applicable to Subcontractor Representatives, are included in any Subcontractor’s written agreement for Sub-Delegation subcontracts. A copy of the CMS Agreement shall be made available to Subcontractor upon Subcontractor’s request. Subcontractor shall comply with Title XVIII of the Social Security Act and the regulations adopted there under by CMS for the Medicare program for all applicable laws, regulations and CMS instructions. [42 CFR §422.504(i)(1)(4)(5); 422.504(i)(3)(ii)(iii)]

3.5.1 Delegation. Subcontractor acknowledges that the credentials of medical

professionals affiliated with the Subcontractor will either be reviewed by the PLAN or if Subcontractor is privileged by the PLAN to hold an authorized delegation agreement; Subcontractor acknowledges that the credentialing process will be reviewed by the PLAN and the PLAN will audit the Subcontractors credentialing process on an ongoing basis. HC Generations may, in its sole and absolute discretion, delegate Utilization Management, Credentialing, medical records review, claims processing, and/or other activities consistent with regulatory and accrediting standards. Such delegation may occur on the effective date of this Agreement or at any time if HC Generations determines the provider is capable of performing such Delegated Activity and if provider accepts such delegation responsibility. The acceptance of responsibility for any Delegated Activity shall be evidenced by an executed delegated agreement from HC Generations to Provider that will set forth, among other things, the date that the delegation activity commenced. To the extent any responsibilities and reporting duties are delegated to Provider, the terms and conditions of the delegation are specified in the Provider Manual and the Delegated Agreement. . The PLAN retains the right to approve, suspend, or terminate any delegated activity. The Provider Manual may be amended at any time by HC Generations, to reflect changes in delegation standards, delegation status, performance measures, reporting requirements, or other provisions. [42 CFR §422.504(i)(3)(iii); 422.504(i)(4); 422.504(i)(5); 422.504(i)(4)(iii); 422.504(i)(4)(iv)(A)/(B); 422.504(i)(4)(i)]


3.5.2 Sub-Delegation. Provider shall not further delegate the Performance of Delegated

Activities to any of its Providers or any other organization or entity without the prior written consent of HC Generations.

3.5.3 Revocation and Resumption of Delegated Activities. HC Generations or CMS may

revoke any or all Delegated Activities at any time if HC Generations or CMS determines that such Delegated Activities are not being performed in accordance with the standards and requirements established by HC Generations, the Provider Manual and CMS, or if HC Generations or CMS determines that performance of Delegated Activities is inconsistent with or potentially violates Applicable CMS regulatory guidance. [42 CFR §422.504(i)(4)(ii); 422.504(i)(5)]

3.6 Medicare Participation Standards. Subcontractor and Subcontractor Representatives shall

meet the standards for participation and all applicable requirements for providers of health care services under the Medicare program. In addition, Subcontractor shall require that all facilities and offices utilized by Subcontractor to provide Medicare Covered Services to Health Choice Generations Members shall comply with facility standards established by CMS.

3.7 No Billing of Medicare Members (Medicare Member Hold Harmless Provision). PLAN will

inform Subcontractor of Medicare and Medicaid benefits and rules specific to Members eligible for Medicare and Medicaid. Subcontractor hereby agrees that in no event, including, without limitation, non-payment by the PLAN, the PLAN’s insolvency or breach of the Agreement, shall Subcontractor bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Health Choice Generations Member or person, other than the PLAN, acting on his or her behalf, for Medicare Covered Services provided pursuant to the Agreement. Subcontractor shall not hold any Health Choice Generations Member liable for payment of fees that are the legal obligation of the PLAN. [42 CFR §422.502 (g)(1)(i); 422.504(g)(1)(iii)]

Subcontractor shall not maintain any action at law or equity against a Health Choice Generations Member to collect sums owed by the PLAN to Subcontractor (Part A or Part B) when the State is responsible for paying such amounts. The PLAN will not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under Title XIX if the individual were not enrolled in the PLAN Subcontractor will accept the PLAN payment as payment in full or appropriately bill the correct State source. Upon notice of any such action, the PLAN may terminate the Agreement as provided above and take all other appropriate action consistent with the terms of the Agreement to eliminate such charges, including, without limitation, requiring Subcontractor to return all sums collected as surcharges from Health Choice Generations Members or their representatives. For purposes of the Agreement,” Surcharges” are additional fees for Medicare Covered Services, which are not disclosed to Health Choice Generations Members in the Subscriber Agreement and Evidence of Coverage are not allowable co-payments and are not authorized by the Agreement. Nothing in the Agreement shall be construed to prevent Subcontractor from providing non-Medicare Covered Services on a usual and customary fee-for-service basis to Health Choice Generations Members provided that Subcontractor has requested that a Health Choice Generations Member sign a waiver indicating the Health Choice Generations Member’s financial responsibility for charges for non-Medicare Covered Services and as long as Heath Choice Generations Member is informed by Subcontractor that said services are non-Medicare Covered Services prior to being rendered and that Health Choice Generation Member signs such waiver prior to or at the time non-Medicare Covered Services are rendered.


3.8 Confidentiality of Medicare Member Records. Subcontractor shall establish and maintain procedures and controls so that no medical or enrollee information contained in Subcontractor’s records be used by or disclosed by Subcontractor, Subcontractor Representatives, or Subcontractor’s agents, officers, or employees except as provided in 42 CFR §422.504(a)(13); 422.118, as amended, and regulations prescribed there under.

For any medical records or other health and enrollment information it maintains with respect to enrollees, an MA organization must establish procedures to do the following: (a) Abide by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information. The MA organization must safeguard the privacy of any information that identifies a particular enrollee and have procedures that specific (1) For what purposes the information will be used within the organization; and (2) To whom and for what purposes it will disclose the information outside the organization. (b) Ensure that medical information is released only in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas. (c) Maintain the records and information in an accurate and timely manner. (d) Ensure timely access by enrollees to the records and information that pertain to them. 3.9 Compliance with Reporting Requirements. Subcontractor shall cooperate and supply to

PLAN statistical and encounter data pertaining to Medicare Covered Services provided by Subcontractor, any requested documents, statements or other information defined by CMS may request to carry out its functions under the Medicare Advantage program which may include but limited to: (1) the cost of Subcontractor operations, (2) patterns of utilization, (3) availability, accessibility, and acceptability of services, (4) to the extent practical, developments in the health status of its Health Choice Generation Members, (5) information demonstrating that the provider has a fiscally sound operation and (6) other matters that CMS may require. [42 CFR §422.516 (a)(1-6); 422.504(a)(8); 422-310 (b)]

3.10 Compliance with Policies and Procedures. Subcontractor shall comply with all PLAN

policies and procedures. 3.11 Specific Provisions Pertaining to Benefits, Coverage and Beneficiary Protections.

Without limiting any of Subcontractor’s other obligations under this Attachment, Subcontractor specifically agrees to comply with the following policies and procedures: 42 CFR §422.100(g)(1)(2); 422.112(a)(3]

a. PLAN’s policies pertaining to the collection of co-payments which prohibits the

collection of co-payments for routine injections, routine immunizations, flu immunizations, and the administration of pneumococcal/pneumonia vaccine.

b. PLAN’s policies pertaining to pre-certification which provide that Health Choice

Generations Members may directly access a contracted provider for mammography and influenza vaccinations and women’s health specialists for routine and preventative health care.


c. PLAN’s policies pertaining to complex and serious conditions which provide for procedures to identify, assess, and establish treatment plans for persons with complex or serious medical conditions.

d. PLAN’s policies pertaining to enrollment and assessment of new Health Choice

Generations Members including requirements to conduct a health assessment of all new Health Choice Generations Members within ninety (90) days of the effective date of their enrollment.

3.12 Survival of Provisions following Termination. Subcontractor agrees that the provisions of

this Section and the obligations of Subcontractor herein shall survive termination of the Agreement regardless of the cause giving rise to such termination, and shall be construed to be for the benefit of Health Choice Generations Members.

SECTION 4 INTEGRATION; CONFLICTS. 4.1 This Attachment represents the complete agreement between the parties regarding the

subject matter hereof, and no other changes or modifications of the Agreement are intended nor shall any such other changes or modifications exist. In the event of a conflict between the terms of the Agreement and this Attachment, the terms of this Attachment shall control.

SECTION 5 CHANGES TO AGREEMENT 5.1 Neither party may make changes to this agreement nor add or terminate additional facilities

without prior written notice. Prior written notice of requested change, additions or terminations, must be submitted to the receiving party within 30 days. All changes requested by SUBCONTRACTOR must be approved by HC Generations.

5.2 Notice. Any notice required or permitted to be given pursuant to the Agreement submitted in

writing to Health Choice Generations shall be sent to the address below:

Health Choice Generations Network Services 410 N. 44th St., Ste. 510 Phoenix, AZ 85008


ATTACHMENT E

This Attachment E will remain in place until such time as each provider has successfully completed the credentialing requirements of Health Choice Arizona, Inc. This Contract will become null and void if provider(s) fails to complete the credentialing requirements pursuant to Section 6 Termination & Default paragraph 6.2.5 of the Contract. Each provider listed under Attachment A of this agreement agreed to abide by all terms and conditions of this agreement and shall be reimbursed according to Attachments B-1 and B-2.

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