Amended And Restated

Amended and Restated Contract Between the Georgia Department of Community Health and Wellcare of Georgia, Inc. For Provision of Services to Georgia Families Contract No. 0654 Amendment #12



Exhibit 10.35

CERTAIN CONFIDENTIAL INFORMATION CONTAINED IN THIS DOCUMENT (INDICATED BY ASTERISKS) HAS BEEN OMITTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE COMMISSION PURSUANT TO A REQUEST FOR CONFIDENTIAL TREATMENT.

 
 
 

 

CONTRACT BETWEEN

THE GEORGIA DEPARTMENT OF COMMUNITY HEALTH

AND

WELLCARE OF GEORGIA, INC.

FOR

PROVISION OF SERVICES TO GEORGIA FAMILIES

CONTRACT NO. 0654


1




TABLE OF CONTENTS
 
1.0
SCOPE OF SERVICE
16
 
 
 
1.1
BACKGROUND
16
 
 
 
1.2
ELIGIBILITY FOR GEORGIA FAMILIES
17
 
 
 
1.2.1
MEDICAID
17
 
 
 
1.2.2
PEACHCARE FOR KIDS®
18
 
 
 
1.2.3
EXCLUSIONS
18
 
 
 
1.3
SERVICE REGIONS
19
 
 
 
1.4
DEFINITIONS
19
 
 
 
1.5
ACRONYMS
33
 
 
 
2.0
DCH RESPONSIBILITIES
35
 
 
 
2.1
GENERAL PROVISIONS
35
 
 
 
2.2
LEGAL COMPLIANCE
35
 
 
 
2.3
ELIGIBILITY AND ENROLLMENT
35
 
 
 
2.4
DISENROLLMENT
37
 
 
 
2.5
MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING
37
 
 
 
2.6
COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
38
 
 
 
2.7
NETWORK
38
 
 
 
2.8
QUALITY MONITORING
38
 
 
 
2.9
COORDINATION WITH CONTRACTOR'S KEY STAFF
38
 
 
 
2.10
FORMAT STANDARDS
39
 
 
 
2.11
FINANCIAL MANAGEMENT
39
 
 
 
2.12
INFORMATION SYSTEMS
39
 
 
 
2.13
READINESS OR ANNUAL REVIEW
39
 
 
 
3.0
GENERAL CONTRACTOR RESPONSIBILITIES
39

2



4.0
SPECIFIC CONTRACTOR RESPONSIBILITIES
40
 
 
 
4.1
ENROLLMENT
40
 
 
 
4.1.1
ENROLLMENT PROCEDURES
40
 
 
 
4.1.2
SELECTION OF PRIMARY CARE PROVIDER (PCP)
41
 
 
 
4.1.3
NEWBORN ENROLLMENT
42
 
 
 
4.1.4
REPORTING REQUIREMENTS
42
 
 
 
4.2
DISENROLLMENT
42
 
 
 
4.2.1
DISENROLLMENT INITIATED BY THE MEMBER OR P4HB PARTICIPANT
42
 
 
 
4.2.2
DISENROLLMENT INITIATED BY THE CONTRACTOR
43
 
 
 
4.2.3
ACCEPTABLE REASONS FOR DISENROLLMENT REQUESTED BY CONTRACTOR
44
 
 
 
4.2.4
UNACCEPTABLE REASONS FOR DISENROLLMENT REQUESTS BY CONTRACTOR
44
 
 
 
4.3
MEMBER AND P4HB PARTICIPANT SERVICES
44
 
 
 
4.3.1
GENERAL PROVISIONS
44
 
 
 
4.3.2
REQUIREMENTS FOR WRITTEN MATERIALS
45
 
 
 
4.3.3
MEMBER HANDBOOK AND P4HB PARTICIPANTS INFORMATION REQUIREMENTS
45
 
 
 
4.3.4
MEMBER AND P4HB PARTICIPANT RIGHTS
48
 
 
 
4.3.5
PROVIDER DIRECTORY
49
 
 
 
4.3.6
MEMBER AND P4HB PARTICIPANT IDENTIFICATION (ID) CARD
50
 
 
 
4.3.7
TOLL-FREE MEMBER AND P4HB PARTICIPANT SERVICES LINE
51
 
 
 
4.3.8
INTERNET PRESENCE/WEB SITE
51
 
 
 
4.3.9
CULTURAL COMPETENCY
52
 
 
 
4.3.10
TRANSLATION SERVICES
52
 
 
 
4.3.11
REPORTING REQUIREMENTS
52
 
 
 
4.4
MARKETING
52
 
 
 
4.4.1
PROHIBITED ACTIVITIES
52

3



4.4.2
ALLOWABLE ACTIVITIES
53
 
 
 
4.4.3
STATE APPROVAL OF MATERIALS
53
 
 
 
4.4.4
PROVIDER MARKETING MATERIALS
53
 
 
 
4.5
COVERED BENEFITS AND SERVICES
53
 
 
 
4.5.1
INCLUDED SERVICES
53
 
 
 
4.5.2
INDIVIDUALS W/ DISABILITIES EDUCATION ACT (IDEA) SERVICES
54
 
 
 
4.5.3
ENHANCED SERVICES
55
 
 
 
4.5.4
MEDICAL NECESSITY
55
 
 
 
4.5.5
EXPERIMENTAL, INVESTIGATIONAL OR COSMETIC PROCEDURES, DRUGS, SERVICES OR DEVICES
55
 
 
 
4.5.6
MORAL OR RELIGIOUS OBJECTIONS
55
 
 
 
4.6
SPECIAL COVERAGE PROVISIONS
56
 
 
 
4.6.1
EMERGENCY SERVICES
56
 
 
 
4.6.2
POST-STABILIZATION SERVICES
57
 
 
 
4.6.3
URGENT CARE SERVICES
59
 
 
 
4.6.4
FAMILY PLANNING SERVICES
59
 
 
 
4.6.5
STERILIZATIONS, HYSTERECTOMIES AND ABORTIONS
60
 
 
 
4.6.6
PHARMACY
61
 
 
 
4.6.7
IMMUNIZATIONS
62
 
 
 
4.6.8
TRANSPORTATION
62
 
 
 
4.6.9
PERINATAL SERVICES
62
 
 
 
4.6.10
PARENTING EDUCATION
63
 
 
 
4.6.11
MENTAL HEALTH AND SUBSTANCE ABUSE
63
 
 
 
4.6.12
ADVANCE DIRECTIVES
63
 
 
 
4.6.13
FOSTER CARE FORENSIC EXAM
64



4



4.6.14
LABORATORY SERVICES
64
 
 
 
4.6.15
MEMBER COST-SHARING
64
 
 
 
4.7
EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) PROGRAM: HEALTH CHECK
64
 
 
 
4.7.1
GENERAL PROVISIONS
64
 
 
 
4.7.2
OUTREACH AND INFORMING
64
 
 
 
4.7.3
SCREENING
65
 
 
 
4.7.4
TRACKING
66
 
 
 
4.7.5
DIAGNOSTIC AND TREATMENT SERVICES
66
 
 
 
4.7.6
REPORTING REQUIREMENTS
67
 
 
 
4.8
PROVIDER NETWORK AND ACCESS
67
 
 
 
4.8.1
GENERAL PROVISIONS
67
 
 
 
4.8.2
PRIMARY CARE PROVIDERS (PCPS)
68
 
 
 
4.8.3
DIRECT ACCESS
70
 
 
 
4.8.4
PHARMACIES
70
 
 
 
4.8.5
HOSPITALS
70
 
 
 
4.8.6
LABORATORIES
70
 
 
 
4.8.7
MENTAL HEALTH/SUBSTANCE ABUSE
70
 
 
 
4.8.8
FEDERALLY QUALIFIED HEALTH CENTERS (FQHCS)
71
 
 
 
4.8.9
RURAL HEALTH CLINICS (RHCS)
71
 
 
 
4.8.10
FAMILY PLANNING CLINICS
71
 
 
 
4.8.11
NURSE PRACTIONERS CERTIFIED (NP-CS) AND CERTIFIED NURSE MIDWIVES (CNMS)
71
 
 
 
4.8.12
DENTAL PRACTITIONERS
72
 
 
 
4.8.13
GEOGRAPHIC ACCESS REQUIREMENTS
72
 
 
 
4.8.14
WAITING MAXIMUMS ND APPOINTMENT REQUIREMENTS
73
 
 
 

5



4.8.15
CREDENTIALING
74
 
 
 
4.8.16
MAINSTREAMING
75
 
 
 
4.8.17
COORDINATION REQUIREMENTS
75
 
 
 
4.8.18
NETWORK CHANGES
75
 
 
 
4.8.19
OUT-OF-NETWORK PROVIDERS
76
 
 
 
4.8.20
SHRINERS HOSPITALS FOR CHILDREN
76
 
 
 
4.8.21
REPORTING REQUIREMENTS
77
 
 
 
4.9
PROVIDER SERVICES
77
 
 
 
4.9.1
GENERAL PROVISIONS
77
 
 
 
4.9.2
PROVIDER HANDBOOKS
77
 
 
 
4.9.3
EDUCATION AND TRAINING
78
 
 
 
4.9.4
PROVIDER RELATIONS
78
 
 
 
4.9.5
TOLL-FREE PROVIDER SERVICES TELEPHONE LINE
79
 
 
 
4.9.6
INTERNET PRESENCE/WEB SITE
79
 
 
 
4.9.7
PROVIDER COMPLIANT SYSTEM
79
 
 
 
4.9.7.1
CLAIMS ADJUSTMENT REQUESTS
81
 
 
 
4.9.1
REPORTING REQUIREMENTS
82
 
 
 
4.10
PROVIDER CONTRACTS AND PAYMENTS
82
 
 
 
4.10.1
PROVIDER CONTRACTS
82
 
 
 
4.10.2
PROVIDER TERMINATION
84
 
 
 
4.10.3
PROVIDER INSURANCE
85
 
 
 
4.10.4
PROVIDER PAYMENT
85
 
 
 
4.10.5
REPORTING REQUIREMENTS
86
 
 
 
4.10.6
PROVIDER PAYMENT AGREEMENT
87
 
 
 
4.11
UTILIZATION MANAGEMENT AND CARE COORDINATION RESPONSIBILITIES
87
 
 
 

6



4.11.1
UTILIZATION MANAGEMENT
87
 
 
 
4.11.2
PRIOR AUTHORIZATION AND PRE-CERTIFICATION
88
 
 
 
4.11.3
REFERRAL REQUIREMENTS AND P4HB PARTICIPANTS
88
 
 
 
4.11.4
TRANSITION OF MEMBERS
89
 
 
 
4.11.5
BACK TRANSFERS
91
 
 
 
4.11.6
COURT-ORDERED EVALUATIONS AND SERVICES
92
 
 
 
4.11.7
SECOND OPINIONS
92
 
 
 
4.11.8
CARE COORDINATION RESPONSIBILITIES
92
 
 
 
4.11.9
CASE MANAGEMENT
92
 
 
 
4.11.10
DISEASE MANAGEMENT
93
 
 
 
4.11.11
DISCHARGE PLANNING
93
 
 
 
4.11.12
REPORTING REQUIREMENTS
94
 
 
 
4.12
QUALITY IMPROVEMENT
94
 
 
 
4.12.1
GENERAL PROVISIONS
94
 
 
 
4.12.2
QUALITY STRATEGIC PLAN REQUIREMENTS
94
 
 
 
4.12.3
PERFORMANCE MEASURES
95
 
 
 
4.12.4
REPORTING REQUIREMENTS
95
 
 
 
4.12.5
QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT (QAPI) PROGRAM
96
 
 
 
4.12.6
PERFORMANCE IMPROVEMENT PROJECTS
97
 
 
 
4.12.7
PRACTICE GUIDELINES
97
 
 
 
4.12.8
FOCUSED STUDIES
98
 
 
 
4.12.9
PATIENT SAFETY PLAN
98
 
 
 
4.12.10
RESERVED
98
 
 
 
4.12.11
EXTERNAL QUALITY REVIEW
98
 
 
 
4.12.12
REPORTING REQUIREMENTS
98
 
 
 

7



4.13
FRAUD AND ABUSE
99
 
 
 
4.13.1
PROGRAM INTEGRITY
99
 
 
 
4.13.2
COMPLIANCE PLAN
99
 
 
 
4.13.3
COORDINATION WITH DCH AND OTHER AGENCIES
100
 
 
 
4.13.4
REPORTING REQUIREMENTS
100
 
 
 
4.14
INTERNAL GRIEVANCE/APPEALS SYSTEM
100
 
 
 
4.14.1
GENERAL REQUIREMENTS
100
 
 
 
4.14.1.2
MEMBER MEDICAL REVIEW PROCESS FOR PEACHCARE FOR KIDS®
101
 
 
 
4.14.2
GRIEVANCE PROCESS
102
 
 
 
4.14.3
PROPOSED ACTION
102
 
 
 
4.14.4
ADMINISTRATIVE REVIEW PROCESS
103
 
 
 
4.14.5
NOTICE OF ADVERSE ACTION
104
 
 
 
4.14.6
ADMINISTRATIVE LAW HEARING
104
 
 
 
4.14.7
CONTINUATION OF BENEFITS WHILE THE CONTRACTOR APPEAL AND ADMINISTRATIVE LAW HEARING ARE PENDING
105
 
 
 
4.14.8
REPORTING REQUIREMENTS
106
 
 
 
4.15
ADMINISTRATIVE AND MANAGEMENT
106
 
 
 
4.15.1
GENERAL PROVISIONS
106
 
 
 
4.15.2
PLACE OF BUSINESS AND HOURS OF OPERATION
106
 
 
 
4.15.3
TRAINING
106
 
 
 
4.14.4
DATA AND REPORT CERTIFICATION
107
 
 
 
4.16
CLAIMS MANAGEMENT
107
 
 
 
4.16.1
GENERAL PROVISIONS
107
 
 
 
4.16.2
OTHER CONSIDERATIONS
108
 
 
 
4.16.3
ENCOUNTER DATA SUBMISSION REQUIREMENTS
108
 
 
 
4.16.4
REPORTING REQUIREMENTS
109

8



4.16.5
EMERGENCY HEALTH CARE SERVICES
109
 
 
 
4.17
INFORMATION MANAGEMENT AND SYSTEMS
110
 
 
 
4.17.1
GENERAL PROVISIONS
110
 
 
 
4.17.2
HEALTH INFORMATION TECHNOLOGY AND EXCHANGE
110
 
 
 
4.17.3
GLOBAL SYSTEM ARCHITECHTURE AND DESIGN REQUIREMENTS
111
 
 
 
4.17.4
DATA AND DOCUMENT MANAGEMENT REQUIREMENTS BY MAJOR INFORMATION TYPE
112
 
 
 
4.17.5
SYSTEM AND DATA INTEGRATION REQUIREMENTS
112
 
 
 
4.17.6
SYSTEM ACCESS MANAGEMENT ND INFORMATION ACCESSIBLITY REQUIREMENTS
112
 
 
 
4.17.7
SYSTEMS AVAILABILITY AND PERFORMANCE REQUIREMENTS
113
 
 
 
4.17.8
SYSTEM USER AND TECHNICAL SUPPORT REQUIREMENTS
114
 
 
 
4.17.9
SYSTEM CHANGE MANAGEMENT REQUIREMENTS
115
 
 
 
4.17.10
SYSTEM SECURITY AND INFORMATION CONFIDENTIALITY AND PRIVACY REQUIREMENTS
116
 
 
 
4.17.11
INFORMATION MANAGEMENT PROCESS & INFORMATION SYSTEMS DOCUMENTATION REQUIREMENTS
116
 
 
 
4.17.12
REPORTING REQUIREMENTS
117
 
 
 
4.18
REPORTING REQUIREMENTS
117
 
 
 
4.18.1
GENERAL PROCEDURES
117
 
 
 
4.18.2
WEEKLY REPORTING
117
 
 
 
4.18.3
MONTHLY REPORTING
117
 
 
 
4.18.4
QUARTERLY REPORTING
119
 
 
 
4.18.5
ANNUAL REPORTS
124
 
 
 
4.18.6
AD HOC REPORTS
125
 
 
 
5.0
DELIVERABLES
125
 
 
 
5.1
CONFIDENTIALITY
125
 
 
 
5.2
NOTICE OF APPROVAL/DISAPPROVAL
125
 
 
 

9



5.3
RESUBMISSION WITH CORRECTIONS
126
 
 
 
5.4
NOTICE OF APPROVAL/DISAPPROVAL OF RESUBMISSION
126
 
 
 
5.5
DCH FAILS TO RESPOND
126
 
 
 
5.6
REPRESENTATIONS
126
 
 
 
5.7
CONTRACT DELIVERABLES
126
 
 
 
5.8
CONTRACT REPORTS
128
 
 
 
6.0
TERM OF CONTRACT
130
 
 
 
7.0
PAYMENT FOR SERVICES
130
 
 
 
7.1
GENERAL PROVISIONS
130
 
 
 
7.2
PERFORMANCE INCENTIVES
131
 
 
 
8.0
FINANCIAL MANAGEMENT
131
 
 
 
8.1
GENERAL PROVISIONS
131
 
 
 
8.2
SOLVENCY AND RESERVES STANDARDS
132
 
 
 
8.3
REINSURANCE
132
 
 
 
8.4
THIRD PARTY LIABILITY AND COORDINATION OF BENEFITS
132
 
 
 
8.4.2
COST AVOIDANCE
132
 
 
 
8.4.3
COMPLIANCE
132
 
 
 
8.5
PHYSICIAN INCENTIVE PLAN
133
 
 
 
8.6
REPORTING REQUIREMENTS
133
 
 
 
9.0
PAYMENT OF TAXES
135
 
 
 
10.0
RELATIONSHIP OF PARTIES
135
 
 
 
11.0
INSPECTION OF WORK
135
 
 
 
12.0
STATE PROPERTY
136
 
 
 
13.0
OWNERSHIP AND USE OF DATA
136
 
 
 
13.1
SOFTWARE AND OTHER UPGRADES
137
 
 
 

10



14.0
CONTRACTOR: STAFFING ASSIGNMENTS & CREDENTIALS
137
 
 
 
14.1
STAFFING CHANGES
138
 
 
 
14.2
CONTRACTOR'S FAILURE TO COMPLY
138
 
 
 
15.0
CRIMINAL BACKGROUND CHECKS
138
 
 
 
16.0
SUBCONTRACTS
139
 
 
 
16.1
USE OF SUBCONTRACTORS
139
 
 
 
16.2
COST OR PRICING BY SUBCONTRACTORS
139
 
 
 
17.0
LICENSE, CERTIFICATE, PERMIT REQUIREMENT
139
 
 
 
18.0
RISK OF LOSS AND REPRESENTATIONS
140
 
 
 
19.0
PROHIBITION OF GRATUITIES AND LOBBYIST DISCLOSURES
140
 
 
 
20.0
RECORDS REQUIREMENTS
140
 
 
 
20.1
RECORDS RETENTION REQUIREMENTS
141
 
 
 
20.2
ACCESS TO RECORDS
141
 
 
 
20.3
MEDICAL RECORDS REQUESTS
142
 
 
 
21.0
CONFIDENTIALITY REQUIREMENTS
142
 
 
 
21.1
GENERAL CONFIDENTIALITY REQUIREMENTS
142
 
 
 
21.2
HIPAA COMPLIANCE
142
 
 
 
22.0
TERMINATION OF CONTRACT
142
 
 
 
22.1
GENERAL PROCEDURES
142
 
 
 
22.2
TERMINATION BY DEFAULT
142
 
 
 
22.3
TERMINATION FOR CONVENIENCE
143
 
 
 
22.4
TERMINATION FOR INSOLVENCY OR BANKRUPTCY
143
 
 
 
22.5
TERMINATION FOR INSUFFICIENT FUNDING
143
 
 
 
22.6
TERMINATION PROCEDURES
143
 
 
 
22.7
TERMINATION CLAIMS
144
 
 
 

11



23.0
LIQUIDATED DAMAGES
145
 
 
 
23.1
GENERAL PROVISIONS
145
 
 
 
23.2
CATEGORY 1
145
 
 
 
23.3
CATEGORY 2
145
 
 
 
23.4
CATEGORY 3
146
 
 
 
23.5
CATEGORY 4
147
 
 
 
23.6
OTHER REMEDIES
148
 
 
 
23.7
NOTICE OF REMEDIES
148
 
 
 
24.0
INDEMNIFICATION
148
 
 
 
25.0
INSURANCE
149
 
 
 
26.0
PAYMENT BOND & IRREVOCABLE LETTER OF CREDIT
149
 
 
 
27.0
COMPLIANCE WITH ALL LAWS
150
 
 
 
27.1
NON-DISCRIMINATION
150
 
 
 
27.2
DELIVERY OF SERVICE AND OTHER FEDERAL LAWS
150
 
 
 
27.3
COST OF COMPLIANCE WITH APPLICABLE LAWS
151
 
 
 
27.4
GENERAL COMPLIANCE
151
 
 
 
28.0
CONFLICT RESOLUTION
151
 
 
 
29.0
CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE
151
 
 
 
30.0
NOTICE
151
 
 
 
31.0
MISCELLANEOUS
152
 
 
 
31.1
CHOICE OF LAW OR VENUE
152
 
 
 
31.2
ATTORNEY'S FEES
152
 
 
 
31.3
SURVIVABILITY
152
 
 
 
31.4
DRUG-FREE WORKPLACE
153
 
 
 
31.5
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT AND OTHER MATTERS
153

12



31.6
WAIVER
153
 
 
 
31.7
FORCE MAJEURE
153
 
 
 
31.8
BINDING
153
 
 
 
31.9
TIME IS OF THE ESSENCE
153
 
 
 
31.10
AUTHORITY
153
 
 
 
31.11
ETHICS IN PUBLIC CONTRACTING
153
 
 
 
31.12
CONTRACT LANGUAGE INTERPRETATION
153
 
 
 
31.13
ASSESSMENT OF FEES
154
 
 
 
31.14
COOPERATION WITH OTHER CONTRACTORS
154
 
 
 
31.15
SECTION TITLES NOT CONTROLLING
154
 
 
 
31.16
LIMITATION OF LIABILITY/EXCEPTIONS
154
 
 
 
31.17
COOPERATION WITH AUDITS
154
 
 
 
31.18
HOMELAND SECURITY CONSIDERATIONS
154
 
 
 
31.19
PROHIBITED AFFILIATIONS IWTH INDIVIDUALS DEBARRED AND SUSPENDED
155
 
 
 
31.20
OWNERSHIP AND FINANCIAL DISCLOSURE
155
 
 
 
32.0
AMENDMENT IN WRITING
155
 
 
 
33.0
CONTRACT ASSIGNMENT
155
 
 
 
34.0
SEVERABILITY
155
 
 
 
35.0
COMPLIANCE WITH AUDITING AND REPORTING REQUIREMENTS FOR NONPROFIT ORGANIZATIONS (O.C.G.A §50-20-1 ET SEQ.)
156
 
 
 
36.0
ENTIRE AGREEMENT
157
 
 
 
SIGNATURE PAGE
157
 
 
 
ATTACHMENT A
 
DRUG FREE WORKPLACE CERTIFICATE
157
 
 
 
ATTACHMENT B
 
 
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, PROPOSED DEBARMENT, AND OTHER RESPONSIBILITY MATTERS
159


13



ATTACHMENT C
 
 
NONPROFIT ORGANIZATION DISCLOSURE FORM
161
 
 
 
ATTACHMENT D
 
 
CONFIDENTIALITY STATEMENT
162
 
 
 
ATTACHMENT E
 
 
BUSINESS ASSOCIATE AGREEMENT
163
 
 
 
ATTACHMENT F
 
 
VENDOR LOBBYIST DISCLOSURE & REGISTRATION CERTIFICATION FORM
166
 
 
 
ATTACHMENT G
 
 
RESERVED
168
 
 
 
ATTACHMENT H
 
 
CAPITATION PAYMENT
169
 
 
 
ATTACHMENT I
 
 
NOTICE OF YOUR RIGHT TO A HEARING
170
 
 
 
ATTACHMENT J
 
 
MAP OF SERVICE REGIONS/LIST OF COUNTIES BY SERVICE REGIONS
171
 
 
 
ATTACHMENT K
 
 
APPLICABLE CO-PAYMENTS
172
 
 
 
ATTACHMENT L
 
 
INFORMATION MANAGEMENT SYSTEMS
173
 
 
 
ATTACHMENT M
 
 
PERFORMANCE MEASURES
185
 
 
 
ATTACHMENT N
 
 
DEMONSTRATION COVERED SERVICES
187
 
 
 
ATTACHMENT O
 
 
DEMONSTRATION QUALITY STRATEGY
190
 
 
 
ATTACHMENT P
 
 
RESOURCE MOTHER OUTREACH
196
 
 
 
ATTACHMENT Q
 
 
CENTERS FOR MEDICARE & MEDICAID SERVICES SPECIAL TERMS AND CONDITIONS
198
 
 
 
ATTACHMENT R
 
 
TABLE OF CONTRACTED RATES
210
 
 
 


14



ATTACHMENT S
 
 
STATEMENT OF ETHICS
211
 
 
 
ATTACHMENT T
 
 
DCH Ethics in Procurement Policy
215
 
 
 
ATTACHMENT U
 
 
Code of Ethics and Conflict of Interest Policy
221

15



THIS AMENDED AND RESTATED CONTRACT is made and entered into by and between the Georgia Department of Community Health (hereinafter referred to as “DCH” or the “Department”) and WellCare of Georgia, Inc. (hereinafter referred to as the “Contractor”) and is made effective on the date signed by the DCH Commissioner (hereinafter referred to as the “Effective Date”).

WHEREAS, DCH is responsible for health care policy, purchasing, planning and regulation pursuant to the Official Code of Georgia Annotated (O.C.G.A.) § 31-2-1 et seq.;
 
WHEREAS, DCH is the single State agency designated to administer medical assistance in Georgia under Title XIX of the Social Security Act of 1935, as amended, and O.C.G.A. §§ 49-4-140 et seq. (the “Medicaid Program”), and is charged with ensuring the appropriate delivery of health care services to Medicaid recipients and PeachCare for Kids® Members;
 
WHEREAS, DCH caused Request for Proposals Number 41900-001-0000000027 (hereinafter the “RFP”) to be issued through the Department of Administrative Services (DOAS), and it is expressly incorporated as if completely restated herein;
 
WHEREAS, DCH received from Contractor a proposal in response to RFP Number 41900-001-0000000027 on or about April 1, 2005 (hereinafter “Contractor’s Proposal”) which is expressly incorporated as if completely restated herein;
 
WHEREAS, DCH accepted Contractor’s Proposal and entered into a contract with Contractor on July 18, 2005, for the provision of various services for the Department;
 
WHEREAS, DCH and Contractor now wish to amend and restate the Contract in its entirety; and
 
WHEREAS, the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services (CMS) must approve this Amended and Restated Contract as a condition precedent to its becoming effective for any purpose.
 
NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Department and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

1.0
SCOPE OF SERVICE
1.0.1
The State of Georgia is implementing reforms to the Medicaid and PeachCare for Kids® programs. These reforms will focus on system-wide improvements in performance and quality, will consolidate fragmented systems of care, and will prevent unsustainable trend rates in Medicaid and PeachCare for Kids® expenditures. The reforms will be implemented through a management of care approach to achieve the greatest value for the most efficient use of resources.
1.0.2
The Contractor shall assist the State of Georgia in this endeavor through the following tasks, obligations, and responsibilities.
1.1
BACKGROUND
1.1.1
In 2003, the Georgia Department of Community Health (DCH) identified unsustainable Medicaid growth and projected that without a change to the system, Medicaid would require 50 percent of all new State revenue by 2008. In addition, Medicaid utilization was driving more than 35 percent of total growth each year. For that reason, DCH decided to employ a management of care approach to organize its fragmented system of care, enhance access, achieve budget predictability, explore possible cost containment opportunities and focus on system-wide performance improvements. Furthermore, DCH believed that managed care could continuously and incrementally improve the quality of healthcare and services provided to patients and improve efficiency by utilizing both human and material resources more effectively and more efficiently. The DCH Division of Managed Care and Quality submitted a State Plan Amendment in 2004 to implement a full-risk mandatory Medicaid Managed Care program called Georgia Families.
1.1.2
Effective June 1, 2006 the state of Georgia implemented Georgia Families (GF), a managed care program through which health care services are delivered to members of Medicaid and PeachCare for Kids®. The intent of this program is to:


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Offer care coordination to members
Enhance access to health care services
Achieve budget predictability as well as cost containment
Create system-wide performance improvements
Continually and incrementally improve the quality of health care and services provided to members
Improve efficiency at all levels

1.1.3
The GF program is designed to:

Improve the Health Care status of the Member and Planning for Healthy Babies (P4HB) 1115 Demonstration Participant population;
Establish a Provider Home for the Member and P4HB Interpregnancy Care Participant through its use of assigned Primary Care Providers (PCPs);
Establish a climate of contractual accountability among the state, the care management organizations and the health care Providers;
Slow the rate of expenditure growth in the Medicaid program; and
Expand and strengthen a sense of the Member’s and P4HB Participant’s responsibility that leads to more appropriate utilization of health care services
1.2
ELIGIBILITY FOR GEORGIA FAMILIES
1.2.1
Medicaid
 
1.2.1.1
The following Medicaid eligibility categories are required to enroll in GF:
Low Income Families – Adults and children who meet the standards of the old AFDC (Aid to Families with Dependent Children) program
Transitional Medicaid – Former Low-Income Medicaid (LIM) families who are no longer eligible for LIM because their earned income exceeds the income limit.
Pregnant Women (Right from the Start Medicaid - RSM) – Pregnant women with family income at or below two hundred percent (200%) of the federal poverty level who receive Medicaid through the RSM program.
Children (Right from the Start Medicaid - RSM) – Children less than nineteen (19) years of age whose family income is at or below the appropriate percentage of the federal poverty level for their age and family.
Children (newborn) – A child born to a woman who is eligible for Medicaid on the day the child is born.
Women Eligible Due to Breast and Cervical Cancer Women less than sixty-five (65) years of age who have been screened through Title XV Center for Disease Control (CDC) screening and have been diagnosed with breast or cervical cancer.
Refugees – Those individuals who have the required INS documentation showing they meet a status in one of these groups: refugees, asylees, Cuban parolees/Haitian entrants, Amerasians or human trafficking victims.
Planning for Healthy Babies 1115 Demonstration Waiver Participants (otherwise known as P4HB Participants) – Women ages 18 through 44 who are otherwise uninsured with family income at or below two hundred percent (200%) of the Federal poverty level. This Demonstration includes two distinct groups: women eligible for Family Planning Services only and women eligible for Interpregnancy Care and Family Planning Services.
 
1.2.1.2
The following Medicaid eligibility categories are required to receive Resource Mothers Outreach through GF:


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Women ages 18 through 44 who qualify under the Low Income Medicaid Class of Assistance under the Georgia Medicaid State Plan who are already enrolled in GF and who deliver a Very Low Birth Weight (VLBW) baby on or after January 1, 2011.

Women ages 18 through 44 who qualify under the Aged Blind and Disabled Classes of Assistance under the Georgia Medicaid State Plan and who deliver a VLBW baby on or after January 1, 2011.

1.2.2    PeachCare for Kids®
 
1.2.2.1
PeachCare for Kids® – The State Children’s Health Insurance Program (SCHIP) in Georgia. Children less than nineteen (19) years of age who have family income that is less than two hundred thirty-five percent (235%) of the federal poverty level, who are not eligible for Medicaid, or any other health insurance program are eligible for services under PeachCare for Kids®. Effective January 1, 2012, employees of the State of Georgia may enroll their children in PeachCare for Kids® if the employee meets income and other eligibility requirements of the program.
1.2.3
Exclusions
1.2.3.1
The following recipients are excluded from Enrollment in GF, even if the recipient is otherwise eligible for GF per section 1.2.1 and section 1.2.2.

Recipients eligible for Medicare;

Recipients that are Members of a Federally Recognized Indian Tribe;

Recipients that are enrolled in fee-for-service Medicaid through Supplemental Security Income prior to enrollment in GF. Members that are already enrolled in a CMO through GF will remain in that CMO until the disenrollment is completed through the normal monthly process.

Children less than twenty-one (21) years of age who are in foster care or other out-of-home placement;

Children less than twenty-one (21) years of age who are receiving foster care or other adoption assistance under Title IV-E of the Social Security Act.

Medicaid children enrolled in the Children’s Medical Services program administered by the Georgia Department of Public Health;

Children less than twenty-one (21) years of age who are receiving foster care or other adoption assistance under Title IV-E of the Social Security Act (NOTE: Foster Children in “Relative” placement remain within the Georgia Families program);

Children enrolled in the Georgia Pediatric Program (GAPP);

Recipients enrolled under group health plans for which DCH provides payment for premiums, deductibles, coinsurance and other cost sharing, pursuant to Section 1906 of the Social Security Act.

Individuals enrolled in a Hospice category of aid.

Individuals enrolled in a Nursing Home category of aid.

Individuals enrolled in a Community Based Alternative for Youths (CBAY)

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1.2.3.2
The following recipients are excluded from the P4HB Demonstration (hereinafter referred to as “the Demonstration”):
 
Women who become pregnant while enrolled in the Demonstration.
Women determined to be infertile (sterile) or who are sterilized while enrolled in the Demonstration.
Women who become eligible for any other Medicaid or commercial insurance program.
Women who no longer meet the Demonstration’s eligibility requirements
Women who are or become incarcerated.
1.3
SERVICE REGIONS
1.3.1
For the purposes of coordination and planning, DCH has divided the State, by county, into six (6) Service Regions. See Attachment J for a listing of the counties in each Service Region.
1.3.2
Members and P4HB Participants will choose or will be assigned to a Care Management Organization (CMO) plan that is operating in the Service Region in which they reside.
1.3.3
Contractor has the option of operating in all six (6) Service Regions within the State. Should Contractor choose this option, Contractor shall seek DCH approval pursuant to Section 1.3.4. Once approval is obtained, Contractor shall provide health care services in no less than all six (6) Service Regions and must meet all requirements set forth in the Contract, including, but not limited to, the following Sections: 4.8.5.2, 4.8.7.1, 4.8.8.1, 4.8.9.1, 4.8.13, 4.8.14, 4.8.17.1, 4.11.1.2, 4.11.1.3, 4.15.2.1, and 26.1.
1.3.4
Before DCH will approve the Contractor’s expansion into all six (6) Service Regions, the Contractor must demonstrate its ability to comply with all Contract requirements in these Service Regions by submitting the following to DCH no later than 5:00 pm EST on December 5, 2011: (a) an affidavit that the Contractor has met all applicable Contract requirements in these Service Regions; and (b) geographic access reports and supporting documentation regarding network access. If the Department approves the Contractor’s request, the effective date of the Service Region expansion will be January 1, 2012.
1.3.5
DCH reserves the right to require that the Contractor’s expansion in a particular Service Region reach all areas of the Service Region in question.
1.4
DEFINITIONS

Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

Abandoned Call: A call in which the caller elects a valid option and is either not permitted access to that option or disconnects from the system.

Abuse:  Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid 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 Member and P4HB Participant practices that result in unnecessary cost to the Medicaid program.

Administrative Law Hearing:  The appeal process administered by the State in accordance with O.C.G.A. §49-4-153 and as required by federal law, available to Members, P4HB Participants and Providers after they exhaust the Contractor’s Appeals Process.

Administrative Review:  The formal reconsideration, as a result of the proper and timely submission of a Provider’s, Member’s or P4HB Participant’s request, by an Office or Unit of the Division, which has proposed an adverse action.

Administrative Service(s):  The contractual obligations of the Contractor that include but may not be limited to utilization management, credentialing providers, network management, quality improvement, marketing, enrollment, Member and P4HB Participant services, claims payment, management information systems, financial management, and reporting.


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Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).
 
Advance Directives: A written instruction, such as a living will or durable power of attorney for Health Care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of Health Care when the individual is incapacitated.

After-Hours:  Provider office/visitation hours extending beyond the normal business hours of a Provider, which are Monday-Friday 9-5:30 and may extend to Saturday hours.

Agent:  An entity that contracts with the State of Georgia to perform administrative functions, including but not limited to: fiscal agent activities; outreach, eligibility, and Enrollment activities; Systems and technical support; etc.

Appeal: A request for review of an action, as “action” is defined in 42 C.F.R. §438.400.

Appeals Process:  The overall process that includes Appeals at the Contractor level and access to the State Fair Hearing process (the State’s Administrative Law Hearing).

Assess:  Means the process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

At Risk:  Any service for which the Provider agrees to accept responsibility to provide, or arrange for, in exchange for the Capitation payment and Obstetrical: Delivery Payments.

Authoritative Host:  A system that contains the master or “authoritative” data for a particular data type, e.g. Member, Provider, CMO, etc. The Authoritative Host may feed data from its master data files to other systems in real time or in batch mode. Data in an Authoritative Host is expected to be up-to-date and reliable.
Authorized Representative:  A person authorized by the Member or P4HB Participant in writing to make health-related decisions on behalf of a Member or P4HB Participant, including, but not limited to Enrollment and Disenrollment decisions, filing Appeals and Grievances with the Contractor, and choice of a Primary Care Physician (PCP). The authorized representative is either the Parent or Legal Guardian for a child. For an adult this person is either the legal guardian (guardianship action), health care or other person that has power of attorney, or another signed HIPAA compliant document indicating who can make decisions on behalf of the member. 

Automatic Assignment (or Auto-Assignment):  The Enrollment of an eligible person, for whom Enrollment is mandatory, in a CMO plan chosen by DCH or its Agent. Also the assignment of a new Member or P4HB IPC Participant to a PCP chosen by the CMO Plan, pursuant to the provisions of this Contract.

Benefits:  The Health Care services set forth in this Contract, for which the Contractor has agreed to provide, arrange, and be held fiscally responsible.

Blocked Call:  A call that cannot be connected immediately because no circuit is available at the time the call arrives or the telephone system is programmed to block calls from entering the queue when the queue backs up beyond a defined threshold.

Business Days: Monday through Friday from 9 A.M. to 5 P.M., excluding State holidays.

Calendar Days:  All seven days of the week.

Capitation:  A Contractual agreement through which a Contractor agrees to provide specified Health Care services to Members and P4HB Participants for a fixed amount per month. Payments are contingent upon the availability of appropriated funds.

Capitation Payment:  A payment, fixed in advance, that DCH makes to a Contractor for each Member and P4HB Participant covered under a Contract for the provision of medical services and assigned to the Contractor. This payment is made regardless of whether the Member or P4HB Participant receives Covered Services or Benefits during the period covered by the payment. Payments are contingent upon the availability of appropriated funds.


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Capitation Rate:  The fixed monthly amount that the Contractor is paid by DCH for each Member and P4HB Participant assigned to the Contractor to ensure that Covered Services and Benefits under this Contract are provided. Payments are contingent upon the availability of appropriated funds.

Capitated Service:  Any Covered Service for which the Contractor receives an actuarially sound Capitation Payment.

Care Coordination: A set of Member-centered, goal-oriented, culturally relevant, and logical steps to assure that a Member receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care Coordination is also referred to as Care Management.

Care Management Organization (CMO): An entity organized for the purpose of providing Health Care, has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers, and furnishes Health Care services on a capitated basis to Members and P4HB Participants in a designated Service Region.

Case Management: Any intensive intervention undertaken with the purpose of helping Members and P4HB IPC Participants receive appropriate care. In the case of a P4HB IPC Participant, case management follows the delivery of a Very Low Birth Weight infant where that P4HB Participant has any disease(s) or condition(s) which may have contributed to the Very Low Birth Weight birth. Case Management is distinguished from utilization management in that it is voluntary and it is distinguished from disease management by its intensity and focus on any disease(s) or conditions the Member and P4HB IPC Participant has.

Centers for Medicare & Medicaid Services (CMS):  The Agency within the U.S. Department of Health and Human Services with responsibility for the Medicare, Medicaid and the State Children’s Health Insurance Program.

Certified Nurse Midwife (CNM): A registered professional nurse who is legally authorized under State law to practice as a nurse-midwife, and has completed a program of study and clinical experience for nurse-midwives or equivalent.

Children’s Health Insurance Program (CHIP formerly State Children’s Health Insurance Program (SCHIP)): A joint federal-state Health Care program for targeted, low-income children, established pursuant to Title XXI of the Social Security Act. Georgia’s CHIP is called PeachCare for Kids®.

Chronic Condition:  Any ongoing physical, behavioral, or cognitive disorder, including chronic illnesses, impairments and disabilities. There is an expected duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications, special diet, assistive device, etc) and service use or need beyond that which is considered Routine Care.

Claim:  A bill for services, a line item of services, or all services for one recipient within a bill.

Claims Administrator:  The entity engaged by DCH to provide Administrative Service(s) to the CMO Plans in connection with processing and adjudicating risk-based payment, and recording health benefit encounter Claims for Members and P4HB Participants.

Claim Adjustment:  A claim that has been incorrectly paid, incorrectly submitted or, as the result of an updated payment policy, the payment amount can be changed.

Clean Claim:  A claim received by the CMO for adjudication, in a nationally accepted format in compliance with standard coding guidelines, which requires no further information, adjustment, or alteration by the Provider of the services in order to be processed and paid by the CMO. The following exceptions apply to this definition: i. A Claim for payment of expenses incurred during a period of time for which premiums are delinquent; ii. A Claim for which Fraud is suspected; and iii. A Claim for which a Third Party Resource should be responsible.

Cold-Call Marketing:  Any unsolicited personal contact by the CMO Plan, with a potential Member or P4HB Participant, for the purposes of marketing.

Community Mental Health Rehabilitation Services (CMHRS): Services that are intended for the maximum reduction of mental disability and restoration of an individual to his or her best possible functional level.

Completion/Implementation Timeframe: The date or time period projected for a project goal or objective to be met, for progress to be demonstrated or for a proven intervention to be established as the standard of care for the Contractor.


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Condition:  A disease, illness, injury, disorder, of biological, cognitive, or psychological basis for which evaluation, monitoring and/or treatment are indicated.

Consecutive Enrollment Period:  The consecutive twelve (12) month period beginning on the first day of Enrollment or the date the notice is sent, whichever is later. For Members and P4HB Participants that use their option to change CMO plans without cause during the first ninety (90) Calendar Days of Enrollment, the twelve-month consecutive Enrollment period will commence when the Member or P4HB Participant enrolls in the new CMO plan. This is not to be construed as a guarantee of eligibility during the consecutive Enrollment period.

Contested Claim:  A Claim that is denied because the Claim is an ineligible Claim, the Claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the Claim requires special treatment.

Contract:  The written agreement between the State and the Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

Contract Award: The date upon which DCH issues the Apparent Successful Offeror Letters.

Contract Execution:  The date upon which all parties have signed the Contract.

Contractor:  The Care Management Organization with a valid Certificate of Authority in Georgia that contracts hereunder with the State for the provision of comprehensive Health Care services to Members on a capitated basis.

Contractor’s Representative:  The individual legally empowered to bind the Contractor, using his/her signature block, including his/her title. This individual will be considered the Contractor’s Representative during the life of any Contract entered into with the State unless amended in writing.

Co-payment:  The part of the cost-sharing requirement for Members in which a fixed monetary amount is paid for certain services/items received from the Contractor’s Providers.

Core Services: Covered services for both the Rural Health Centers (RHC) and Federally Qualified Health Centers (FQHC) programs defined as follows: Physician services, including required physician supervision of Physician Assistants (PAs), Nurse Practitioners (NPs), and Certified Nurse Midwives (CNMs); services and supplies furnished as incident to physician professional services; services of PAs, NPs and CNMs; services of clinical psychologists and clinical social workers (when providing diagnosis and treatment of mental illness); services and supplies furnished as incident to professional services provided by PAs, NPs, CNMs, clinical psychologists, and clinical social workers; Visiting nurse services on a part time or intermittent basis to homebound patients (limited to areas in which there is a designated shortage of home health agencies).

Corrective Action Plan:  The detailed written plan required by DCH to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the CMO.
Corrective Action Preventive Action (CAPA): CAPA focuses on the systematic investigation of discrepancies (failures and/or deviations) in an attempt to prevent their reoccurrence. To ensure that corrective and preventive actions are effective, the systematic investigation of the failure incidence is pivotal in identifying the corrective and preventive actions undertaken.

Cost Avoidance:  A method of paying Claims in which the Provider is not reimbursed until the Provider has demonstrated that all available health insurance has been exhausted.

Covered Services:  Those Medically Necessary Health Care services provided to Members, the payment or indemnification of which is covered under this Contract or those Demonstration services provided to P4HB Participants, the payment or indemnification of which is covered under this Contract.

Credentialing:  The Contractor’s determination as to the qualifications and ascribed privileges of a specific Provider to render specific Health Care services.

Critical Access Hospital (CAH): Critical access hospital means a hospital that meets the requirements of the federal Centers for Medicare and Medicaid Services to be designated as a critical access hospital and that is recognized by the Department of Community Health as a critical access hospital for purposes of Medicaid.

Cultural Competency:  A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among and between groups and the sensitivity to know

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how these differences influence relationships with Members and P4HB Participants. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Member and P4HB Participant needs, and to work with knowledgeable persons of and from the community in developing focused interactions, communications, and other supports.

Deliverable:  A document, manual or report submitted to DCH by the Contractor to fulfill requirements of this Contract.

Demonstration: The 1115 Demonstration waiver program in Georgia supported by CMS that expands the delivery of family planning services to uninsured women, ages 18 through 44, who have family income at or below 200 percent of the Federal poverty level (FPL) and who are not otherwise eligible for Medicaid or the Children’s Health Insurance Program (CHIP). Also referred to as the Family Planning Waiver or the P4HB Program.

Demonstration Enrollee: An individual meeting P4HB Program eligibility requirements who selects or is otherwise assigned to a Georgia Families Care Management Organization in order to receive Demonstration services.

Demonstration Enrollment: The process by which an individual eligible for the P4HB program applies to utilize a Georgia Families Care Management Organization to receive Demonstration services and such application is approved by DCH or its Agent.

Demonstration Disenrollment:  The removal of a P4HB Participant from participation in the Demonstration.

Demonstration Period: The period from January 1, 2011 through December 31, 2013 in which the Demonstration will be effective.
Demonstration Provider: A physician, advanced practice nurse or other health care provider who meets the State’s Medicaid provider enrollment requirements for the Demonstration, hospital, facility, or pharmacy licensed or otherwise authorized to provide Demonstration related Services to P4HB Participants within the State or jurisdiction in which they are furnished. Also known as P4HB Provider.

Demonstration Related Emergency Medical Condition: A medical condition resulting from a Demonstration related Service and manifesting itself by acute symptoms of sufficient severity (including severe pain) 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 placing the health of the woman in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. A Demonstration related Emergency Medical condition shall not be defined on the basis of lists of diagnoses or symptoms.

Demonstration Related Post Stabilization Services: Covered Services related to Demonstration related Emergency Medical Condition that are provided after a P4HB Participant is stabilized in order to maintain the stabilized condition or to improve or resolve the P4HB Participant’s condition.

Demonstration Related Services: Those Demonstration Services identified in the CMS Special Terms and Conditions and approved by CMS that are available to P4HB Participants.

Demonstration Related Urgent Care Services: Medically Necessary treatment of a Demonstration related injury, illness or another type of Condition (usually not life threatening) which should be treated within twenty-four (24) hours.

Dental Subspecialty Providers:  Endodontists; Oral Pathologist; Orthodontist; Oral Surgeon; Periodontist; Pedodontist; Public Health Dentist; and Prosthodontist.

Department of Community Health (DCH):  The Agency in the State of Georgia responsible for oversight and administration of the Medicaid program, the PeachCare for Kids® program, the Planning for Healthy Babies Program and the State Health Benefits Plan (SHBP).

Department of Insurance (DOI):  The Agency in the State of Georgia responsible for licensing, overseeing, regulating, and certifying insuring entities.

Diagnostic Related Group (DRG):  Any of the payment categories that are used to classify patients and especially Medicare patients for the purpose of reimbursing hospitals for each case in a given category with a fixed fee regardless of the actual costs incurred and that are based especially on the principal diagnosis, surgical procedure used, age of patient, and expected length of stay in the hospital.


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Diagnostic Services:  Any medical procedures or supplies recommended by a physician or other licensed medical practitioner, within the scope of his or her practice under State law, to enable him or her to identify the existence, nature or extent of illness, injury, or other health deviation in a Member or P4HB Participant.

Discharge: Point at which Member or P4HB Participant is formally released from a hospital, by the treating physician, an authorized member of the physician’s staff or by the Member or P4HB Participant after they have indicated, in writing, their decision to leave the hospital contrary to the advice of their treating physician.
Disenrollment:  The removal of a Member from participation in the Contractor’s plan, but not necessarily from the Medicaid or PeachCare for Kids® program.

Documented Attempt: A bona fide, or good faith, attempt to contract with a Provider. Such attempts may include written correspondence that outlines contracted negotiations between the parties, including rate and contract terms disclosure, as well as documented verbal conversations, to include date and time and parties involved.

Durable Medical Equipment (DME):  Equipment, including assistive technology, which: a) can withstand repeated use; b) is used to service a health or functional purpose; c) is ordered by a qualified practitioner to address an illness, injury or disability; and d) is appropriate for use in the home, work place, or school.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program:  A Title XIX mandated program that covers screening and Diagnostic Services to determine physical and mental deficiencies in Members less than 21 years of age, and Health Care, treatment, and other measures to correct or ameliorate any deficiencies and Chronic Conditions discovered. P4HB Participants are not eligible to participate in the EPSDT Program.

Emergency Medical Condition:  A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) 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 placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of bodily functions, or serious dysfunction of any bodily organ or part. An Emergency Medical Condition shall not be defined on the basis of lists of diagnoses or symptoms.

Emergency Services:  Covered inpatient and outpatient services furnished by a qualified Provider needed to evaluate or stabilize an Emergency Medical Condition that is found to exist using the prudent layperson standard.

Encounter:  A distinct set of health care services provided to a P4HB Participant, Medicaid or PeachCare for Kids® Member enrolled with a Contractor on the dates that the services were delivered.

Encounter Data:  Health Care Encounter Data include: (i) All data captured during the course of a single Health Care encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices and equipment associated with the Member or P4HB Participant receiving services during the Encounter; (ii) The identification of the Member or P4HB Participant receiving and the Provider(s) delivering the Health Care services during the single Encounter; and, (iii) A unique, i.e. unduplicated, identifier for the single Encounter.

Enrollee:  See Member.

Enrollment:  The process by which an individual eligible for Medicaid or PeachCare for Kids® applies (whether voluntary or mandatory) to utilize the Contractor’s plan in lieu of fee for service and such application is approved by DCH or its Agent.

Enrollment Broker:  The entity engaged by DCH to assist in outreach, education and Enrollment activities associated with the GF program.
Enrollment Period:  The twelve (12) month period commencing on the effective date of Enrollment.

Evaluate:  The process used to examine and determine the level of quality or the progress toward improvement of quality and/or performance related to Contractor service delivery systems.

External Quality Review (EQR):  The analysis and evaluation by an external quality review organization of aggregated information on quality, timeliness, and access to the Health Care services that a CMO or its Subcontractors furnish to Members and to DCH.

External Quality Review Organization (EQRO):  An organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality review, and other related activities.

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Family Planning Provider: A physician, advanced practice nurse, or other health care provider who meets the State’s Medicaid provider enrollment requirements for the Demonstration and delivers or prescribes Family Planning Services.
 
Family Planning Services: Family planning services and supplies include at a minimum:

Education and counseling necessary to make informed choices and understand contraceptive methods;
Initial and annual complete physical examinations;
Follow-up, brief and comprehensive visits;
Pregnancy testing;
Contraceptive supplies and follow-up care;
Diagnosis and treatment of sexually transmitted diseases; and
Infertility assessment

Family Planning Waiver: See Demonstration.

Federal Financial Participation (FFP):  The funding contribution that the federal government makes to the Georgia Medicaid and PeachCare for Kids® programs.

Federally Qualified Health Center (FQHC):  An entity that provides outpatient health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.

Fee-for-Service (FFS):  A method of reimbursement based on payment for specific services rendered to a Member.

Financial Relationship:  A direct or indirect ownership or investment interest (including an option or non vested interest) in any entity. This direct or indirect interest may be in the form of equity, debt, or other means and includes any indirect ownership or investment interest no matter how many levels removed from a direct interest, or a compensation arrangement with an entity.

Fraud:  An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable federal or State law.
Georgia Families (GF): The risk-based managed care delivery program for Medicaid and PeachCare for Kids® in which the Department contracts with Care Management Organizations to manage the care of eligible Members and P4HB Participants.
 
Georgia Technology Authority (GTA): The state agency that manages the state’s information technology (IT) infrastructure i.e. data center, network and telecommunications services and security, establishes policies, standards and guidelines for state IT, promotes an enterprise approach to state IT, and develops and manages the state portal.
 
Grievance:  An expression of dissatisfaction about any matter other than an Action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided or aspects of interpersonal relationships such as rudeness of a Provider or employee, or failure to respect the Enrollee’s or P4HB Participant’s rights.
 
Grievance System:  The overall system that address the manner in which the CMO handles Grievances at the Contractor level.

Health Care:  Health Care means care, services, or supplies related to the health of an individual. Health Care includes, but is not limited to, the following: (i) Preventive, diagnostic, therapeutic, rehabilitative, maintenance, or palliative care, and counseling, service, assessment, or procedure with respect to the physical or mental Condition, or functional status, of an individual or that affects the structure or function of the body; and (ii) Sale or dispensing of a drug, device, equipment, or other item in accordance with a prescription.

Health Care Professional:  A physician or other Health Care Professional, including but not limited to podiatrists, optometrists, chiropractors, psychologists, dentists, physician’s assistants, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians licensed in the State of Georgia.

Health Check:  The State of Georgia’s Early and Periodic Screening, Diagnostic, and Treatment program pursuant to Title XIX of the Social Security Act.


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Health Information Technology: Hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for our support the use of health care entities or patients for the electronic creation, maintenance, access, or exchange of health information. Source is ARRA - H.R.1 -115 Sec. 3000 (5)

Health Information Technology for Economic and Clinical Health Act (HITECH Act) Title IV: The legislation establishes a transparent and open process for the development of standards that will allow for the nationwide electronic exchange of information between doctors, hospitals, patients, health plans, the government and others by the end of 2009. It establishes a voluntary certification process for health information technology products. The National Institute of Standards and Technology will provide for the testing of such products to determine if they meet the national standards that allow for the secure electronic exchange and use of health information.

Health Insurance Portability and Accountability Act (HIPAA):  A federal law that includes requirements to protect the privacy of individually identified health information in any format, including written or printed, oral and electronic, to protect the security of individually identified health information in electronic format, to prescribe methods and formats for exchange of electronic medical information, and to uniformly identify providers. When referenced in this Contract it includes all related rules, regulations and procedures.

Health Maintenance Organization:  As used in Section 8.6 a Health Maintenance Organization is an entity that is organized for the purpose of providing Health Care and has a Health Maintenance Organization Certificate of Authority granted by the State of Georgia, which contracts with Providers and furnishes Health Care services on a capitated basis to Members in a designated Service Region.

Health Professional Shortage Area (HPSA): An area designated by the United States Department of Health and Human Services’ Health Resources and Services Administration (HRSA) as being underserved in primary medical care, dental or mental health providers. These areas can be geographic, demographic or institutional in nature. A care area can be found using the following website: http://hpsafind.hrsa.gov/.

Healthcare Effectiveness Data and Information Set (HEDIS): A widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA).

Historical Provider Relationship: A Provider who has been the main source of Demonstration, Medicaid or PeachCare for Kids® services for the Member or P4HB Participant during the previous year (decided on by the most recent Provider on the Member’s or P4HB Participant’s claim history).

Immediately: Within twenty-four (24) hours.

In-Network Provider:  A Provider that has entered into a Provider Contract with the Contractor to provide services.

Incentive Arrangement:  Any mechanism under which a Contractor may receive additional funds over and above the Capitation rates, for exceeding targets specified in the Contract.

Incurred-But-Not-Reported (IBNR):  Estimate of unpaid Claims liability, includes received but unpaid Claims.

Individuals with Disabilities Education Act (IDEA): A United States federal law that ensures services to children with disabilities throughout the United States. IDEA governs how states and public agencies provide early intervention, special education and related services to children with disabilities.

Information:  i. Structured Data: Data that adhere to specific properties and Validation criteria that is stored as fields in database records. Structured queries can be created and run against structured data, where specific data can be used as criteria for querying a larger data set; ii. Document: Information that does not meet the definition of structured data includes text, files, spreadsheets, electronic messages and images of forms and pictures.

Information System/Systems:  A combination of computing hardware and software that is used in: (a) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of information, i.e. structured data (which may include digitized audio and video) and documents; and/or (b) the processing of such information for the purposes of enabling and/or facilitating a business process or related transaction.

Inpatient Facility: Hospital or clinic for treatment that requires at least one overnight stay.
Insolvent: Unable to meet or discharge financial liabilities.

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Interpregnancy Care (IPC): An additional benefit available to some P4HB Participants who meet the Demonstration’s eligibility requirements and who delivered a Very Low Birth Weight baby on or after initiation of the Demonstration.

Interpregnancy Care Services: Services available under the Demonstration for P4HB Participants who meet the eligibility criteria for the IPC program. These services are in addition to Family Planning Services and include: limited primary care services; management and treatment of chronic diseases; substance abuse treatment (detoxification and intensive outpatient rehabilitation); case management, including Resource Mothers Outreach; limited dental; prescription drugs (non-family planning) for the treatment of chronic conditions that may increase the risk of a subsequent VLBW delivery and non-emergency transportation.

Interpregnancy Care Service Providers: Those Demonstration Providers serving the IPC P4HB Participants including nurse case managers and Resource Mothers.

Limited-English-Proficient Population:  Individuals with a primary language other than English who must communicate in that language if the individual is to have an equal opportunity to participate effectively in, and benefit from, any aid, service or benefit provided by the health Provider.

Low Birth Weight: Birth weight below 2,500 grams (5.5 pounds).

Mandatory Enrollment:  The process whereby an individual eligible for the Demonstration, Medicaid or PeachCare for Kids® is required to enroll in a Contractor’s plan, unless otherwise exempted or excluded, to receive covered Demonstration, Medicaid or PeachCare for Kids® services.

Marketing:  Any communication from a CMO plan to any Demonstration, Medicaid or PeachCare for Kids® eligible individual that can reasonably be interpreted as intended to influence the individual to enroll in that particular CMO plan, or not enroll in or disenroll from another CMO plan.

Marketing Materials:  Materials that are produced in any medium, by or on behalf of a CMO, and can reasonably be interpreted as intended to market to any Demonstration, Medicaid or PeachCare for Kids® eligible individual.

Material Subcontractor:  A Subcontractor, excluding Providers, receiving Subcontractor payments from the Contractor in amounts equal to or greater than $10 million annually during the state fiscal year.

Measurable: Applies to a Contractor objective and means the ability to determine definitively whether or not the objective has been met, or whether progress has been made toward a positive outcome.

Medicaid:  The joint federal/state program of medical assistance established by Title XIX of the Social Security Act, which in Georgia is administered by DCH.

Medicaid Care Management Organizations Act: O.C.G.A. §33-21A-1, et seq. MEDICAID CARE MANAGEMENT ORGANIZATIONS ACT. A bill passed by the Georgia General Assembly, signed into law by the Governor, and effective July 1, 2008 which outlines several administrative requirements with which the administrators of the Medicaid Managed Care plan, Georgia Families, must comply. Some of the requirements include dental provider networks, emergency room claims payment requirements, eligibility verification, and others.

Medicaid Eligible:  An individual eligible to receive services under the Medicaid Program but not necessarily enrolled in the Medicaid Program.

Medicaid Management Information System (MMIS):  Computerized system used for the processing, collecting, analysis, and reporting of Information needed to support Medicaid and SCHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

Medical Director:  The licensed physician designated by the Contractor to exercise general supervision over the provision of health service Benefits by the Contractor.

Medical Records:  The complete, comprehensive records of a Member or P4HB Participant including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Member’s or P4HB Participant’s participating Primary Care or Demonstration physician or Provider, that document all medical services received by the Member or P4HB Participant,

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including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable DCH rules and regulations, and signed by the medical professional rendering the services.

Medical Screening:  An examination: i. provided on hospital property, and provided for that patient for whom it is requested or required, ii. performed within the capabilities of the hospital’s emergency room (ER) (including ancillary services routinely available to its ER) iii. the purpose of which is to determine if the patient has an Emergency Medical Condition, and iv. performed by a physician (M.D. or D.O.) and/or by a nurse practitioner, or physician assistant as permitted by State statutes and regulations and hospital bylaws.

Medically Necessary Services:  Those services that meet the definition found in Section 4.5.

Member: A Medicaid or PeachCare for Kids® recipient who is currently enrolled in a CMO plan.

Methodology: The planned process, steps, activities or actions taken by a Contractor to achieve a goal or objective, or to progress toward a positive outcome.

Monitoring:  The process of observing, evaluating, analyzing and conducting follow-up activities.

National Committee for Quality Assurance (NCQA):  An organization that sets standards, and evaluates and accredits health plans and other managed care organizations.

Net Capitation Payment:  The Capitation Payment made by DCH to Contractor less any quality assessment fee made by Contractor to DCH. This payment amount also excludes a payment to a Contractor for obstetrical or other medical services that are on a per occurrence basis rather than a per member basis.

Non-Emergency Transportation (NET):  A ride, or reimbursement for a ride, provided so that a Member or P4HB Participant with no other transportation resources can receive services from a medical
provider. NET does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.

Non-Institutional Claims:  Claims submitted by a medical Provider other than a hospital, nursing facility, or intermediate care facility/mentally retarded (ICF/MR).

Normal Birth Weight: Birth weight greater than or equal to 2,500 grams (5.5 pounds).

Nurse Practitioner Certified (NP-C):  A registered professional nurse who is licensed by the State of Georgia and meets the advanced educational and clinical practice requirements beyond the two or four years of basic nursing education required of all registered nurses.

Objective: Means a measurable step, generally in a series of progressive steps, to achieve a goal.

Obstetrical Delivery Payment: A payment, fixed in advance, that DCH makes to a Contractor for each birth of a child to a Member. The Contractor is responsible for all medical services related to the delivery of the Member’s child.

Out-of-Network Provider:  A Provider of services that does not have a Provider contract with the Contractor.

Participating Provider:  A Provider that has signed a contract with CMOs to provide services to Georgia Families members and P4HB Participants.
 
Patient Protection and Affordable Care Act (PPACA): The Patient Protection and Affordable Care Act is a federal statute, signed into law on March 23, 2010. The law includes numerous health-related provisions that will take effect over a four year period, including expanding Medicaid eligibility, subsidizing insurance premiums, establishing health insurance exchanges and support of medical research.
 
P4HB Participant: An individual meeting the eligibility requirements for the Demonstration who is enrolled in and/or receiving Demonstration Services through the Contractor. Also referred to as Participant.

P4HB Provider: See Demonstration Provider.


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PeachCare for Kids®:  The State of Georgia’s Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

Performance Concern:  The informal documentation of an issue. The CMO is required to respond to the Performance Concern by defining a process to detect, analyze and eliminate non-compliance and potential causes of non-compliance. This is a “warning” and failure to complete the Corrective Action Preventive Action/Performance Concern (CAPA/PC) form may result in formal action against the contractor (CAPA). If the concern is a Performance Concern, the following information must be completed by the offending CMO:

Direct Cause:  The cause that directly resulted in the event (the first cause in the chain).

Corrective Action: actions taken to correct the root cause generally a reactive process used to address problems after they have occurred

Performance Improvement Project (PIP): A planned process of data gathering, evaluation and analysis to determine interventions or activities that are projected to have a positive outcome. A PIP includes measuring the impact of the interventions or activities toward improving the quality of care and service delivery.

Pharmacy Benefit Manager (PBM):  An entity responsible for the provision and administration of pharmacy benefit management services including but not limited to claims processing and maintenance of associated systems and related processes.

Physician Assistant (PA):  A trained, licensed individual who performs tasks that might otherwise be performed by physicians or under the direction of a supervising physician.

Physician Incentive Plan:  Any compensation arrangement between a Contractor and a physician or physician group that may directly have the effect of reducing or limiting services furnished to Members.

Planning for Healthy Babies Program: The name of the 1115 Demonstration Waiver Program in Georgia.

Post-Stabilization Services:  Covered Services, related to an Emergency Medical Condition that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member’s condition.

Potential P4HB Participant: An individual meeting the eligibility requirements for the Demonstration who is subject to mandatory Enrollment in a care management program but is not yet enrolled in a specific CMO plan.

Potential Enrollee:  See Potential Member.

Potential Member: A Medicaid or CHIP recipient who is subject to mandatory Enrollment in a care management program but is not yet the Member of a specific CMO plan.

Pre-Certification:  Review conducted prior to a Member’s or P4HB Participant’s admission, stay or other service or course of treatment in a hospital or other facility.

Preconception Health Care: The primary prevention of maternal and perinatal morbidity and mortality, comprised of interventions that identify and modify biomedical, behavioral and social risks to pregnancy outcomes for women and their offspring. To have maximal impact on pregnancy outcomes, strategies to address risks must occur before conception or before prenatal care is typically initiated.

Preferred Health Organization (PHO): A coordinated care plan that: (a) has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan; (b) provides for reimbursement for all covered benefits regardless of whether the benefits are provided with the network of providers; and (c) is offered by an organization that is not licensed or organized under State law as an HMO.

Pregnancy Rate:  The number of pregnancies occurring to females in a specified age group per 1,000 females in the specified age group. The rate is calculated by using the following formula: Pregnancy
rate = [Number of pregnancies in age group / Female population in age group] * 1000. Rates that use Census Population Estimates in the denominator are unable to be calculated when the selected population is unknown.


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Prevalent Non-English Language:  A language other than English, spoken by a significant number or percentage of potential Members or P4HB Participants.

Preventive Services:  Services provided by a physician or other licensed health practitioner within the scope of his or her practice under State law to: prevent disease, disability, and other health Conditions or their progression; treat potential secondary Conditions before they happen or at an early remediable stage; prolong life; and promote physical and mental health and efficiency.

Primary Care:  All Health Care services and laboratory services, including periodic examinations, preventive Health Care and counseling, immunizations, diagnosis and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of Referrals to specialty Providers described in this Contract, and for maintaining continuity of patient care. These services are customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician, and may be furnished by a nurse practitioner to the extent the furnishing of those services is legally authorized in the State in which the practitioner furnishes them.

Primary Care Provider (PCP):  A licensed medical doctor (MD) or doctor of osteopathy (DO) or certain other licensed medical practitioner who, within the scope of practice and in accordance with State certification/licensure requirements, standards, and practices, is responsible for providing all required Primary Care services to Members or IPC P4HB Participants. A PCP shall include general/family practitioners, pediatricians, internists, physician’s assistants, CNMs or NP-Cs, provided that the practitioner is able and willing to carry out all PCP responsibilities in accordance with these Contract provisions and licensure requirements.

Prior Authorization:  Authorization granted in advance of the rendering of a service after appropriate medical review. (Also known as “pre-authorization” or “prior approval”).

Proposed Action:  The proposal of an action for the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; the failure to provide services in a timely manner; or the failure of the CMO to act within the time frames provided in 42 CFR 438.408(b).

Prospective Payment System (PPS): A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities.

Provider:  Any person (including physicians or other Health Care Professionals), partnership, professional association, corporation, facility, hospital, or institution certified, licensed, or registered by the State of Georgia to provide Health Care Services that has contracted with a Care Management Organization to provide health care services to Members and P4HB Participants.
Provider Complaint:  A written expression by a Provider, which indicates dissatisfaction or dispute with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions.

Provider Contract:  Any written contract between the Contractor and a Provider that requires the Provider to perform specific parts of the Contractor’s obligations for the provision of Health Care services under this Contract.

Provider Directory: A listing of health care service providers under contract with the CMO that is prepared by the CMO as a reference tool to assist members and P4HB Participants in locating Providers available to provide services.

Provider Number (or Provider Billing Number): An alphanumeric code utilized by health care payers to identify providers for billing, payment, and reporting purposes.

Provider Payment Agreement Act (PPA):  A law enacted by the Georgia state legislature and codified as O.C.G.A. § 31-8-179 et seq.

PPA Provider:  An institution licensed pursuant to Chapter 7 of Title 31 of the Official Code of Georgia Annotated which is primarily engaged in providing to inpatients, by or under the supervision of physicians, diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons or rehabilitation services for the rehabilitation of injured, disabled, or sick persons. Such term includes public, private, rehabilitative, geriatric, osteopathic, and other specialty hospitals but shall not include psychiatric hospitals as defined in paragraph (7) of Code Section 37-3-1, critical access hospitals as defined in paragraph (3) of Code Section 33-21A-2, or any state owned or state operated hospitals.


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Prudent Layperson: A person with average knowledge of health and medicine who could reasonably expect the absence of immediate medical attention to result in an emergency medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that could cause:

Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;

Serious impairment to bodily functions; or

Serious dysfunction of any bodily organ or part.

Qualified Electronic Health Record: "An Electronic record of health-related information on an individual that includes patient demographic and clinical health information, such as medical history and problem lists; and has the capacity to provide clinical decision support; to support physician order entry; to capture and query information relevant to health care quality; and to exchange electronic health information with and integrate such information from other sources." Source is ARRA - H.R.1 -115 Sec. 3000 (13)

Quality:  The degree to which a CMO increases the likelihood of desired health outcomes of its Members and P4HB Participants through its structural and operational characteristics, and through the provision of health services that are consistent with current professional knowledge.

Re-admission:  Subsequent admissions of a patient to a hospital or other health care institution for treatment.

Referral:  A request by a PCP for a Member or P4HB Participant to be evaluated and/or treated by a different physician, usually a specialist.

Referral Services:  Those Health Care services provided by a health professional other than the Primary Care Provider and which are ordered and approved by the Primary Care Provider or the Contractor.

Reinsurance:  An agreement whereby the Contractor transfers risk or liability for losses, in whole or in part, sustained under this Contract. A reinsurance agreement may also exist at the Provider level.

(Claims) Reprocessing:  Upon determination of the need to correct the outcome of one or more claims processing transactions, the subsequent attempt to process a single claim or batch of claims.

Remedy: The State’s means to enforce the terms of the Contract through performance guarantees and other actions.

Resource Mother: A paraprofessional that provides a broad range of services to P4HB IPC Participants and their families.

Risk Contract:  A Contract under which the Contractor assumes financial risk for the cost of the services covered under the Contract, and may incur a loss if the cost of providing services exceeds the payments made by DCH to the Contractor for services covered under the Contract.

Routine Care: Treatment of a Condition that would have no adverse effects if not treated within twenty-four (24) hours or could be treated in a less acute setting (e.g., physicians office) or by the patient.

Rural Health Clinic (RHC): A clinic certified to receive special Medicare and Medicaid reimbursement. The purpose of the RHC program is improving access to primary care in underserved rural areas. RHCs are required to use a team approach of physicians and midlevel practitioners (nurse practitioners, physician assistants, and certified nurse midwives) to provide services. The clinic must be staffed at least 50% of the time with a midlevel practitioner. RHCs may also provide other health care services, such as mental health or vision services, but reimbursement for those services may not be based on their allowable costs.

Rural Health Services: Medical services provided to rural sparsely populated areas isolated from large metropolitan counties.

Scope of Services:  Those specific Health Care services for which a Provider has been credentialed, by the plan, to provide to Members and P4HB Participants.

Service Authorization:  A Member’s or P4HB Participant’s request for the provision of a service.


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Service Region:  A geographic area comprised of those counties where the Contractor is responsible for providing adequate access to services and Providers.

Short Term:  A period of thirty (30) Calendar Days or less.

Significant Traditional Providers:  Those Providers that provided the top eighty percent (80%) of Medicaid encounters for the GF-eligible population in the base year of 2004.
Span of Control:  Information systems and telecommunications capabilities that the CMO itself operates or for which it is otherwise legally responsible according to the terms and conditions of this Contract. The CMO span of control also includes Systems and telecommunications capabilities outsourced by the CMO.

Stabilized: With respect to an emergency medical condition; that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or, with respect to a woman in labor, the woman has delivered (including the placenta).

State:  The State of Georgia.

State Fair Hearing:  See Administrative Law Hearing

Subcontract:  Any written contract between the Contractor and a third party, including a Provider, to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor:  Any third party who has a written Contract with the Contractor to perform a specified part of the Contractor’s obligations under this Contract.

Subcontractor Payments:  Any amounts the Contractor pays a Provider or Subcontractor for services they furnish directly, plus amounts paid for administration and amounts paid (in whole or in part) based on use and costs of Referral Services (such as Withhold amounts, bonuses based on Referral levels, and any other compensation to the physician or physician group to influence the use for Referral Services). Bonuses and other compensation that are not based on Referral levels (such as bonuses based solely on quality of care furnished, patient satisfaction, and participation on committees) are not considered payments for purposes of Physician Incentive Plans.

System Access Device: A device used to access System functions; can be any one of the following devices if it and the System are so configured: i. Workstation (stationary or mobile computing device) ii. Network computer/”winterm” device, iii. “Point of Sale” device, iv. Phone, v. Multi-function communication and computing device, e.g. PDA.

System Unavailability: Failure of the system to provide a designated user access based on service level agreements or software/hardware problems within the Contractor’s span of control. 

System Function Response Time: Based on the specific sub function being performed,
Record Search Time-the time elapsed after the search command is entered until the list of matching records begins to appear on the monitor.
Record Retrieval Time-the time elapsed after the retrieve command is entered until the record data begins to appear on the monitor.
Print Initiation Time- the elapsed time from the command to print a screen or report until it appears in the appropriate queue.
On-line Claims Adjudication Response Time- the elapsed time from the receipt of the transaction by the Contractor from the Provider and/or switch vendor until the Contractor hands-off a response to the Provider and/or switch vendor.

Systems:  See Information Systems.
Telecommunication Device for the Deaf (TDD):  Special telephony devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.

Third Party Resource:  Any person, institution, corporation, insurance company, public, private or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease or disability of an applicant for or recipient of medical assistance.

Transition of Care: The movement of patients made between health care practitioners and/or settings as their condition and care needs change during the course of a chronic or acute illness.


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Urgent Care:  Medically Necessary treatment for an injury, illness, or another type of Condition (usually not life threatening) which should be treated within twenty-four (24) hours.

Utilization:  The rate patterns of service usage or types of service occurring within a specified time.

Utilization Management (UM):  A service performed by the Contractor which seeks to assure that Covered Services provided to Members and P4HB Participants are in accordance with, and appropriate under, the standards and requirements established by the Contract, or a similar program developed, established or administered by DCH.

Utilization Review (UR):  Evaluation of the clinical necessity, appropriateness, efficacy, or efficiency of Health Care services, procedures or settings, and ambulatory review, prospective review, concurrent review, second opinions, care management, discharge planning, or retrospective review.

Validation:  The review of information, data, and procedures to determine the extent to which they are accurate, reliable, free from bias and in accord with standards for data collection and analysis.

Very Low Birth Weight (VLBW): Birth weight below 1,500 grams (3.3 pounds).

Week:  The traditional seven-day week, Sunday through Saturday.

Withhold:  A percentage of payments or set dollar amounts that a Contractor deducts from a practitioner’s service fee, Capitation, or salary payment, and that may or may not be returned to the physician, depending on specific predetermined factors.

Working Days: Monday through Friday but shall not include Saturdays, Sundays, or State and Federal Holidays.

Work Week:  The traditional work week, Monday through Friday.
1.5
ACRONYMS

AFDC – Aid to Families with Dependent Children

AICPA – American Institute of Certified Public Accountants

CAH – Critical Access Hospital

CAPA – Corrective Action Preventive Action

CAPA/PC – Corrective Action Preventive Action/Performance Concern

CDC – Centers for Disease Control

CFR – Code of Federal Regulations

CHIP – Children’s Health Insurance Program – formerly known as the State Children’s Health Insurance Program (SCHIP)

CMO – Care Management Organization

CMS – Centers for Medicare & Medicaid Services

CNM – Certified Nurse Midwives

CSB – Community Service Boards

DCH – Department of Community Health

DME – Durable Medical Equipment

DOI – Department of Insurance


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EB – Enrollment Broker

EPSDT – Early and Periodic Screening, Diagnostic, and Treatment

EQR – External Quality Review

EQRO – External Quality Review Organization

EVS - Eligibility Verification System

FFS – Fee-for-Service

FQHC – Federally Qualified Health Center

GF – Georgia Families

GTA - Georgia Technology Authority

HHS – US Department of Health and Human Services

HIPAA – Health Insurance Portability and Accountability Act

HMO – Health Management Organization

IBNR – Incurred-But-Not-Reported

INS – U.S. Immigration and Naturalization Services

IPC – Interpregnancy Care component of the 1115 Demonstration Waiver

LIM – Low-Income Medicaid

MMIS – Medicaid Management Information System

NAIC – National Association of Insurance Commissioners

NCQA – National Committee for Quality Assurance

NET – Non-Emergency Transportation

NP-C – Certified Nurse Practitioners

NPI – National Provider Identifier

P4HB – Planning for Healthy Babies 1115 Demonstration Waiver

PA – Physician Assistant

PBM – Pharmacy Benefit Manager

PC - Performance Concern

PCP – Primary Care Provider

PPS – Prospective Payment System

QAPI – Quality Assessment Performance Improvement

RHC – Rural Health Clinic

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RSM – Right from the Start Medicaid

SCHIP – State Children’s Health Insurance Program

SSA – Social Security Act

TANF – Temporary Assistance for Needy Families

TDD – Telecommunication Device for the Deaf

UM – Utilization Management

UPIN – Unique Physician Identifier Number

UR – Utilization Review

2.0    DCH RESPONSIBILITIES
2.1
GENERAL PROVISIONS
2.1.1
DCH is responsible for administering the GF program. The agency will administer Contracts, monitor Contractor performance, and provide oversight in all aspects of the Contractor operations.
2.1.2
DCH is responsible for providing training materials regarding the P4HB Demonstration including specific materials regarding the Resource Mothers Outreach component of the Demonstration.
2.2
LEGAL COMPLIANCE
 
DCH will comply with, and will monitor the Contractor’s compliance with, all applicable State and federal laws and regulations. Notwithstanding the foregoing, the CMO remains responsible for compliance with all applicable State and federal laws and regulations.
2.3
ELIGIBILITY AND ENROLLMENT
2.3.1
The State of Georgia has the sole authority for determining eligibility for the Medicaid program and whether Medicaid beneficiaries are eligible for Enrollment in GF. DCH or its Agent will determine eligibility for PeachCare for Kids® and will collect applicable premiums. DCH or its agent will continue responsibility for the electronic eligibility verification system (EVS).
 
2.3.1.1
The State of Georgia has the sole authority for determining eligibility for the P4HB Demonstration and whether P4HB Participants are eligible for enrollment in GF. DCH or its Agent will determine eligibility for the Demonstration and will continue responsibility for the electronic eligibility verification system (EVS).
2.3.2
DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all Members who are determined eligible for GF. A Member shall have thirty (30) Calendar Days to select a CMO plan and a PCP. Each Family Head of Household shall have thirty (30) Calendar Days to select one (1) CMO plan for the entire Family and PCP for each member. DCH or its Agent will issue a monthly notice of all Enrollments to the CMO plan.
 
2.3.2.1
DCH or its Agent will review the Medicaid Management Information System (MMIS) file daily and send written notification and information within two (2) Business Days to all P4HB Participants who are determined eligible for GF. A P4HB Participant shall have thirty (30) Calendar Days to select a CMO and a Family Planning Provider. A P4HB Participant eligible for IPC services under GF will have thirty (30) Calendar Days to select a CMO plan, a Family
 
Planning Provider and a PCP. The Family Planning Provider and the PCP may be the same provider.
2.3.3
If the Member does not choose a CMO plan within thirty (30) Calendar Days of being deemed eligible for GF, DCH or its Agent will Auto-Assign the individual to a CMO plan using the following algorithm:
 

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If an immediate family member(s) of the Member is already enrolled in one CMO plan, the Member will be Auto-Assigned to that plan;
If there are no immediate family members already enrolled and the Member has a Historical Provider Relationship with a Provider, the Member will be Auto-Assigned to the CMO plan where the Provider is contracted;
If the Member does not have a Historical Provider Relationship with a Provider in any CMO plan, or the Provider contracts with all plans, the Member will be Auto-Assigned based on an algorithm determined by DCH that may include quality, cost, or other measures.
 
2.3.3.1
If the Potential P4HB Participant does not choose a CMO Plan within thirty (30) Calendar Days of being deemed eligible for the Demonstration, DCH or its Agent will Auto-Assign the individual to a CMO plan using the algorithm described in Section 2.3.3 for Members.
 
2.3.3.2
Women already enrolled in GF due to pregnancy will have an expedited enrollment into the Demonstration upon termination of their pregnancy benefits. Members determined to be eligible for the Demonstration must be afforded the opportunity to choose a new CMO, if desired, for the delivery of Demonstration related Services. All P4HB Participants will have thirty (30) days from the date of eligibility notification to choose a CMO.
 
2.3.3.3
The Contactor will notify its current pregnant Members at least thirty (30) Calendar Days prior to the expected date of delivery and prior to the date upon which the Member will end RSM, that they may be eligible to enroll in the Demonstration and may choose to switch to a different CMO plan for receipt of Demonstration services. Members who do not make a choice will be deemed to have chosen to remain in their current CMO plan for receipt of the Demonstration services they are eligible to receive.
2.3.4
Enrollment, whether chosen or Auto-Assigned, will be effective at 12:01 a.m. on the first (1st) Calendar Day of the month following the Member or P4HB Participant’s selection or Auto-Assignment, for those Members or P4HB Participants assigned on or between the first (1st) and twenty-fourth (24th) Calendar Day of the month. For those Members or P4HB Participants assigned on or between the twenty-fifth (25th) and thirty-first (31st) Calendar Day of the month, Enrollment will be effective at 12:01 a.m. on the first (1st) Calendar Day of the second (2nd) month after assignment.
2.3.5
DCH or its Agent may include quality measures in the Auto-Assignment algorithm. Members or P4HB Participants will be Auto-Assigned to those plans that have higher scores based on quality, cost, or other measures to be defined by DCH. This factor will be applied after determining that there are no Historical Provider Relationships.
2.3.6
In any Service Region, DCH may, at its discretion, set a threshold percentage for the enrollment of members or P4HB Participants in a single plan and change this threshold percentage at its discretion. Members or P4HB Participants will not be Auto-Assigned to a CMO plan that exceeds this threshold unless a family member or P4HB Participant is enrolled in the CMO plan or a Historical Provider Relationship exists with a Provider that does not participate in any other CMO plan in the Service Region. When DCH changes the threshold percentage in any Service Region, DCH will provide the CMOs in the Service Region with a minimum of fourteen (14) days advance notice in writing.
2.3.7
DCH or its Agent will have five (5) Business Days to notify Members or P4HB Participants and the CMO plan of the Auto-Assignment. Notice to the Member or P4HB Participant will be made in writing and sent via surface mail. Notice to the CMO plan will be made via file transfer.
2.3.8
DCH or its Agent will be responsible for the consecutive Enrollment period and re-Enrollment functions.
2.3.9
Conditioned on continued eligibility, all Members or P4HB Participants will be enrolled in a CMO plan for a period of twelve (12) consecutive months. This consecutive Enrollment period will commence on the first (1st) day of Enrollment or upon the date the notice is sent, whichever is later. If a Member or P4HB Participant disenrolls from one CMO plan and enrolls in a different CMO plan, consecutive Enrollment period will begin on the effective date of Enrollment in the second (2nd) CMO plan.
2.3.10
DCH or its Agent will automatically enroll a Member or P4HB Participant into the CMO plan in which he or she was most recently enrolled if the Member or P4HB Participant has a temporary loss of eligibility, defined as less than sixty (60) Calendar Days. In this circumstance, the consecutive Enrollment period will continue as though there has been no break in eligibility, keeping the original twelve (12) month period.

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2.3.11
DCH or its Agent will notify Members or P4HB Participants at least once every twelve (12) months, and at least sixty (60) Calendar Days prior to the date upon which the consecutive Enrollment period ends (the annual Enrollment opportunity), that they have the opportunity to switch CMO plans. Members or P4HB Participants who do not make a choice will be deemed to have chosen to remain with their current CMO plan.
2.3.12
In the event a temporary loss of eligibility has caused the Member or P4HB Participant to miss the annual Enrollment opportunity, DCH or its Agent will enroll the Member or P4HB Participant in the CMO plan in which he or she was enrolled prior to the loss of eligibility. The Member or P4HB Participant will receive a new 60-calendar day notification period beginning the first day of the next month.
2.3.13
In accordance with current operations, the State will issue a Medicaid number to a newborn upon notification from the hospital, or other authorized Medicaid Provider.
2.3.14
Upon notification from a CMO plan that a Member is an expectant mother, DCH or its Agent shall mail a newborn enrollment packet to the expectant mother. This packet shall include information that the newborn will be Auto-Assigned to the mother’s CMO plan and that she may, if she wants, select a PCP for her newborn prior to the birth by contacting her CMO plan. The mother shall have ninety (90) Calendar Days from the day a Medicaid number was assigned to her newborn to choose a different CMO plan.
2.3.15
DCH may, at its sole discretion, elect to modify this threshold and/or use quality based auto-assignments for reasons it deems necessary and proper.
2.4
DISENROLLMENT
2.4.1
DCH or its Agent will process all CMO plan Disenrollments. This includes Disenrollments due to non-payment of the PeachCare for Kids® premiums, loss of eligibility for GF due to other reasons, and all Disenrollment requests Members or P4HB Participants or CMO plans submit via telephone, surface mail, internet, facsimile, and in person.
2.4.2
DCH or its Agent will make final determinations about granting Disenrollment requests and will notify the CMO plan via file transfer and the Member or P4HB Participant via surface mail of any Disenrollment decision within five (5) Calendar Days of making the final determination
Whether requested by the Member or P4HB Participant or the Contractor the following are the Disenrollment timeframes:
If the Disenrollment request is received by DCH or its agent on or before the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the month following the month in which the request was filed; and
If the Disenrollment request is received by DCH or its agent after the managed care monthly process on the twenty-fourth (24th) Calendar Day of the month, the Disenrollment will be effective at midnight the first (1st) day of the second (2nd) month following the month in which the request was filed.
2.4.3
If a Member is hospitalized in an acute inpatient facility on the first day of the month their Disenrollment is to be effective, the Member will remain enrolled until the month following their discharge from the inpatient facility. When Disenrollment is necessary due to a change in eligibility category, or eligibility for GF, the Member will be disenrolled according to the timeframes identified in Section 2.4.2.
2.4.4
When disenrollment is necessary because a Member loses Medicaid or PeachCare for Kids® eligibility (for example, he or she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.
 
2.4.4.1
When disenrollment is necessary because a P4HB Participant loses eligibility for the Demonstration (for example, she has died, been incarcerated, or moved out-of-state) disenrollment shall be immediate.
2.5
MEMBER AND P4HB PARTICIPANT SERVICES AND MARKETING
2.5.1
DCH will provide to the Contractor its methodology for identifying the prevalent non-English languages spoken. For the purposes of this Section, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids® eligible individuals in the State.

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2.5.2
DCH will review and prior approve all marketing materials.
2.5.3
DCH will provide the Contractor with the Demonstration’s logo and design along with specific Demonstration language to be used in all written materials distributed to P4HB Participants and Potential P4HB Participants.
2.6
COVERED SERVICES & SPECIAL COVERAGE PROVISIONS
 
DCH will use submitted Encounter Data, and other data sources, to determine Contractor compliance with federal requirements that eligible Members under the age of twenty-one (21) receive periodic screens and preventive/well child visits in accordance with the specified periodicity schedule. DCH will use the participant ratio as calculated using the CMS 416 methodology for measuring the Contractor’s performance.
 2.6.1
P4HB Participants are not eligible to participate in the EPSDT program.
2.6.2
Specific services available under this Demonstration are outlined in Attachment N to this Contract.
2.7
NETWORK
2.7.1
DCH will provide to the Contractor up-to-date changes to the State’s list of excluded Providers, as well as any additional information that will affect the Contractor’s Provider network.
2.7.2
DCH will consider all Contractors’ requests to waive network geographic access requirements in rural areas. All such requests shall be submitted in writing.
2.7.3
DCH will provide the State’s Provider Credentialing policies to the Contractor upon execution of this Contract.
2.8
QUALITY MONITORING
2.8.1
DCH will have a written strategy for assessing and improving the quality of services provided by the Contractor. In accordance with 42 CFR 438.204, this strategy will, at a minimum, monitor:
The availability of services;
The adequacy of the Contractor’s capacity and services;
The Contractor’s coordination and continuity of care for Members;
The coverage and authorization of services;
The Contractor’s policies and procedures for selection and retention of Providers;
The Contractor’s compliance with Member information requirements in accordance with 42 CFR §438.10;
The Contractor’s compliance with State and federal privacy laws and regulations relative to Member’s confidentiality;
The Contractor’s compliance with Member Enrollment and Disenrollment requirements and limitations;
The Contractor’s Grievance System;
The Contractor’s oversight of all Subcontractor relationships and delegations;
The Contractor’s adoption of practice guidelines, including the dissemination of the guidelines to Providers and Providers’ application of them;
The Contractor’s quality assessment and performance improvement program; and
The Contractor’s health information systems.
The Contractor shall respond to requests for information within the stipulated time frame.
2.8.2
DCH will have a written strategy for assessing and improving the quality of services provided by the Contractor for the Demonstration and the outcomes resulting from those services. This strategy is incorporated in Attachment O.
2.9
COORDINATION WITH CONTRACTOR’S KEY STAFF

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2.9.1
DCH will make diligent good faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of GF operations.
2.9.2
Specifically, DCH will designate individuals within the department who will serve as a liaison to the corresponding individual on the Contractor’s staff, including:

A program integrity staff Member;
A quality oversight staff Member;
A Grievance System staff Member who will also ensure that the State Administrative Law Hearing process is consistent with the Rules of the Office of the State Administrative Hearings Chapter 616-1-2 and with any other applicable rule, regulation, or procedure whether State or federal;
An information systems coordinator; and
A vendor management staff Member.

2.10
FORMAT STANDARDS
 
DCH will provide to the Contractor its standards for formatting all Reports requested of the Contractor. DCH will require that all Reports be submitted electronically.
 
 
 
DCH and Contractor agree that any change (new or revised standards) to Contractor’s Reports which is set forth in Amendment 12 to the Contract (new or revised standards) shall not become effective until January 1, 2012.
2.11
FINANCIAL MANAGEMENT
2.11.1
In order to facilitate the Contractor’s efforts in using Cost Avoidance processes to ensure that primary payments from the liable third party are identified and collected to offset medical expenses; DCH will include information about known Third Party Resources on the electronic Enrollment data given to the Contractor.
2.11.2
DCH will monitor Contractor compliance with federal and State physician incentive plan rules and regulations.
2.12
INFORMATION SYSTEMS
2.12.1
DCH will supply the following information to the Contractor:

Application and database design and development requirements (standards) that is specific to the State of Georgia.
Networking and data communications requirements (standards) that are specific to the State of Georgia.
Specific information for integrity controls and audit trail requirements.
State web portal (Georgia.gov) integration standards and design guidelines.
Specifications for data files to be transmitted by the Contractor to DCH and/or its agents.
Specifications for point-to-point, uni-directional or bi-directional interfaces between Contractor and DCH systems.
2.13
READINESS OR ANNUAL REVIEW
2.13.1
DCH will conduct a readiness review of each new CMO at least 30 days prior to Enrollment of Medicaid and/or PeachCare for Kids® recipients in the CMO plan and an annual review of each existing CMO plan. The readiness and financial review will include, at a minimum, one (1) or more as determined by DCH on-site review. DCH will conduct the reviews to provide assurances that the Contractor is able and prepared to perform all administrative functions and is providing for high quality of services to Members.

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2.13.2
Specifically, DCH’s review will document the status of the Contractor with respect to meeting program standards set forth in this Contract, as well as any goals established by the Contractor. A multidisciplinary team appointed by DCH will conduct the readiness and annual review. The scope of the reviews will include, but not be limited to, review and/or verification of:

Network Provider composition and access;
Staff;
Marketing materials;
Content of Provider agreements;
EPSDT plan;
Member services capability;
Comprehensiveness of quality and Utilization Management strategies;
Policies and procedures for the Grievance System and Complaint System;
Financial solvency;
Contractor litigation history, current litigation, audits and other government investigations both in Georgia and in other states; and
Information systems’ Claims payment system performance and interfacing capabilities.

The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.

Members may not be enrolled in a CMO plan until DCH has determined that the Contractor is capable of meeting these standards. A Contractor’s failure to pass the readiness review 30 days prior to the beginning of service delivery may result in immediate Contract termination. Contractor’s failure to pass the annual review may result in corrective action and pending contract termination.

DCH will provide the Contractor with a summary of the findings as well as areas requiring remedial action.

3.0
GENERAL CONTRACTOR RESPONSIBILITIES

The Contractor shall immediately notify DCH of any of the following:

Change in business address, telephone number, facsimile number, and e-mail address;
Change in corporate status or nature;
Change in business location;
Change in solvency;
Change in corporate officers, executive employees, or corporate structure;
Change in ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address;
Change in incorporation status; or
Change in federal employee identification number or federal tax identification number.
Change in CMO litigation history, current litigation, audits and other government investigations both in Georgia and in other states.
3.1
The Contractor shall not make any changes to any of the requirements herein, without explicit written approval from Commissioner of DCH, or his or her designee.

4.0    SPECIFIC CONTRACTOR RESPONSIBILITIES

The Contractor shall complete the following actions, tasks, obligations, and responsibilities:
4.1
ENROLLMENT
4.1.1
Enrollment Procedures

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4.1.1.1
DCH or its Agent is responsible for Enrollment, including auto-assignment of a CMO plan; Disenrollment; education; and outreach activities. The Contractor shall coordinate with DCH and its Agent as necessary for all Enrollment and Disenrollment functions.
4.1.1.2
DCH or its Agent will make every effort to ensure that recipients ineligible for Enrollment in GF are not enrolled in GF. However, to ensure that such recipients are not enrolled in GF, the Contractor shall assist DCH or its Agent in the identification of recipients that are ineligible for Enrollment in GF, as discussed in Section 1.2.3, should such recipients inadvertently become enrolled in GF.
 
4.1.1.2.1
DCH or its Agent will make every effort to ensure that individuals ineligible for Enrollment in the Demonstration are not enrolled in GF as P4HB Participants. However, to ensure that such individuals are not enrolled in the Demonstration, the Contractor shall assist DCH or its Agent in the identification of P4HB Participants that are ineligible for enrollment in the Demonstration, as discussed in Section 1.2.3, but have been inadvertently enrolled in GF as P4HB Participants
4.1.1.3
The Contractor shall assist DCH or its Agent in the identification of recipients that become ineligible for Medicaid (for example, those who have died, been incarcerated, or moved out-of-state).
4.1.1.4
The Contractor shall accept all individuals for enrollment without restrictions. The Contractor shall not discriminate against individuals on the basis of religion, gender, race, color, or national origin, and will not use any policy or practice that has the effect of discriminating on the basis of religion, gender, race, color, or national origin or on the basis of health, health status, pre-existing Condition, or need for Health Care services.
4.1.2
Selection of a Primary Care Provider (PCP)
4.1.2.1
At the time of plan selection, Members, with counseling and assistance from DCH or its Agent, will choose an In-Network PCP. If a Member fails to select a PCP, or if the Member has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign Members to a PCP based on the following algorithm:

Assignment shall be made to a Provider with whom, based on FFS Claims history, the Member has a Historical Provider Relationship, provided that the geographic access requirements in 4.8.13 are met;
If there is no Historical Provider Relationship the Member shall be Auto-Assigned to a Provider who is the assigned PCP for an immediate family member enrolled in the CMO plan, if the Provider is an appropriate Provider based on the age and gender of the Member;
If other immediate family members do not have an assigned PCP, Auto-Assignment shall be made to a Provider with whom a family member has a Historical Provider Relationship; if the Provider is an appropriate Provider based on the age and gender of the Member;
If there is no Member or immediate family member historical usage Members shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on the age and sex of the Member, and geographic proximity.
 
4.1.2.1.1
At the time of plan selection, Family Planning Only P4HB Participants, with counseling and assistance from DCH or its Agent, will be encouraged to choose a Primary Care Provider. Because primary care services are not covered services under the Demonstration for the Family Planning Only P4HB Participants, the Contractor is required to maintain an up-to-date list of available Providers affiliated with the Georgia Association for Primary Health Care and other primary care Providers serving the uninsured and underinsured populations who are available to provide primary care services. The Contractor must not use Demonstration funds to reimburse for primary care services delivered to Family Planning Only P4HB Participants.
 
4.1.2.1.2
At the time of plan selection, IPC P4HB Participants, with counseling and assistance from DCH or its Agent, will be encouraged to choose an In-Network PCP. If an IPC P4HB Participant fails to select a PCP, or if the IPC P4HB Participant has been Auto-Assigned to the CMO plan, the Contractor shall Auto-Assign the IPC P4HB Participant to a PCP based on the algorithm identified in 4.1.2.1. If there is no IPC P4HB Participant or immediate family member historical usage, IPC P4HB Participants shall be Auto-Assigned to a PCP, using an algorithm developed by the Contractor, based on geographic proximity.

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4.1.2.2
PCP assignment shall be effective immediately. The Contractor shall notify the Member via surface mail of their Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
 
4.1.2.2.1
For IPC P4HB Participants, PCP assignment shall be effective immediately. The Contractor shall notify the IPC P4HB Participant via surface mail of her Auto-Assigned PCP within ten (10) Calendar Days of Auto-Assignment.
 
4.1.2.3
The Contractor shall submit its PCP Auto-Assignment Policies and Procedures to DCH for review and approval as updated.
4.1.3
Newborn Enrollment
 
4.1.3.1
All newborns shall be Auto-Assigned by DCH or its Agent to the mother’s CMO plan.
 
4.1.3.2
The Contractor shall be responsible for notifying DCH or its Agent of any Members who are expectant mothers at least sixty (60) Calendar Days prior to the expected date of delivery. The Contractor shall be responsible for notifying DCH or its Agent of newborns born to enrolled members that do not appear on a monthly roster within 60 days after birth.
 
4.1.3.3
The Contractor shall provide assistance to any expectant mother who contacts them wishing to make a PCP selection for her newborn and record that selection.
 
 4.1.3.4
Within twenty-four (24) hours of the birth, the Contractor shall ensure the submission of a newborn notification form to DCH or its agent. If the mother has made a PCP selection, this information shall be included in the newborn notification form. If the mother has not made a PCP selection, the Contractor shall Auto-Assign the newborn to a PCP within thirty (30) days of the birth. Auto-Assignment shall be made using the algorithm described in Section 4.1.2.1. Notice of the PCP Auto-Assignment shall be mailed to the mother within twenty-four (24) hours.
4.1.4
Reporting Requirements
 
4.1.4.1
The Contractor shall submit to DCH monthly Member Data Conflict Report (formerly Member Information Reports) as described in Section 4.18.3.7.
 
4.1.4.2
The Contractor shall submit to DCH monthly Eligibility and Enrollment Reconciliation Reports as described in Section 4.18.3.2.

4.2    DISENROLLMENT
4.2.1
Disenrollment Initiated by the Member or P4HB Participant
 
4.2.1.1
A Member or P4HB Participant may request Disenrollment from a CMO plan without cause during the ninety (90) Calendar Days following the date of the Member’s or P4HB Participants initial Enrollment with the CMO plan or the date DCH or its Agent sends the Member or P4HB Participant notice of the Enrollment, whichever is later. A Member or P4HB Participant may request Disenrollment without cause every twelve (12) months thereafter.
 
4.2.1.2
A Member or P4HB Participant may request Disenrollment from a CMO plan for cause at any time. The following constitutes cause for Disenrollment by the Member or P4HB Participant:
The Member or P4HB Participant moves out of the CMO plan’s Service Region;
The CMO plan does not, because of moral or religious objections, provide the Covered Service the Member or P4HB Participant seeks;
The Member or P4HB Participant needs related services to be performed at the same time and not all related services are available within the network. The Member’s or P4HB Participants Provider or another Provider have determined that receiving service separately would subject the Member or P4HB Participant to unnecessary risk;
The Member or P4HB Participant requests to be assigned to the same CMO plan as family members or P4HB Participants; and

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The Member’s or P4HB Participants Medicaid eligibility category changes to a category ineligible for GF, and/or the Member or P4HB Participant otherwise becomes ineligible to participate in GF.
Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the Contract, or lack of Providers experienced in dealing with the Member’s or P4HB Participants Health Care needs. (DCH or its Agent shall make determination of these reasons.)
 
4.2.1.3
The Contractor shall provide assistance to Members or P4HB Participants seeking to disenroll. This assistance shall consist of providing the forms to the Member or P4HB Participant and referring the Member or P4HB Participant to DCH or its Agent who will make Disenrollment determinations.
 
4.2.1.4
A P4HB Participant may request Disenrollment from a CMO plan for cause at any time during the ninety (90) Calendar Days following the date of the P4HB Participant’s initial enrollment with the CMO plan or the date DCH or its Agent sends the Participant notice of the enrollment into the Demonstration, whichever is later. The following constitutes cause for Disenrollment by the P4HB Participant:
 
The P4HB Participant moves out of the CMO plan’s Service Region;
The P4HB Participant requests to be assigned to the same CMO plan as family members; and
The P4HB Participant otherwise becomes ineligible for participation in the Demonstration.
Other reasons, per 42 CFR 438.56(d)(2), include, but are not limited to, poor quality of care, lack of access to services covered under the Demonstration amendment, or lack of Demonstration Providers experienced in dealing with the P4HB Participant’s health care needs. (DCH or its Agent shall make determination of these reasons.)
4.2.2
Disenrollment Initiated by the Contractor
 
4.2.2.1
The Contractor shall complete all Disenrollment paperwork for Members or P4HB Participants it is seeking to disenroll.
 
4.2.2.1.1
The Contractor shall complete all Disenrollment paperwork for any P4HB Participants it seeks to disenroll.
 
4.2.2.2
The Contractor shall notify DCH or its Agent upon identification of a Member or P4HB Participant who it knows or believes meets the criteria for Disenrollment, as defined in Section 4.2.3.
 
4.2.2.2.1
The Contractor shall notify DCH or its Agent upon identification of a P4HB Participant who it knows or believes meets the following criteria for disenrollment from the Demonstration:
The P4HB Participant no longer meets the eligibility criteria for the Demonstration.
The IPC P4HB Participant has reached the end of the twenty-four (24) months of eligibility for the IPC component of the Demonstration.
The P4HB Participant becomes pregnant while enrolled in the Demonstration;
The P4HB Participant becomes infertile through a sterilization procedure;
The P4HB Participant moves out of the CMO plan’s Service Region;
The P4HB Participant’s utilization of services is fraudulent or abusive;
The Participant’s eligibility category changes to a category ineligible for participation in the P4HB program;
The P4HB Participant has died, been incarcerated, or moved out of State, thereby making her ineligible for Medicaid.

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4.2.2.3
Prior to requesting Disenrollment of a Member or P4HB Participant for reasons described in Sections 4.2.3, the Contractor shall document at least three (3) interventions over a period of ninety (90) Calendar Days that occurred through treatment, case management, and Care Coordination to resolve any difficulty leading to the request. The Contractor shall provide at least one (1) written warning to the Member or P4HB Participant, certified return receipt requested, regarding implications of his or her actions. DCH recommends that this notice be delivered within ten (10) Business Days of the Member’s or P4HB Participants action.
 
4.2.2.4
The Contractor shall cite to DCH or its Agent at least one (1) acceptable reason for Disenrollment outlined in Section 4.2.3 before requesting Disenrollment of the Member or P4HB Participant.
 
4.2.2.5
The Contractor shall submit Disenrollment requests to DCH or its Agent and the Contractor shall honor all Disenrollment determinations made by DCH or its Agent. DCH’s decision on the matter shall be final, conclusive and not subject to appeal.
4.2.3
Acceptable Reasons for Disenrollment Requested by Contractor
 
The Contractor may request Disenrollment if:

The Member’s Utilization of services is Fraudulent or abusive;
The Member has moved out of the Service Region;
The Member is placed in a long-term care nursing facility, State institution, or intermediate care facility for the mentally retarded;
The Member’s Medicaid eligibility category changes to a category ineligible for GF, and/or the Member otherwise becomes ineligible to participate in GF. Disenrollments due to Member eligibility will follow the normal monthly process as described in Section 2.4.3. Disenrollments will be processed as of the date that the member eligibility category actually changes and will not be made retroactive, regardless of the effective date of the new eligibility category. Note exception when SSI members are hospitalized.
The Member has any other condition as so defined by DCH; or
The Member has died, been incarcerated, or moved out of State, thereby making them ineligible for Medicaid.
4.2.4
Unacceptable Reasons for Disenrollment Requests by Contractor
 
4.2.4.1
The Contractor shall not request Disenrollment of a Member or P4HB Participant for discriminating reasons, including:
Adverse changes in a Member’s or P4HB Participants health status;
Missed appointments;
Utilization of medical services;
Diminished mental capacity;
Pre-existing medical condition;
Uncooperative or disruptive behavior resulting from his or her special needs; or
Lack of compliance with the treating physician’s plan of care.
 
4.2.4.2
The Contractor shall not request Disenrollment because of the Member’s or P4HB Participants attempt to exercise his or her rights under the Grievance System.
 
4.2.4.3
The request of one PCP to have a Member or P4HB IPC Participant assigned to a different Provider shall not be sufficient cause for the Contractor to request that the Member or P4HB IPC Participant be disenrolled from the plan. Rather, the Contractor shall utilize its PCP assignment process to assign the Member or P4HB IPC Participant to a different and available PCP.
4.3
MEMBER AND P4HB PARTICIPANT SERVICES
4.3.1
General Provisions

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The Contractor shall ensure that Members are aware of their rights and responsibilities, the role of PCPs, how to obtain care, what to do in an emergency or urgent medical situation, how to request a Grievance, Appeal, or Administrative Law Hearings, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications that allow the Members to submit questions and receive responses from the Contractor. The Contractor shall ensure that P4HB Participants are aware of their rights and responsibilities, the role of the Family Planning Provider and PCP (for IPC P4HB Participants only), how to obtain care, what to do in an emergency or urgent medical situation arising from the receipt of Demonstration related Services, how to submit a Grievance, request an Appeal, or Administrative Law Hearing, and how to report suspected Fraud and Abuse. The Contractor shall convey this information via written materials and via telephone, internet, and face-to-face communications that allow the P4HB Participant to submit questions and receive responses from the Contractor.
4.3.2
Requirements for Written Materials
 
4.3.2.1
The Contractor shall make all written materials available in alternative formats and in a manner that takes into consideration the Member’s or P4HB Participants special needs, including those who are visually impaired or have limited reading proficiency. The Contractor shall notify all Members or P4HB Participants and Potential Members that information is available in alternative formats and how to access those formats.
 
4.3.2.2
The Contractor shall make all written information available in English, Spanish and all other prevalent non-English languages, as defined by DCH. For the purposes of this Contract, prevalent means a non-English language spoken by a significant number or percentage of Medicaid and PeachCare for Kids® eligible individuals in the State.
 
4.3.2.3
All written materials distributed to Members or P4HB Participants shall include a language block, printed in Spanish and all other prevalent non-English languages, that informs the Member or P4HB Participant that the document contains important information and directs the Member to call the Contractor to request the document in an alternative language or to have it orally translated.
 4.3.2.4
All written materials shall be worded such that they are understandable to a person who reads at the fifth (5th) grade level. Suggested reference materials to determine whether this requirement is being met are:

Fry Readability Index;
PROSE The Readability Analyst (software developed by Education Activities, Inc.);
Gunning FOG Index;
McLaughlin SMOG Index;
The Flesch-Kincaid Index; or
Other word processing software approved by DCH.
 
4.3.2.5
The Contractor shall provide written notice to DCH of any changes to any written materials provided to the Members or P4HB Participant. Written notice shall be provided at least thirty (30) Calendar Days before the effective date of the change.
 
4.3.2.6
The Contractor must submit all written materials, including information for the Web site, to DCH for approval prior to use or mailing. DCH will approve or identify any required changes to the member or P4HB Participant materials within 30 days of submission. DCH reserves the right to require the discontinuation of any member materials that violate the terms of this contract.
4.3.3
Member Handbook and P4HB Participants Information Requirements
 
4.3.3.1
The Contractor shall mail to all newly enrolled Members a Member Handbook within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The Contractor shall mail to all enrolled Member households a Member Handbook every other year thereafter unless requested sooner by the member.
 
4.3.3.1.1
The Contractor shall mail to all newly enrolled P4HB Participants an information packet including but not limited to the following:

General information pertaining to the Demonstration (eligibility, enrollment and disenrollment criteria, and information pertaining to the Demonstration’s program components – family planning only, IPC, Resource Mothers Outreach).

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A list of benefits and services available under each Demonstration component
A list of service exclusions or limitations under each Demonstration component
Information about the role of the Family Planning Provider
Information about the selection of a Primary Care Provider affiliated with the Georgia Association for Primary Health Care and whose services are not covered under the Demonstration
Information on where and how P4HB Participants may access other benefits and services not available from or not covered by the Contractor under the Demonstration
Information about the role of the PCP for the IPC P4HB Participant only
Information about appointment procedures
Information on how to access Demonstration services, including non-emergency transportation (NET) available to the IPC P4HB Participants only
A notice stating that the Contractor shall be liable only for those Demonstration services authorized by CMS under the Demonstration
A description of all pre-certification, prior authorization or other requirements for Demonstration related Services and treatments
The geographic boundaries of the Service Regions
Notice of all appropriate mailing addresses and telephone numbers to be utilized by P4HB Participants seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site
A description of the P4HB Participant’s rights and responsibilities as described in Section 4.3.4
The policies and procedures for Disenrollment from the Demonstration
Information on Advance Directives
A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request
Information on the extent to which, and how, after hours and emergency coverage are provided, including the following:
What constitutes an Urgent and Emergency Demonstration related Medical Condition, Demonstration related Emergency Services, and Demonstration related Post Stabilization Services;
The fact that Prior Authorization is not required for Demonstration related Emergency Services;
The process and procedures for obtaining Demonstration related Emergency Services, including the use of the 911 telephone systems or its local equivalent;
The location of any emergency settings and other locations at which Demonstration Providers and hospitals furnish Demonstration related Emergency and Post Stabilization Services; and
The fact that a P4HB Participant has a right to use any hospital or other setting for Demonstration related Emergency Services
Information on the Grievance Systems policies and procedures, as described in Section 4.14 of the Contract. This description must include the following:
The right to file a Grievance and Appeal with the Contractor;
The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
The availability of assistance in filing a Grievance or Appeal with the Contractor;
The toll-free numbers P4HB Participants can use to file a Grievance or an Appeal with the Contractor by phone;

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The right to a State Administrative Law hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
Notice that if the P4HB Participant files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the P4HB Participant may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the P4HB Participant; and
Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover the Demonstration related Service.
The Contractor shall submit to DCH for review and approval any changes and edits to the P4HB Participant Information Packet at least thirty (30) Calendar Days before the effective date of change.
 
4.3.3.2
Pursuant to the requirements set forth in 42 CFR 438.10, the Member Handbook shall include, but not be limited to:

A table of contents;
Information about the roles and responsibilities of the Member (this information to be supplied by DCH);
Information about the role of the PCP;
Information about choosing a PCP;
Information about what to do when family size changes;
Appointment procedures;
Information on Benefits and services, including a description of all available GF Benefits and services;
Information on how to access services, including Health Check services, non-emergency transportation (NET) services, and maternity and family planning services;
An explanation of any service limitations or exclusions from coverage;
A notice stating that the Contractor shall be liable only for those services authorized by the Contractor;
Information on where and how Members may access Benefits not available from or not covered by the Contractor;
The Medical Necessity definition used in determining whether services will be covered;
A description of all pre-certification, prior authorization or other requirements for treatments and services;
The policy on Referrals for specialty care and for other Covered Services not furnished by the Member’s PCP;
Information on how to obtain services when the Member is out of the Service Region and for after-hours coverage;
Cost-sharing;
The geographic boundaries of the Service Regions;
Notice of all appropriate mailing addresses and telephone numbers to be utilized by Members seeking information or authorization, including an inclusion of the Contractor’s toll-free telephone line and Web site;
A description of Utilization Review policies and procedures used by the Contractor;
A description of Member rights and responsibilities as described in Section 4.3.4;
The policies and procedures for Disenrollment;
Information on Advance Directives;
A statement that additional information, including information on the structure and operation of the CMO plan and physician incentive plans, shall be made available upon request;


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4.3.3.3
Information on the extent to which, and how, after-hours and emergency coverage are provided, including the following:
 
i.
What constitutes an Urgent and Emergency Medical Condition, Emergency Services, and Post-Stabilization Services;
 
ii.
The fact that Prior Authorization is not required for Emergency Services;
 
iii.
The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;
 
iv.
The locations of any emergency settings and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered herein; and
 
v.
The fact that a Member has a right to use any hospital or other setting for Emergency Services;
 
4.3.3.4
Information on the Grievance Systems policies and procedures, as described in Section 4.14 of this Contract. This description must include the following:
 
i.
The right to file a Grievance and Appeal with the Contractor;
 
ii.
The requirements and timeframes for filing a Grievance or Appeal with the Contractor;
 
iii.
The availability of assistance in filing a Grievance or Appeal with the Contractor;
 
iv.
The toll-free numbers that the Member can use to file a Grievance or an Appeal with the Contractor by phone;
 
v.
The right to a State Administrative Law Hearing, the method for obtaining a hearing, and the rules that govern representation at the hearing;
 
vi.
Notice that if the Member files an Appeal or a request for a State Administrative Law Hearing within the timeframes specified for filing, the Member may be required to pay the cost of services furnished while the Appeal is pending, if the final decision is adverse to the Member; and
 
vii.
Any Appeal rights that the State chooses to make available to Providers to challenge the failure of the Contractor to cover a service.
4.3.3.5
The Contractor shall submit to DCH for review and approval any changes and edits to the Member Handbook at least thirty (30) Calendar Days before the effective date of change.
4.3.4
Member and P4HB Participant Rights
 
4.3.4.1
The Contractor shall have written policies and procedures regarding the rights of Members and shall comply with any applicable federal and State laws and regulations that pertain to Member rights. These rights shall be included in the Member Handbook. At a minimum, said policies and procedures shall specify the Member’s right to:
Receive information pursuant to 42 CFR 438.10;
Be treated with respect and with due consideration for the Member’s dignity and privacy;
Have all records and medical and personal information remain confidential;
Receive information on available treatment options and alternatives, presented in a manner appropriate to the Member’s Condition and ability to understand;
Participate in decisions regarding his or her Health Care, including the right to refuse treatment;

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Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience or retaliation, as specified in other federal regulations on the use of restraints and seclusion;
Request and receive a copy of his or her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
Be furnished Health Care services in accordance with 42 CFR 438.206 through 438.210;
Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the Member is treated;
Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Member for which DCH does not pay the Contractor; not be held liable for Covered Services provided to the Member for which DCH or the CMO plan does not pay the Health Care Provider that furnishes the services; and not be held liable for payments of Covered Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of amount the Member would owe if the Contractor provided the services directly; and
Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.
 
4.3.4.2
The Contractor shall have written policies and procedures regarding the rights of P4HB Participants and shall comply with any applicable federal and State laws and regulations that pertain to P4HB Participant rights. These rights shall be included in the P4HB Participant Information Packet. At a minimum, said policies and procedures shall specify the P4HB Participant’s right to:
Receive information pursuant to 42CFR 438.10;
Be treated with respect and with due consideration for the P4HB Participant’s dignity and privacy;
Have all records and medical and personal information remain confidential;
Receive information on available Demonstration related treatment options and alternatives, presented in a manner appropriate to the P4HB Participant’s condition and ability to understand;
Participate in decisions regarding her Demonstration services;
Request and receive a copy of her Medical Records pursuant to 45 CFR 160 and 164, subparts A and E, and request to amend or correct the record as specified in 45 CFR 164.524 and 164.526;
Be furnished Demonstration related Services in accordance with 42 CFR 438.206 through 438.210 as appropriate;
Freely exercise her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the P4HB Participant is treated;
Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Demonstration related Services provided to the P4HB Participant for which DCH does not pay the Contractor; not be held liable for Demonstration related Services provided to the P4HB Participant for which neither DCH nor the CMO pays the Demonstration Provider that furnishes the Demonstration related Services; and not be held liable for payments of Demonstration related Services furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of the amount the P4HB Participant would owe if the Contractor provided the services directly; and
Only be responsible for cost sharing in accordance with 42 CFR 447.50 through 42 CFR 447.60 and Attachment K of this Contract.
4.3.5
Provider Directory
4.3.5.1
The Contractor shall mail via surface mail a Provider Directory to all new Members or P4HB Participants within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the State’s Agent.

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4.3.5.2
The Provider Directory shall include names, locations, office hours, telephone numbers of and non-English language spoken by, current contracted Providers. This includes, at a minimum, information on PCPs, specialists, Family Planning Providers, dentists, pharmacists, FQHCs and RHCs, mental health and substance abuse Providers, and hospitals. The Provider Directory shall also identify Providers that are not accepting new patients.
4.3.5.3
The Contractor shall submit the Provider Directory to DCH for review and prior approval as updated.
4.3.5.4
The Contractor shall up-date and amend the Provider Directory on its Web site within five (5) Business Days of any changes, produces and distributes quarterly up-dates to all Members or P4HB Participants, and re-print the Provider Directory and distribute to all Members at least once per year.
4.3.5.5
The Contractor shall post on its website a searchable list of all providers with which the care management organization has contracted. At a minimum, this list shall be searchable by provider name, specialty, and location.
4.3.6
Member and P4HB Participant Identification (ID) Card
4.3.6.1
The Contractor shall mail via surface mail a Member ID Card to all new Members according to the following timeframes:

Within ten (10) Calendar Days of receiving the notice of Enrollment from DCH or the Agent for Members who have selected a CMO plan and a PCP;
Within ten (10) Calendar Days of PCP assignment or selection for Members that are Auto-Assigned to the CMO plan.
4.3.6.2
The Member ID Card must, at a minimum, include the following information:

The Member’s name;
The Member’s Medicaid or PeachCare for Kids® identification number;
The PCP’s name, address, and telephone numbers (including after-hours number if different from business hours number);
The name and telephone number(s) of the Contractor;
The Contractor’s twenty-four (24) hour, seven (7) day a week toll-free Member services telephone number;
Instructions for emergencies; and
Includes minimum or instructions to facilitate the submission of a claim by a Provider.
4.3.6.3
The Contractor shall reissue the Member ID Card within ten (10) Calendar Days of notice if a Member reports a lost card, there is a Member name change, the PCP changes, or for any other reason that results in a change to the information disclosed on the Member ID Card.
4.3.6.4
The Contractor shall submit a front and back sample Member ID Card to DCH for review and approval as updated.
4.3.6.5
The Contractor shall mail via surface mail a P4HB Participant ID Card to all new P4HB Participants in the Demonstration within ten (10) Calendar Days of receiving the notice of enrollment from DCH or its Agent. The P4HB Participant’s ID Card must meet all requirements as specified in Sections 4.3.6.2, 4.3.6.3 and 4.3.6.4. The P4HB Participant’s ID Card will identify the Demonstration component in which the P4HB Participant is enrolled:

A Pink color will signify the P4HB Participants as eligible for Family Planning Services Only.
A Purple color will signify the P4HB Participants as eligible for Interpregnancy Care Services and Family Planning Services.
A Yellow color will signify the P4HB Participant as eligible for Case Management - Resource Mothers Outreach Only.

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4.3.6.6
At the time the P4HB Participant’s ID card is supplied to a P4HB Participant, the Contractor shall provide written materials that explain the meaning of the color coding of the ID card and its relevance to Demonstration benefits.
4.3.7
Toll-free Member and P4HB Participant Services Line

 
4.3.7.1
The Contractor shall operate a toll-free telephone line to respond to Member and P4HB Participant questions, comments and inquiries.
 
4.3.7.2
The Contractor shall develop Telephone Line Policies and Procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards.
 
4.3.7.3
The Contractor shall submit these Telephone Line Policies and Procedures, including performance standards pursuant to Section 4.3.7.7, to DCH for review and approval as updated.
 
4.3.7.4
The telephone line shall handle calls from non-English speaking callers, as well as calls from Members and P4HB Participants who are hearing impaired.
 
4.3.7.5
The Contractor’s call center systems shall have the capability to track call management metrics identified in Attachment L.
 
4.3.7.6
The telephone line shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. EST, Monday through Friday, excluding State holidays. The telephone line staff shall be trained to accurately respond to Member and P4HB Participant questions in all areas, including, but not limited to, Covered Services, the provider network, and non-emergency transportation (NET).
 
4.3.7.7
The Contractor shall develop performance standards and monitor Telephone Line performance by recording calls and employing other monitoring activities. At a minimum, the standards shall require that, on a monthly basis, eighty percent (80%) of calls are answered by a person within thirty (30) seconds, the Blocked Call rate does not exceed one percent (1%), and the rate of Abandoned Calls does not exceed five percent (5%).
 
4.3.7.8
The Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. EST Monday through Friday and at all hours on weekends and holidays. This automated system must provide callers with operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Contractor’s Representative shall return messages on the next Business Day.
 
4.3.7.9
The Contractor shall develop Call Center Quality Criteria and Protocols to measure and monitor the accuracy of responses and phone etiquette as it relates to the Toll-free Telephone Line. The Contractor shall submit the Call Center Quality Criteria and Protocols to DCH for review and approval annually.
4.3.8
Internet Presence/Web Site
 
4.3.8.1
The Contractor shall provide general and up-to-date information about the CMO plan’s program, its Provider network, its customer services, and its Grievance and Appeals Systems on its Web site.
 
4.3.8.2
The Contractor shall maintain a Member and P4HB Participant portal that allows Members to access a searchable Provider Directory that shall be updated within five (5) Business Days upon changes to the Provider network.
 
4.3.8.3
The Web site must have the capability for Members and P4HB Participants to submit questions and comments to the Contractor and for members to receive responses.
 
4.3.8.4
The Web site must comply with the marketing policies and procedures and with requirements for written materials described in this Contract and must be consistent with applicable State and federal laws.

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4.3.8.5
In addition to the specific requirements above, the Contractor’s Web site shall be functionally equivalent, with respect to functions described in this Contract, to the Web site maintained by the State’s Medicaid fiscal agent. www.ghp.georgia.gov/wps/portal
 
4.3.8.6
The Contractor shall submit Web site screenshots to DCH for review and approval as updated.
 
4.3.8.7
The Contractor shall provide general and up to date information about the Demonstration on its website. This information must incorporate DCH’s messaging regarding the Demonstration.
 
4.3.8.8
The Contractor shall provide links from its website to the DCH P4HB website.
4.3.9
Cultural Competency
 
4.3.9.1
In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency Plan describing how the Contractor will ensure that services are provided in a culturally competent manner to all Members and P4HB Participants, including those with limited English proficiency. The Cultural Competency Plan must describe how the Providers, individuals and systems within the CMO plan will effectively provide services to people of all cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individual Members and P4HB Participants and protects and preserves the dignity of each.
 
4.3.9.2
The Contractor shall submit the Cultural Competency Plan to DCH for review and approval as updated.
 
4.3.9.3
The Contractor may distribute a summary of the Cultural Competency Plan to the In-Network Providers if the summary includes information on how the Provider may access the full Cultural Competency Plan on the Web site. This summary shall also detail how the Provider can request a hard copy from the CMO at no charge to the Provider.
4.3.10
Translation Services
 
4.3.10.1
The Contractor is required to provide oral translation services of information to any Member or P4HB Participant who speaks any non-English language regardless of whether a Member or P4HB Participant speaks a language that meets the threshold of a Prevalent Non-English Language. The Contractor is required to notify its Members or P4HB Participants of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to the Member or P4HB Participant for translation services.
4.3.11
Reporting Requirements
 
4.3.11.1
The Contractor shall submit monthly Telephone and Internet Activity Reports to DCH as described in Section 4.18.3.1
4.4
MARKETING
4.4.1
Prohibited Activities
 
4.4.1.1
The Contractor is prohibited from engaging in the following activities:

Directly or indirectly engaging in door-to-door, telephone, or other Cold-Call Marketing activities to Potential Members or P4HB Participants;
Offering any favors, inducements or gifts, promotions, and/or other insurance products that are designed to induce Enrollment in the Contractor’s plan, and that are not health related and/or worth more than $10.00 cash;
Distributing information plans and materials that contain statements that DCH determines are inaccurate, false, or misleading. Statements considered false or misleading include, but are not limited to, any assertion or statement (whether written or oral) that the recipient must enroll in the Contractor’s plan in order to obtain Benefits or in order to not lose Benefits or that the Contractor’s plan is endorsed by the federal or State government, or similar entity; and

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Distributing information or materials that, according to DCH, mislead or falsely describe the Contractor’s Provider network, the participation or availability of network Providers, the qualifications and skills of network Providers (including their bilingual skills); or the hours and location of network services.
4.4.2
Allowable Activities
 
4.4.2.1
The Contractor shall be permitted to perform the following marketing activities:

Distribute general information through mass media (i.e. newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising, and other media outlets);
Make telephone calls, mailings and home visits only to Members currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services offered by or available through the Contractor;
Distribute brochures and display posters at Provider offices and clinics that inform patients that the clinic or Provider is part of the CMO plan’s Provider network, provided that all CMO plans in