Common use of Clarifying Information Clause in Contracts

Clarifying Information. Patients for this project will only count as actively engaged if they receive either a PHQ-2 or 9 or SBIRT screenings. • All five principals of the IMPACT model must be in place for a site to count. • Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so. • Appropriate screenings would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical record. CNYCC Defined Details: In order to be considered actively engaged by definitions set by CNYCC, Medicaid members must: • Have traditional Medicaid, be dually eligible for Medicaid and Medicare, or be a member of Medicaid Managed Care (e.g. Fidelis, Total Care or United Healthcare) AND • Screened using the screenings listed below AND Screened for: Screen Used: Depression/Suicide PHQ-2/PHQ-9/A (depression, adults/adolescents) Substance Use/Abuse Inc. Tobacco Audit C – for Alcohol ASSIST DAST-10 • Have NOT been submitted to other PPSs for payment. Data Reporting Requirements (all Models) The data reporting requirements set forth in this appendix apply solely to the Behavioral Health/Primary Care Integration project (3ai) regarding Medicaid Members who are considered actively engaged by the definitions and details stated above. Data Elements Partners shall report the following data elements to CNYCC with the frequency set forth below: • Patient Last Name • Patient First Name • Client Identification Number (CIN) or Medicaid Managed Care Subscriber ID • Date of Encounter • Screen Performed – enter multiple screens if applicable In addition to the information (data elements) that is reported to CNYCC, Partners must retain the following information in the event of an audit. • Full Name of Patient who participated in Model 1, Model 2 or Model 3 Behavioral Health/Primary Care Integration • Eligibility Status (Medicaid or Medicaid Managed Care, Services received, screenings performed) • Current Address (if reported) • Current Phone Number (if reported) • Current Email Address (if reported) • Dates of any additional encounters or follow-up with Medicaid Member Reporting Schedule Partners shall report the number of actively engaged patients by the Monday following the second Thursday of each month by 10 AM. Please see the chart below for exact due dates of Actively Engaged Patient Rosters. Partners are responsible for uploading a Member Roster file that includes the data elements that were defined above for all engaged patients for the previous month. In order to send the file, Partners must utilize CNYCC’s Secure File Transfer Protocol (SFTP) Site. Instructions for site use, usernames and passwords will be distributed to individuals identified by Partner Organizations; this information will be sent separately.

Clarifying Information. Patients for this project will only count as actively engaged if they receive either a PHQ-2 or 9 or SBIRT screenings. • All five principals of the IMPACT model must be in place for a site to count. • Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so. • Appropriate screenings would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical record. CNYCC Defined Details: In order to be considered actively engaged by definitions set by CNYCC, Medicaid members must: • Have traditional Medicaid, be dually eligible for Medicaid and Medicare, or be a member of Medicaid Managed Care (e.g. Fidelis, Total Care or United Healthcare) AND • Screened using the screenings listed below AND Screened for: Screen Used: Depression/Suicide PHQ-2/PHQ-9/A (depression, adults/adolescents) Substance Use/Abuse Inc. Tobacco Audit C – for Alcohol ASSIST DAST-10 • Have NOT been submitted to other PPSs for payment. Data Reporting Requirements (all Models) The data reporting requirements set forth in this appendix apply solely to the Behavioral Health/Primary Care Integration project (3ai) regarding Medicaid Members who are considered actively engaged by the definitions and details stated above. Data Elements Partners shall report the following data elements to CNYCC with the frequency set forth below: • Patient Last Name • Patient First Name • Client Identification Number (CIN) or Medicaid Managed Care Subscriber ID • Date of Encounter • Screen Performed – enter multiple screens if applicable In addition to the information (data elements) that is reported to CNYCC, Partners must retain the following information in the event of an audit. • Full Name of Patient who participated in Model 1, Model 2 or Model 3 Behavioral Health/Primary Care Integration • Eligibility Status (Medicaid or Medicaid Managed Care, Services received, screenings performed) • Current Address (if reported) • Current Phone Number (if reported) • Current Email Address (if reported) • Dates of any additional encounters or follow-up with Medicaid Member Reporting Schedule Partners shall report the number of actively engaged patients by each Monday for the previous week. For example: On Monday, February 15th, partners are responsible for submitting patient engagement numbers for Monday, February 8th to Sunday, February 14th. CNYCC has contracted with a Project Management software vendor who is developing a webform for each organization. Once the webform has been finalized and deployed, partners will be responsible for entering actively engaged numbers patients on Mondays for the week prior; the webform will be sent automatically each week. On the first Monday following the second Thursday of each month by 10 AM. Please see the chart below for exact due dates of Actively Engaged Patient Rosters. Partners a new month, partners are responsible for uploading a Member Roster file that includes the data elements that were defined above for all engaged patients for the previous month. In order to send the file, Partners partners must utilize CNYCC’s Secure File Transfer Protocol (SFTP) Site. Instructions for site use, usernames and passwords will be distributed to individuals identified by Partner Organizations; this information will be sent separately.

Clarifying Information. Patients Currently XXX® is the only activation measure being considered for implementation in this project will only count as actively engaged if they receive either a PHQ-2 or 9 or SBIRT screeningsproject. • All five principals of the IMPACT model If additional patient engagement techniques are utilized, they must be in place for a site evidenced-based and/or peer reviewed, demonstrating that they are patient activation techniques that are equal to countor better than XXX®. • Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so. • Appropriate screenings XXX® surveys completed by parents/guardians on behalf of younger patients would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical recordfor active engagement. CNYCC Defined Details: In order to be considered actively engaged by definitions set by CNYCC, Medicaid members must: • Have Medicaid Members must have traditional Medicaid, be dually eligible for Medicaid and Medicare, or be a member of Medicaid Managed Care (e.g. Fidelis, Total Care Care, or United Healthcare) AND • Screened using Have been categorized as a Low or Non-Utilizer based on the screenings listed below pre-screening questionnaire AND Screened for: Screen Used: Depression/Suicide PHQ-2/PHQ-9/A (depression• Have not been XXX® screened more than once in the same Demonstration Year. Once a new Demonstration Year has begun, adults/adolescents) Substance Use/Abuse Inc. Tobacco Audit C – for Alcohol ASSIST DAST-10 the Medicaid Member can be counted again if they are re-screened AND • Have NOT been submitted to other PPSs for paymentpayment OR • Be uninsured • Have not been XXX® screened more than once in the same Demonstration Year. Once a new Demonstration Year has begun, the Medicaid Member can be counted again if they are re-screened AND • Have NOT been submitted to other PPSs for payment Data Reporting Requirements (all Models) The data reporting requirements set forth in this appendix apply solely to the Behavioral Health/Primary Care Integration Patient Activation project (3ai) regarding Medicaid Members and the uninsured who are considered actively engaged by the definitions and details stated above. Data Elements Partners shall report collect the following data elements to CNYCC with which will be captured in the frequency set forth below: Recording Requirement Spreadsheet. • Patient Last Name • Patient First Name • Client Identification Number (CIN) or Medicaid Managed Care Subscriber ID (if Medicaid Member) or Unique ID (Insignia Defined for Uninsured) • Healthcare Insurance Status – Low Utilizer, Non Utilizer or Uninsured ONLY • Consent for Release of Information – Yes or No • Date of Encounter XXX® Screening/Initial Referral Date • Screen Performed – enter multiple screens if applicable In addition to the information Date of Coaching for Activation (data elements) that is reported to CNYCC, Partners must retain the following information in the event of an audit. • Full Name of Patient who participated in Model 1, Model 2 or Model 3 Behavioral Health/Primary Care Integration • Eligibility Status (Medicaid or Medicaid Managed Care, Services received, screenings performedCFA®) • Current Address (if reported) • Current Phone Number (if reported) • Current Email Address (if reported) • Dates of any additional encounters or follow-up with Medicaid Member Primary/Preventive Services Coordination Date – Not Required at This Time, More Info Forthcoming Reporting Schedule Partners shall report are responsible for uploading the number of actively engaged patients Recording Requirements Spreadsheet by the Monday following the second Thursday of each month by 10 AM. Please see the chart below for exact due dates of Actively Engaged Patient Rosters. Partners are responsible for uploading a Member Roster file that includes the data elements that were defined above for all engaged patients for the previous month. In order to send the file, Partners must utilize CNYCC’s Secure File Transfer Protocol (SFTP) Site. Instructions for site use, usernames and passwords will be distributed to individuals identified by Partner Organizations; this information will be sent separately.. Partners will be sent an excel template that they can use to create their spreadsheet for data submission. The file naming convention should be: 2di Date Parent Organization Name Actively Engaged Patient Roster. Please do not send a cumulative patient spreadsheet; each month submitted should have unique patients. If anyone has any questions regarding project requirements, please contact: Xxxxxxx Xxxxxxx Xxxxxxx.xxxxxxx@xxxxxxxx.xxx 000-000-0000

Clarifying Information. Patients for this project will only count as actively engaged if they receive either a PHQ-2 or 9 or SBIRT screenings. • All five principals of the IMPACT model must be in place for a site to count. • Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so. • Appropriate screenings would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical record. CNYCC Defined Details: In order to be considered actively engaged by definitions set by CNYCC, Medicaid members must: • Have traditional Medicaid, be dually eligible for Medicaid and Medicare, or be a member of a Medicaid Managed Care (e.g. e.g., through Fidelis, Total Care or United Healthcare) AND • Screened using the screenings listed below an evidence-based screening such PHQ-2 or 9/SBIRT AND Screened for: Screen Used: Depression/Suicide PHQ-2/PHQ-9/A (depression, adults/adolescents) Substance Use/Abuse Inc. Tobacco Audit C – for Alcohol ASSIST DAST-10 • Have NOT been submitted to other PPSs for payment. Data Reporting Requirements (all Models) The data reporting requirements set forth in this appendix apply solely to the Behavioral Health/Primary Care Integration project (3ai) regarding Medicaid Members who are considered actively engaged by the definitions and details stated above. Data Elements Partners Primary care practices & behavioral health providers shall report the following data elements to CNYCC with the frequency set forth below: • Patient Last Name • Patient First Name • Client Identification Number (CIN) or Medicaid Managed Care Subscriber ID • Date of Encounter • Screen Performed – enter multiple screens if applicable In addition to the information (data elements) that is reported to CNYCC, Partners primary care pratices & behavioral health providers must retain the following information in the event of an audit. • Full Name of Patient who participated in Model 1, Model 2 or Model 3 Behavioral Health/Primary Care Integration • Eligibility Status (Medicaid or Medicaid Managed Care, Services received, screenings performed) • Current Address (if reported) • Current Phone Number (if reported) • Current Email Address (if reported) • Dates of any additional encounters or follow-up with Medicaid Member Reporting Schedule Partners shall report the number of actively engaged patients by each Monday for the previous week. For example: On Monday, February 15th, Partners are responsible for submitting patient engagement numbers for Monday, February 8th to Sunday, February 14th. In the interim, Partners will be required to email numbers to Xxxxxxx Xxxxxxx, Project Manager, at Xxxxxxx.Xxxxxxx@xxxxxxxx.xxx. CNYCC has contracted with a Project Management software vendor who is developing a webform for each organization. Once the webform has been finalized and deployed, Partners will be responsible for entering actively engaged numbers patients on Mondays for the week prior; the webform will be sent automatically each week. On the first Monday following the second Thursday of each month by 10 AM. Please see the chart below for exact due dates of Actively Engaged Patient Rosters. a new month, Partners are responsible for uploading a Member Roster file that includes the data elements that were defined above for all engaged patients for the previous month. In order to send the file, Partners must utilize CNYCC’s Secure File Transfer Protocol (SFTP) Site. Instructions for site use, usernames and passwords will be distributed to individuals identified by Partner Organizations; this information will be sent separately.

Clarifying Information.  Patients for this project will only count as actively engaged if they receive either a PHQ-2 or 9 or SBIRT screenings. •  All five principals of the IMPACT model must be in place for a site to count. •  Any staffer working within the IMPACT model who is qualified to perform a preventive care screening as required within the project can do so. •  Appropriate screenings would only count if the PCP or the clinical staff is provided the results of the screen and they are incorporated into the medical record. CNYCC Defined Details: In order to be considered actively engaged by definitions set by CNYCC, Medicaid members must: •  Have traditional Medicaid, be dually eligible for Medicaid and Medicare, or be a member of Medicaid Managed Care (e.g. Fidelis, Total Care or United Healthcare) AND •  Screened using the screenings listed below AND Screened for: Screen Used: Depression/Suicide PHQ-2/PHQ-9/A (depression, adults/adolescents) Substance Use/Abuse Inc. Tobacco Audit C – for Alcohol ASSIST DAST-10 •  Have NOT been submitted to other PPSs for payment. Data Reporting Requirements (all Models) The data reporting requirements set forth in this appendix apply solely to the Behavioral Health/Primary Care Integration project (3ai) regarding Medicaid Members who are considered actively engaged by the definitions and details stated above. Data Elements Partners shall report the following data elements to CNYCC with the frequency set forth below: •  Patient Last Name •  Patient First Name •  Client Identification Number (CIN) or Medicaid Managed Care Subscriber ID •  Date of Encounter •  Screen Performed – enter multiple screens if applicable In addition to the information (data elements) that is reported to CNYCC, Partners must retain the following information in the event of an audit. •  Full Name of Patient who participated in Model 1, Model 2 or Model 3 Behavioral Health/Primary Care Integration •  Eligibility Status (Medicaid or Medicaid Managed Care, Services received, screenings performed) •  Current Address (if reported) •  Current Phone Number (if reported) •  Current Email Address (if reported) •  Dates of any additional encounters or follow-up with Medicaid Member Reporting Schedule Partners shall report the number of actively engaged patients by each Monday for the previous week. For example: On Monday, February 15th, partners are responsible for submitting patient engagement numbers for Monday, February 8th to Sunday, February 14th. CNYCC has contracted with a Project Management software vendor who is developing a webform for each organization. Once the webform has been finalized and deployed, partners will be responsible for entering actively engaged numbers patients on Mondays for the week prior; the webform will be sent automatically each week. On the first Monday following the second Thursday of each month by 10 AM. Please see the chart below for exact due dates of Actively Engaged Patient Rosters. Partners a new month, partners are responsible for uploading a Member Roster file that includes the data elements that were defined above for all engaged patients for the previous month. In order to send the file, Partners partners must utilize CNYCC’s Secure File Transfer Protocol (SFTP) Site. Instructions for site use, usernames and passwords will be distributed to individuals identified by Partner Organizations; this information will be sent separately.