Common use of County Obligations Clause in Contracts

County Obligations. 28 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public information 30 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 be performed on the next regular business day. 33 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 Coordination Unit (CCU) which shall: 35 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 // 1 2. Perform concurrent and retrospective utilization review of the medical appropriateness, level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understanding: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 4. Assist in coordinating the transitions of MSN Patients to appropriate outpatient care, lower 23 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, durable medical equipment, pharmacy services and home health care. 25 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 34 perform its obligations under this Contract. The standards of medical care and professional duties of 35 CONTRACTOR’s employees providing Hospital Services under this Contract shall be determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 regulations of any and all governmental authorities relating to licensure and regulation of 3 CONTRACTOR. 4 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the Contract. 6

County Obligations. 28 11 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 12 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 13 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 be performed on the next regular business day. 33 14 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 Coordination Unit (CCU) CCU which shall: 35 1. Coordinate 15 shall coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 CCU Enrollees as specified in 16 Paragraph III of this Exhibit A to the Agreement. 17 C. ADMINISTRATOR shall not be responsible for the coordination of the social services needs of such patients. 37 // 1 2. Perform concurrent and retrospective utilization review of the medical appropriateness, level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 that direct the CCU shall use to work with CONTRACTOR to develop reporting 18 and information sharing activities to address the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understandingfollowing: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by 19 1. Deny claims based on recommendations from the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 32. Communicate with Coordinate collection and evaluation of data by CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planningthe CCU. 22 4. Assist in coordinating the transitions of MSN Patients to appropriate outpatient care, lower 23 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, durable medical equipment, pharmacy services and home health care. 25 C. 21 D. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 22 may negotiate separate Letters of Contract Agreement with rates appropriate for securing care for the provision of 27 23 such services with other Contracting ED Hospitals, or Non-Contract HospitalsHospitals and providers, including those that may 28 not be located in 24 Orange County. 29 D. 25 E. If a an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 26 reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is 27 operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. 28 F. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 29 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR Physicians and 30 Other Providers shall 34 perform its their obligations under this Contractthe Agreement. The standards of medical care and 31 professional duties of 35 CONTRACTORPhysician’s and Other Provider’s employees providing Hospital Medical Services under this Contract the 32 Agreement shall be determined, as 36 applicable, by CONTRACTORPhysician’s and Other Provider’s Board of Directors 33 and the standards of care in the community in which 37 // 1 CONTRACTOR is Physician and Other Providers are located and all 34 applicable provisions of law and other rules and 2 regulations of any and all governmental authorities 35 relating to licensure and regulation of 3 CONTRACTORPhysician and Other Providers. 4 F. 36 G. Any administrative duty or obligation to be performed pursuant to the Agreement on a weekend 37 or holiday may be performed on the next regular business day. 1 H. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 2 COUNTY Obligations Paragraph of this Exhibit A to the ContractAgreement. 63

County Obligations. 28 18 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 19 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 20 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. 21 Any 31 administrative duty or obligation to be performed pursuant to the Contract Agreement on a weekend or 22 holiday may 32 be performed on the next regular business day. 33 23 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 24 Coordination Unit (CCU) which shall: 35 25 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 26 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 27 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 28 level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understanding: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 29 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 4. Assist in coordinating the transitions of MSN Patients Enrollees to appropriate outpatient care, 30 lower 23 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 31 facilities, durable medical equipment, pharmacy services and home health care. 25 32 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 33 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 34 shall 34 perform its obligations under this Contractthe Agreement. The standards of medical care and professional 35 duties of 35 CONTRACTOR’s employees providing Hospital Clinic Services under this Contract the Agreement shall be 36 determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the 37 community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 1 regulations of any and all governmental authorities relating to licensure and regulation of 3 2 CONTRACTOR. 4 F. 3 D. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 4 COUNTY Obligations Paragraph of this Exhibit A to the ContractAgreement. 65

County Obligations. 28 2 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 3 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 4 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. 5 Any 31 administrative duty or obligation to be performed pursuant to the Contract thethis Agreement on a weekend or 6 holiday may 32 be performed on the next regular business day. 33 7 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 8 Coordination Unit (CCU) which shall: 35 9 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 10 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 11 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 12 level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties 13 understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of of Care 14 Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 15 utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria 16 for similar purposes 6 within its own operations and with this understanding: 7 17 a. Prior to recommendation of any adjustment in the level of care or denial of any 18 inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the 19 CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days 20 of such 10 determination. 11 21 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 22 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 23 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 24 deems necessary. 15 25 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 26 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 27 established by ADMINISTRATOR. 18 28 d. Intermediary shall reimburse hospital based on the determination of the CCU or 29 Medical 19 Policy Committee as appropriate. 20 30 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 31 discharge planning. 22 32 4. Assist in coordinating the transitions of MSN Patients to appropriate outpatient care, lower 23 33 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 34 facilities, durable medical equipment, pharmacy services and home health care. 25 35 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 36 may negotiate separate Letters of Contract Agreement with rates appropriate for securing care for the provision of 27 37 // 1 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not 2 be located in Orange County. 29 3 D. If a an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 4 reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 5 that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 6 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 7 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 8 shall 34 perform its obligations under this Contractthethis Agreement. The standards of medical care and professional 9 duties of 35 CONTRACTOR’s employees providing Hospital Services under this Contract thethis Agreement shall be 10 determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the 11 community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 12 regulations of any and all governmental authorities relating to licensure and regulation of 3 CONTRACTOR. 4 COUNTY Obligations Paragraph of this Exhibit A to the Agreement. F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the Contract13 CONTRACTOR. 614

County Obligations. 28 15 A. ADMINISTRATOR shall provide oversight of the MSN ProgramMSI Program throughout the term of the 16 Agreement, including appropriate program 29 administration, coordination, planning, evaluation, financial 17 and contract monitoring, public information 30 and referral, standards assurance, and review and analysis of 18 data gathered and reported. 19 1. ADMINISTRATOR shall notify CLINIC, immediately upon becoming aware of any 20 amendments, modifications, changes, or updates to the STCs or the LIHP Agreement. When available, 21 ADMINISTRATOR shall provide CLINIC with a copy of the STCs and the LIHP Agreement, including 22 any written amendments, modifications, changes or updates. 23 2. Any 31 administrative duty or obligation to be performed pursuant to the Contract Agreement on a 24 weekend or holiday may 32 be performed on the next regular business day. 33 25 B. ADMINISTRATOR ADMINISTRATOR, throughout the term of the Agreement, shall establish, either directly 26 and/or through subcontract(s), a Care 34 Coordination Unit Utilization Management Department (CCUUMD) which shall: 35 27 1. Coordinate and make arrangements for the medical needs and care of MSN EnrolleesMSI Eligibles. The 36 CCU 28 UMD shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 29 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 30 level 2 of care, and utilization of all services provided to MSN MSI Patients by All Providers. The parties understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understanding: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 31 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 4. Assist in coordinating the transitions of MSN Patients MSI Eligibles to appropriate outpatient care, lower 23 32 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, durable medical equipment, equipment 33 and pharmacy services and through community-based providers for home health care. 25 C. When needed services are not available through any Contracting Hospital34 4. Conduct patient and health care provider education which shall include, ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 but not be located in Orange Countylimited 35 to: 36 a. Availability of MSI Program services at locations other than UCI Medical Center. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment37 b. MSI Program services available at Contracting Clinics. 32 E. Except as 1 c. Services for which pre-authorization is recommended through the UMD. 2 C. ADMINISTRATOR may enter into separate letters of agreement for Dental Services that cannot 3 be provided herein with respect to discrimination of care to MSN Patients, by Contracting Clinics. 4 D. COUNTY shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 5 CLINIC shall 34 perform its obligations under this Contractthe Agreement. The standards of medical care and 6 professional duties of 35 CONTRACTORCLINIC’s employees providing Hospital Clinic and/or Dental Services under this Contract the 7 Agreement shall be determined, as 36 applicable, by CONTRACTORCLINIC’s Board of Directors and the standards of care 8 in the community in which 37 // 1 CONTRACTOR CLINIC is located and all applicable provisions of law and other rules and 2 9 regulations of any and all governmental authorities relating to licensure and regulation of 3 CONTRACTOR. 4 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the ContractCLINIC. 610

County Obligations. 28 18 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 19 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 20 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. 21 Any 31 administrative duty or obligation to be performed pursuant to the Contract Agreement on a weekend or 22 holiday may 32 be performed on the next regular business day. 33 23 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 24 Coordination Unit (CCU) which shall: 35 25 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 26 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 27 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 28 level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understanding: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 29 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 4. Assist in coordinating the transitions of MSN Patients Enrollees to appropriate outpatient care, 30 lower 23 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 31 facilities, durable medical equipment, pharmacy services and home health care. 25 32 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 33 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 34 shall 34 perform its obligations under this Contractthe Agreement. The standards of medical care and professional 35 duties of 35 CONTRACTOR’s employees providing Hospital Clinic Services under this Contract the Agreement shall be 36 determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the 37 community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 1 regulations of any and all governmental authorities relating to licensure and regulation of 3 2 CONTRACTOR. 4 F. 3 D. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the Contract. 6the

County Obligations. 28 7 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate program 29 8 administration, coordination, planning, evaluation, financial and contract monitoring, public information 30 9 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 10 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 11 be performed on the next regular business day. 33 12 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 13 Coordination Unit (CCU) which shall: 35 14 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 15 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 16 2. Perform concurrent and retrospective utilization review of the medical appropriateness, level 2 17 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 within its own operations and with understanding: 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 deems necessary. 15 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 established by ADMINISTRATORall COUNTY contracted providers. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 4. Assist in coordinating the transitions of MSN Patients Enrollees to appropriate outpatient care, lower 23 19 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, 20 durable medical equipment, pharmacy services and home health care. 25 21 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 33 22 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 34 23 perform its obligations under this the Contract. The standards of medical care and professional duties of 35 24 CONTRACTOR’s employees providing Hospital Clinic Services under this the Contract shall be determined, as 36 25 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the community in which 37 // 1 26 CONTRACTOR is located and all applicable provisions of law and other rules and 2 27 regulations of any and all governmental authorities relating to licensure and regulation of 3 28 CONTRACTOR. 4 F. 29 D. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, writing to modify the 5 COUNTY 30 Obligations Paragraph of this Exhibit A to the Contract. 631

County Obligations. 28 27 A. ADMINISTRATOR COUNTY shall provide oversight of the MSN MSI Program, including appropriate program 29 28 administration, coordination, planning, evaluation, financial and contract monitoring, public information 30 29 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 be performed on the next regular business day. 33 30 B. ADMINISTRATOR COUNTY shall establish, establish either directly and/or through subcontract(s), a Care 34 Coordination Unit Utilization 31 Management Department (CCUUMD) which shall: 35 32 1. Coordinate and make arrangements for the medical needs and care of MSN EnrolleesMSI Eligibles. The 36 CCU 33 UMD shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 34 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level 2 of care, and utilization of all services provided to MSN MSI Patients by All Providers. The parties 36 understand 3 that the CCU UMD shall use the latest available version of the Milliman Continuum Of of Care Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, 37 Criteria as its guideline for such utilization review. 5 ADMINISTRATOR COUNTY acknowledges that CONTRACTOR HOSPITAL may use 1 Interqual criteria for similar purposes 6 within its own operations and with this understanding:: 2 // 3 // 7 4 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by CONTRACTOR HOSPITAL that 5 does not meet continuum of care criteria used by the CCUMilliman criteria, the 9 CCU UMD shall notify CONTRACTOR HOSPITAL of a pending denial recommendation 6 within two (2) business days of such 10 determination. 11 7 b. CONTRACTOR HOSPITAL shall have the opportunity to provide written justification, within two 12 (2) 8 business days after receiving written notice of recommendationrecommended denial, to the CCU UMD which justification 9 may 13 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 HOSPITAL 10 deems necessary. 15 11 c. If the CCU UMD subsequently recommends the adjustment and/or denial of the inpatient day, 16 CONTRACTOR HOSPITAL shall 12 have the right to appeal the decision to the Medical Policy Committee, Review Committee as 17 established by ADMINISTRATORspecified in Paragraph V. of 13 this Exhibit A to the Agreement. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as appropriate. 20 14 3. Communicate with CONTRACTOR HOSPITAL regarding diversions, patient transfers, admissions, and 21 discharge planning. 22 15 4. Assist in coordinating the transitions of MSN MSI Patients to appropriate outpatient care, lower 23 16 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, 17 durable medical equipment, equipment and pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient, HOSPITAL, and Other Provider education which shall include, but not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Center. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 C. When needed services are not available through any Contracting HospitalServices for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, and payment 27 procedures. 28 D. ADMINISTRATOR 26 may negotiate separate Letters additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 34 perform its obligations under this Contract. The standards of medical care and professional duties of 35 CONTRACTOR’s employees providing Hospital Services under this Contract shall be determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 regulations of any and all governmental authorities relating to licensure and regulation of 3 CONTRACTOR. 4 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the Contract. 6Points negotiated by

County Obligations. 28 16 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 17 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 18 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. 19 Any 31 administrative duty or obligation to be performed pursuant to the Contract Agreement on a weekend or 20 holiday may 32 be performed on the next regular business day. 33 21 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 22 Coordination Unit (CCU) which shall: 35 23 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 24 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 25 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 26 level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties 27 understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of of Care 28 Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 29 utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria 30 for similar purposes 6 within its own operations and with this understanding: 7 31 a. Prior to recommendation of any adjustment in the level of care or denial of any 32 inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCUMilliman criteria, the 9 CCU shall notify 33 CONTRACTOR of a pending recommendation within two (2) business days of such 10 determination. 11 34 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 35 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 36 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 37 deems necessary. 15 1 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 2 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, Committee as 17 3 established by ADMINISTRATOR. 18 4 d. Intermediary shall reimburse hospital based on the determination of the CCU or 5 Medical 19 Policy Committee as appropriate. 20 6 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, 7 and 21 discharge planning. 22 8 4. Assist in coordinating the transitions transition of MSN Patients to appropriate outpatient care, lower 23 9 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 10 facilities, durable medical equipment, pharmacy services and home health care. 25 11 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 12 may negotiate separate Letters of Contract Agreement with rates appropriate for securing care for the provision of 27 13 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not be located in Orange County. 29 14 D. If a an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 15 reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 16 that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 17 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 18 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 19 shall 34 perform its obligations under this Contractthe Agreement. The standards of medical care and professional 20 duties of 35 CONTRACTOR’s employees providing Hospital Services under this Contract the Agreement shall be 21 determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the 22 community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 23 regulations of any and all governmental authorities relating to licensure and regulation of 3 24 CONTRACTOR. 4 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 COUNTY Obligations Paragraph of this Exhibit A to the Contract. 625

County Obligations. 28 19 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate program 29 20 administration, coordination, planning, evaluation, financial and contract monitoring, public information 30 21 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 22 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 23 be performed on the next regular business day. 33 24 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 25 Coordination Unit (CCU) which shall: 35 26 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 27 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 28 2. Perform concurrent and retrospective utilization review of the medical appropriateness, level 2 29 of care, and utilization of all services provided to MSN Patients by All Providers. The parties understand 3 30 that the CCU shall use the latest available version of the Milliman Continuum Of Care Criteria, or other 4 31 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. 5 32 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria for similar purposes 6 33 within its own operations and with understanding: 7 34 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 35 day provided by CONTRACTOR that does not meet continuum of care criteria used by the CCU, the 9 36 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days of such 10 37 determination. 11 1 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 2 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 3 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 4 deems necessary. 15 5 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 6 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 7 established by ADMINISTRATOR. 18 8 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 9 Policy Committee as appropriate. 20 10 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 11 discharge planning. 22 12 4. Assist in coordinating the transitions of MSN Patients to appropriate outpatient care, lower 23 13 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 14 facilities, durable medical equipment, pharmacy services and home health care. 25 15 C. When needed services are not available through any Contracting Network Hospital, 16 ADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care 17 for the provision of 27 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, 18 including those that may 28 not be located in Orange County. 29 19 D. If a an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 20 reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that 21 is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 22 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 33 23 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 34 24 perform its obligations under this Contract. The standards of medical care and professional duties of 35 25 CONTRACTOR’s employees providing Hospital Services under this Contract shall be determined, as 36 26 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the community in which 37 // 1 27 CONTRACTOR is located and all applicable provisions of law and other rules and 2 28 regulations of any and all governmental authorities relating to licensure and regulation of 3 29 CONTRACTOR. 4 30 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 31 COUNTY Obligations Paragraph of this Exhibit A to the Contract. 632

County Obligations. 28 31 A. ADMINISTRATOR shall provide oversight of the MSN Program, including appropriate 32 program 29 administration, coordination, planning, evaluation, financial and contract monitoring, public 33 information 30 and referral, standards assurance, and review and analysis of data gathered and reported. 34 Any 31 administrative duty or obligation to be performed pursuant to the Contract this Agreement on a weekend or 35 holiday may 32 be performed on the next regular business day. 33 36 B. ADMINISTRATOR shall establish, either directly and/or through subcontract(s), a Care 34 37 Coordination Unit (CCU) which shall: 35 1 1. Coordinate and make arrangements for the medical needs and care of MSN Enrollees. The 36 2 CCU shall not be responsible for the coordination of the social services needs of such patients. 37 //. 1 3 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 4 level 2 of care, and utilization of all services provided to MSN Patients by All Providers. The parties 5 understand 3 that the CCU shall use the latest available version of the Milliman Continuum Of of Care 6 Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 7 utilization review. 5 ADMINISTRATOR acknowledges that CONTRACTOR may use Interqual criteria 8 for similar purposes 6 within its own operations and with this understanding: 7 9 a. Prior to recommendation of any adjustment in the level of care or denial of any 10 inpatient 8 day provided by CONTRACTOR that does not meet continuum of care criteria used by the 11 CCU, the 9 CCU shall notify CONTRACTOR of a pending recommendation within two (2) business days 12 of such 10 determination. 11 13 b. CONTRACTOR shall have the opportunity to provide written justification, within two 12 14 (2) business days after receiving written notice of recommendation, to the CCU which justification may 13 15 include the application of Interqual criteria and/or other supporting information, as CONTRACTOR 14 16 deems necessary. 15 17 c. If the CCU subsequently recommends the adjustment and/or denial of the inpatient day, 16 18 CONTRACTOR shall have the right to appeal the decision to the Medical Policy Committee, as 17 19 established by ADMINISTRATOR. 18 20 d. Intermediary shall reimburse hospital based on the determination of the CCU or 21 Medical 19 Policy Committee as appropriate. 20 22 3. Communicate with CONTRACTOR regarding diversions, patient transfers, admissions, and 21 23 discharge planning. 22 24 4. Assist in coordinating the transitions of MSN Patients to appropriate outpatient care, lower 23 25 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 26 facilities, durable medical equipment, pharmacy services and home health care. 25 27 C. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 26 28 may negotiate separate Letters of Contract Agreement with rates appropriate for securing care for the provision of 27 29 such services with other Contracting ED Hospitals, or Non-Contract Hospitals, including those that may 28 not 30 be located in Orange County. 29 31 D. If a an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 32 reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 33 that is operated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 32 34 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 35 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 36 shall 34 perform its obligations under this ContractAgreement. The standards of medical care and professional 37 duties of 35 CONTRACTOR’s employees providing Hospital Services under this Contract Agreement shall be 1 determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the 2 community in which 37 // 1 CONTRACTOR is located and all applicable provisions of law and other rules and 2 3 regulations of any and all governmental authorities relating to licensure and regulation of 3 4 CONTRACTOR. 4 5 F. CONTRACTOR and ADMINISTRATOR may mutually agree, in writing, to modify the 5 6 COUNTY Obligations Paragraph of this Exhibit A to the ContractAgreement. 67