Amend_5_with_attach_-_fully_executed.pdf

CONTRACT AMENDMENT

1. AMENDMENT #:

2. CONTRACT #:

YH19-0025

3. EFFECTIVE DATE OF AMENDMENT:

Date of Last Signature

4. PROGRAM:

DHCM

5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Sandata Technologies 26 Harbor Park Drive

Port Washington, NY 11050

6. PURPOSE:

To add additional funding for nine change orders. The total five year contract value will be increased from $44,624,811.44 to $44,822,361.44.

7. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:

To add nine change orders:

1. IM-054 Removal of Improperly Loaded DDD Members/Auths AZ $24,000.00

2. CS-063 Changes to Reason Codes, Resolution Codes, Notes AZ $28,800.00

3. CS-064 Extension of FVV Value Validity – In Production AZ/HI $6,000.00

4. CS-067 Remove Unscheduled Visit Exceptions for Group Visits AZ $0.00

5. CS-068 Sub Limits and Temporary Auth New Addendum, Setup Validation and Testing HI $12,000.00

6. CS-073 New Service-Modifier Combination/New Task HI

• Change Request Fee – $41,500.00 Development/Configuration

• Change Request Fee – Translation $9,500.00

• Services ($950 per language for 10 languages)

7. CS-078 Config change to Visit Entry to 365 days - In Production HI $3,600.00

8. CS-087 Magellan/Molina SFTP Changes AZ $4,200.00

9. CS-096 Alignment of Service/Modifier Combinations/Addition of Modifier Combinations AZ $67,950.00

Total $197,550.00 Therefore,

1. Sandata change orders for increased services are attached.

2. All other contract terms and methodology remain in effect.

NOTE: Please sign, date and return one scanned copy to: Alice McLain, Sr. Procurement Specialist at alice.mclain@azahcccs.gov

Electronic Submission: An electronic or portable document file (PDF) copy of this amendment shall serve as the original.

DocuSign Envelope ID: C1C5407C-70D3-4CD9-9192-83B57D07CB83 mailto:alice.mclain@azahcccs.gov mailto:alice.mclain@azahcccs.gov

8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR

AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.

9. NAME OF CONTRACTOR/PROVIDER:

Sandata

10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

SIGNATURE OF AUTHORIZED INDIVIDUAL:

SIGNATURE:

TYPED NAME:

TYPED NAME:

Meggan LaPorte, CPPO, MSW

TITLE: TITLE:

Chief Procurement Officer

DATE: DATE:

Meggan LaPorte (Oct 8, 2021 13:50 PDT)

Oct 8, 2021

DocuSign Envelope ID: C1C5407C-70D3-4CD9-9192-83B57D07CB83

Akshay Bhandari

CFO

10/12/2021 https://azadoagov.na1.echosign.com/verifier?tx=CBJCHBCAABAAl5Z9TEoddXFeprOBK5ZXOnX1jxV5g2C-

April 16, 2021 Sandata Technologies, LLC sandata.com

Paige Gibson, Customer Success Manager pgibson@sandata.com 516-484-4400 ext. 4022

Brian Lawson, RVP, Business Development blawson@sandata.com 516-484-4400 ext. 3131

Change Request Technical Requirements |

Revision History

Change Request Tracking

AHCCCS/Customer Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Pricing

02/26/21 1.0 Ruth Sewell Initial Draft No

03/23/21 1.1 Judy Ross Technical Review No

04/12/21 1.2 Brian Lawson Pricing/Legal No

05/10/21 1.3 Brian Lawson Estimate Breakdown included per request

No

05/24/21 1.4 Paige Gibson Updates per AHCCCS questions on 5/24

No

07/14/21 1.5 Brian Lawson Updated Approval/Release Dates

No

ZenDesk 183806 Tracking item for Change Request

JIRA SEVV-31766 Development Epic

Other

This section defines the grounds on which the change request is being made, including the contract which is being updated, and any applicable purchase orders from the payer that are referenced/applicable to the EVV program.

This change request (this “Change Request”) is being issued pursuant to Contract YH19-0025.

The Division of Developmental Disabilities (“DDD”), a Managed Care Organization (“MCO”) in the AHCCCS program, incorrectly loaded outdated authorizations to resulting in a large number of members and authorizations loaded to provider accounts that should not have been.

The goal of this analysis and support request is to remove all inappropriate data in the Electronic

Visit Verification (“EVV”) system that was loaded or generated due to old or outdated authorizations being delivered to Sandata from DDD for the AHCCCS EVV program.

• ‘Old or outdated’ are any authorizations for EVV covered services that ended before

10/01/2020 (authorization end effective date < 10/01/2020) - when the AHCCCS EVV program began operational data use and the payer on the authorization is DDD.

This section provides context to the EVV Program, its scope, and how the need for this change request originated (what is the impact based on this change).

• On 02/12/2021, DDD posted the complete set of authorizations they have provided to

Sandata that would be considered in this set.

o This list comprised 729,619 unique authorization records.

o This set had all authorizations from 07/01/2004 through 09/30/20.

• On 02/16/2021, Sandata took this data set, and began worked to determine which of these provider + member combinations should be removed from the EVV systems.

o There is the possibility that some of the provider + member combinations in this set also received service authorizations from any of the other MCO’s in the

AHCCCS program. In that case, those members should remain in the EVV system.

• Sandata pulled the distinct set of provider ID + member ID combinations across the DDD-supplied list of authorizations.

o There were 29,799 distinct member IDs in the set.

o There were 1,530 distinct provider IDs in the set.

o There were 87,211 distinct provider ID + member ID combinations in the set.

o Sandata then compared each of the 87,211 distinct DDD-sourced combinations against those that were in Sandata EVV from all other AHCCCS program payers.

o If there were matches here, those provider ID + member ID combinations should be retained.

o If there was no match for the combination, then that provider ID + member ID combination should be removed.

• Finally, Sandata compared this set of provider ID + member ID combinations against the set of DDD-sourced authorizations from 10/1/2020 to present, to ensure that we would not remove any associations from the old/outdated authorizations that were later re-established with a current authorization.

o Sandata then compared each of the 87,211 distinct DDD-sourced combinations against this set.

o If there were matches here, those provider ID + member ID combinations should be retained.

o If there was no match for the combination, then that provider ID + member ID combination should be removed.

• This analysis will yield the set of authorizations and provider ID + member ID associations that must be removed from the Sandata systems, including the staging environment.

Material changes in the configuration and behavior will include:

Sandata EVV:

• Removal of identified old/outdated authorization records.

• Removal of members from Sandata EVV accounts where the member does not have:

o An authorization for a non-DDD service for that Sandata EVV account o A more recent authorization for service post-dating the identified authorization for that Sandata EVV account or o One or more recorded visits in the Sandata EVV account

This section defines the aspects of this change that are the responsibility of Sandata to perform or deliver. These may include functional alterations to the EVV system, updates to the program parameters or configurations for this customer, as well as training and support considerations that would fall under Sandata’s responsibilities for the program as defined in the contract.

To support the scope changes listed in the Change Request, Sandata will provide the following:

# Item Dev

(hrs)

QA

(hrs)

1 Identify the set of authorizations for DDD with expiration dates before 10-1-2020

24 12

2 Removal of authorizations identified with expiration dates before 10- 1-2020 from the Inter-Op staging area

16 12

3 Removal of authorizations identified with expiration dates before 10- 1-2020 from provider scheduling

16 12

4 Removal of identified authorizations with expiration dates before 10- 1-2020 from Visit Maintenance

16 12

5 Removal of members including all associated information (demographics, phone numbers, addresses, schedules, etc.) who have no remaining authorizations or visits after the removal of the older authorizations and who have no recorded visits from provider Scheduling

12 8

6 Removal of members including all associated information (demographics, phone numbers, addresses, schedules, XREFs etc.) who have no remaining authorizations or visits after the removal of the older authorizations and who have no recorded visits from Visit Maintenance

12 8

DDD has supplied the listing of all authorizations from their systems that meet the criteria of old / outdated to Sandata to perform analysis and begin this process, however, Sandata will re-execute this analysis using the 10-1-2020 date as specified in this change request.

This section defines the aspects of this change that are the responsibility of the payer program customer, their MMIS vendor, or other related program stakeholder entity. These may include policy updates, system alterations, provider outreach items, or other activities that may be required to have this change request realized. Where possible, the dependencies between Sandata responsibilities and the customer responsibilities should be defined.

To support the activities and deliverables defined in this change request, AHCCCS will be required to provide the following:

• Authorizations being removed cannot be resent from the payer. If these authorizations are resent in future files, the Authorization and Member will be readded to the provider account.

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.47 release currently scheduled for December 15th, 2021. This Change Request must be approved no later than September 1st , 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

One-Time Fees

Description Fees

Change Request Fee $24,000

Pricing Notes

One-time Fees will be due 50% upon execution of the Change Request and 50% upon completion of the Change Request as described within.

Approval

Approved By:

Signature/Title Date

Acceptance and approval of this Change Request will initiate the described work (and invoice submission, if applicable).

August 2021 http://sandata.com/ mailto:pgibson@sandata.com mailto:blawson@sandata.com http://sandata.com/ mailto:pgibson@sandata.com mailto:blawson@sandata.com

Revision History

Change Request Tracking

AHCCCS/Customer Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Other Considerations/Deliverables

Reference Materials

Pricing

02/19/2021 1.0 Paige Gibson Initial Draft Yes

06/28/21 1.1 Paige Gibson Follow up from meetings with

AHCCCS

Yes

07/01/21 1.2 Dara Johnson Update/Review of Final Version

Yes

07/06/21 1.3 Paige Gibson Updates from Comments

Yes

07/12/21 1.4 Judy Ross Technical Review Yes

07/19/21 1.5 Team Following AZ and Tech Review

Yes

07/22/21 1.6 Judy Ross Post Changes Review and True-Up for Estimation

Yes

8/3/21 1.7 Dara Johnson Follow up with Responses

Yes

8/6/21 1.8 Judy Ross Review Yes

8/6/21 1.9 Dara Johnson Follow up with responses

Yes

8/9/21 1.10 Judy Ross Review & Responses Yes

8/17/21 1.11 Dara Johnson Follow up with Responses

Yes

8/25/21 1.12 Brian Lawson Final with legal review and pricing

No

8/27/21 1.12 Brian Lawson Updated with Product Scheduling

ZenDesk 189412 Tracking item for Change Order

JIRA SEVV-31284 Epic to track estimation and work

Other CS-063

This change request (this “Change Request”) is being issued pursuant to Contract YH19-0025 between the Arizona Health Care Cost Containment System Administration (“AHCCCS”) and Sandata Technologies, LLC (“Sandata”).

As documented below, AHCCCS needs to change behavior on documentation of visit exceptions.

In addition, as further documented below, AHCCCS needs to add new resolution Codes.

Now that agencies are on the application and resolving Exceptions, AHCCCS would like to streamline the work required in Visit Maintenance.

In that effort:

• AHCCCS would like to remove the Resolution Code ‘Written Documentation Required’.

• AHCCCS would like to make the Reason Note field optional for any selection of the

Reason Codes.

• AHCCCS would like to add new Resolution Codes.

Sandata EVV

• Remove the Resolution code – Written Documentation Maintained

• Change all Reason Notes Fields Requirements to NO

Create the following Resolution Codes:

• Designee Attestation on File

• Timesheet with Signature on File

• Contacted Case Manager and/or Reconvened Treatment/Planning Team

Create the following Reason Code:

• None

Table 1 - Updated Reason/Resolution Code Table

Reason Code Reason

Note Req’d

(Y or N)

Resolution Codes Associated

Caregiver Error N

Member/Designee

Unavailable to Verify

N • Designee Attestation on File

• None

Mobile Device Issue N

Telephony Issue N

Member/Designee Refused

Verification

N

Unsafe Environment N • Designee Attestation on File

• Timesheet with Signature on File

• Contacted Case Manager and/or

Reconvened Treatment/Planning

Team

• Reschedule Within 2 Hours

• Reschedule Within 24 Hours

• Reschedule Within 48 Hours

• Next Scheduled Visit

• Non-Paid Caregiver

Member Refused Service N

Member No Show N

Other N • Timesheet with Signature on File

• None

Caregiver No Show N • Contacted Case Manager and/or

Reconvened Treatment/Planning

Team

• Reschedule Within 2 Hours

• Reschedule Within 24 Hours

• Reschedule Within 48 Hours

• Next Scheduled Visit

• Non-Paid Caregiver

Clinical Need N • Non-EVV Service Provided

Live-In/Onsight Caregiver N

Member Preference N

Alt EVV:

• The Alt EVV addendum will be updated to support the new resolution codes

• Contingency Plan functionality will need to be updated to support a 6th value for

‘Contacted Case Manager and/or Reconvened Treatment/Planning Team’. This value will only be available as part of visit resolution (not part of the client’s plan itself.

• If a reason or resolution code is provided after the cut-off date that is no longer supported:

o If the resolution code provided isn’t supported, the system will remove the invalid resolution code and continue o If the reason code requires a resolution code and it wasn’t provided either because the value was null or was incorrect, including Written Documentation Maintained, the system will reject the ‘Change Log’ record with this information and apply an exception to the visit.

Data Warehouse Feed

• Sandata will effectively pass the new Resolution Codes and all notes via the Data

Warehouse feed.

• No change to existing passage of historical Resolution Codes to the Data Warehouse feed.

This section defines the aspects of this change that are the responsibility of Sandata to perform or deliver. These may include functional alterations to the EVV system, updates to the program parameters or configurations for this customer, as well as training and support considerations that would fall under Sandata’s responsibilities for the program as defined in the contract.

Task # Description

(Hrs)

QA

(Hrs)

Update Business Rules to reflect new reason/resolution code values per Table shown in the 'Reason Resolution Codes' tab

Reconfigure reason/resolution codes per Table shown in the 'Reason Resolution Codes' tab as of a date which will be determined upon signature of this change request

24 12

Enable the ‘Missing Reason Code’ exception as fixable for all Alt EVV accounts

18 10

Update the Alt EVV Addendum to reference the updated reason/resolution codes and note the effective date of the change

5 Update the Alt EVV interface to:

a 1 – accept current reason/resolution codes for visit dates up to the date of the change b 2 – accept new reason/resolution codes for visit dates from the date of the change forward c

3 – if incorrect reason/resolution codes are received, the visit will change log record will be rejected and an appropriate error will be provided and the ‘Missing Reason Code’ exception will be applied.

Clearing this exception will require the Alt EVV vendor to retransmit the visit with an appropriate reason code.

72 40

Data Considerations/Requirements

• Prior to the cut-over date, current reason/resolution codes will apply for all interfaces.

• From the cut-over date forward, new reason/resolution codes will apply for all interfaces.

• The reason/resolution codes will be applied based on the VISIT DATE.

Testing Considerations/Requirements

• The Customer Success Manager will review all changes to ensure that they are properly in place as of the date selected.

Alt EVV (Third-Party) Considerations

• Alt EVV vendors will need to update interfaces to o Provide the current set of reason/resolution codes for visits prior to the date when this change is implemented o Provide the new set of reason/resolution codes from all visits occurring on the date the change is implemented forward

Operational Considerations

• Training Considerations o None

• Support Considerations o Communication will need to be conducted to all Provider Agencies and Fiscal

Intermediaries to inform / explain the changes the date they will take effect. They will also need to understand that their vendors will need to make the changes for any 3rd party EVV systems.

o Any materials referencing reason and resolution codes will need to be updated.

• Report Considerations o None

This section defines the aspects of this change that are the responsibility of the payer program customer, their MMIS vendor, or other related program stakeholder entity. These may include policy updates, system alterations, provider outreach items, or other activities that may be required to have this change request realized. Where possible, the

To support the activities and deliverables defined in this change request, AHCCCS will be required to provide the following:

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.2.1 release currently scheduled for January 26th, 2022. This Change Request must be approved no later than

October 1st, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this

Change Request.

This section elaborates any other pertinent facts regarding the delivery of this change request. This may include timing dependencies, completion deadlines, responsible parties or activities associated with the realization of this change request.

Outreach

• Sandata and AHCCCS will work together on a communication to all Provider Agencies and

Fiscal Intermediaries to review the changes and the date when they will take effect.

Training / Support

• Any training and support materials which reference reason and resolution codes will need to be reviewed and updated by Sandata with the new values.

This section contains any external documentation or reference materials that support the change request, or are revised/impacted as part of this change request.

Reference Item Name Description Version Revision Required?

Current Programmatic Business Rules Document

Sandata Program Information Workbook_AZ-AHCCCS.v21

21 Yes

Current Alt EVV specification

Addendum_AZ_altEVV v1.10.docx 1.10 Yes

Recurring Fees

Change Request Fee $28,800

Pricing Notes

Fees to be invoiced and due 50% once available in UAT and 50% due once completed and available in Production.

February, 2021

Revision History

AHCCCS/Customer Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Pricing

02/23/2021 1.0 Paige Gibson Initial Draft Yes

03/22/21 1.1 Paige Gibson Definition of Hawaii’s value

Yes

05/12/21 1.2 Brian Lawson

Updated with resource estimates, price, and legal review

No

06/02/21 1.3 Brian Lawson Updated Terms No

07/14/21 1.4 Brian Lawson Updated Approval/Release

ZenDesk 192177 Tracking item for Change Order

JIRA

Other CS-064

This change request (this “Change Request”) is being issued pursuant to Contract YH19-0025 between the Arizona Health Care Cost Containment System (“AHCCCS”) and Sandata Technologies, LLC (“Sandata”) for Electronic Visit Verification.

AHCCCS and Med-QUEST need to extend the length of time that the Fixed Visit Verification (“FVV”) values are valid.

Both AHCCCS and Med-QUEST have a significant volume of rural clients receiving both agency and Self- Directed services. Sandata provides FVV devices to AHCCCS under the above-referenced Contract.

Currently, FVV values expire in 7 days. AHCCCS and Med-QUEST agencies/fiscals may not receive the FVV values in 30, 45 or even 60 days. In order to ensure all provider agencies have adequate time to enter FVV values, the validity of FVV values needs to be extended to 60 days for the Med-QUEST program and 30 days for the AHCCCS program.

Material changes in the configuration and behavior should include:

• Configuration change to extend the validity of the FVV value from 7 to 60 days for all providers in the Med-QUEST program.

• Configuration change to extend the validity of the FVV value from 7 to 30 days for all providers in the AHCCCS program.

(hrs)

QA

(hrs)

1 Change the configuration in all Hawaiian agencies and fiscals to extend the FVV validity from 7 to 60 days.

12 8

2 Change the configuration in all Arizona agencies and fiscals to extend the FVV validity from 7 to 30 days.

12 8

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.44 release currently scheduled for September 8th, 2021. This Change Request must be approved no later than July 26th, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

Change Request Fee $6,000

Pricing Notes Fees to be invoiced and due upon completion of work under this Change Request.

May 17, 2021 mailto:blawson@sandata.com

Revision History

Change Request Tracking

AHCCCS/Customer Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Reference Materials

Pricing

02/19/2021 1.0 Paige Gibson Initial Draft Yes

3/15/2021 1.1 Judy Ross Engineering Evaluation

Yes

5/17/2021 1.2 Brian Lawson Pricing and Legal Review

ZenDesk 194561 Tracking item for Change Order

JIRA SEVV-31577

Other CS-067

This change request (this “Change Request”) is being issued pursuant to Contract YH19- 0025 between the Arizona Health Care Cost Containment System (“AHCCCS”) and Sandata Technologies, LLC (“Sandata”) for Electronic Visit Verification.

AHCCCS providers providing Group Visits currently receive an exception for Unscheduled Visits. Each of these visits requires an individual resolution of the exception.

Through this Change Request, AHCCCS would like the application of this exception removed for Group Visits.

• If a visit is flagged as a ‘group visit’ either within the Sandata EVV system or as received from an Alt EVV vendor, do not apply the ‘Unscheduled Visit’ exception.

(hrs)

QA

(hrs)

E1 When calculating the ‘Unscheduled Visit’ Exception, the exception should not apply to Group Visits even if enabled for a given program

36 24

Data Considerations/Requirements

• This change will be applied only to visits with exceptions calculated after the change is in place

• Sandata will perform extensive internal testing on this change prior to production deployment

To support the activities and deliverables defined in this change request, AHCCCS will be required to provide the following:

Outreach by Customer is suggested to all providers prior to the implementation of this change.

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.42 release currently scheduled for July 9th, 2021. This Change Request must be approved no later than June 1st, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

Program Workbook v20 Update to current Program Workbook 20 Yes

Change Request Fee $9,000 WAIVED

Pricing Notes

As long as the scope of the project set forth in this Change Request does not change, the fee for this change request has been waived.

August, 2021

516-484-4400 ext.3131 mailto:blawson@sandata.com

Revision History

Change Request Tracking

HI Med-QUEST Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Pricing

03/04/2021 1.0 Paige Gibson Initial Draft Yes

4/7/21 1.1 Paige Gibson

Updated draft following discussion w/Product and Med-

QUEST

Addition of Temporary Auth testing effort to existing CR

No

5/5/21 1.2 John Kalivas Review/Edit No

6/18/21 1.3 John Kalivas Estimate Provided No

6/28/21 1.4 Brian Lawson Pricing and Legal Review

No

7/30/21 1.5 Brian Lawson Scope Clarification and language tweaks for call with HI

8/1/2021 1.6 Brian Lawson Legal Review No

ZenDesk 196215 Tracking item for Change Order

JIRA

Other CS-068

This Change Order is being issued pursuant to contract YH19-0025 between the Arizona Health Care Cost Containment System (“AHCCCS”) and Sandata Technologies, LLC (“Sandata”) for Electronic Visit Verification.

Hawaii Med-QUEST (“HI” or “Med-QUEST”) has identified a program gap requiring the enforcement of the weekly authorization service delivery sub-limits within the CDS population.

The Med-QUEST program requests the inclusion of service limits through additional data elements passed in the existing Authorization data load process.

The use of sub-limits enforces the authorization details based on the member assessment. The sub-limits will drive compliance with the program rules defined by the Med-QUEST team.

Hawaii will need a concurrent testing effort for Temporary Auths on the MCO feeds to agencies.

Med-QUEST authorizations are subject to change and often are updated based on a medical need or specific "care incident" that will require an adjustment to an existing Authorization record to increasing the number of allowable units. The process should account for the increase and adjust the weekly allocation to align with the new Authorization totals.

Note: Med-QUEST has requested that sub-limit enforcement only be applied to agencies that use the Med-QUEST provided solution, including agency and CDS programs.

Alternate EVV Vendors must enforce sub-limits outside of the Med-QUEST solutions and before sending data to the Hawaii State EVV Aggregator.

Material changes in the configuration and behavior should include:

The goal of this Change Request is to provide a resource to support the MCOs and their testing. To support this, Sandata will provide the following efforts:

• Provide an update to/or a new Alt-EVV Addendum by determining the data for each field.

• Validate the setup and UI.

• Work with the MCOs to change and support Integration testing with the MCOs.

Data Warehouse Feed

• Any changes to the Data Warehouse feed will be identified as part of the revision/creation of the Alt-EVV Addendum.

BI Tool

• Applicable mapping for changes should be included to existing dashboards.

This section defines the aspects of this change that are the responsibility of Sandata to perform or deliver. These may include functional alterations to the EVV system, updates to the program parameters or configurations for this customer, as well as training and support considerations that would fall under Sandata’s responsibilities for the program as defined in the contract.

To support the scope changes listed in the Change Request, Sandata will provide a support resource to provide the following:

(hrs)

QA/SIT

(hrs)

1 Update Addendum to include Sub-limit rules 8 4 2 Configure/Validate the UI to support Sub-limits 20 8 3 Test Data Integration (QA/SIT) 16 12 4 Support HI/MCOs on integration 0 12

Sandata anticipates the support resource will be available within 30 days after execution of this

The support resource will be available for up to 90 days after the date the resource became available or until the hours defined above are exhausted.

This section defines the aspects of this change that are the responsibility of the payer program customer, their MMIS vendor, or other related program stakeholder entity. These may include policy updates, system alterations, provider outreach items, or other activities that may be required to have this change request realized. Where possible, the dependencies between Sandata responsibilities and the customer responsibilities should be defined.

The State and the MCOs are responsible for adhering to the updated Alt-EVV addendum and testing their updated integrations before promoting to production.

Sandata will support the State and MCOs through the testing process as described in this Change Request.

Change Request Fee $12,000

Pricing Notes

One-time Fees will be due upon completion (defined as when QA and SIT are complete) of the Change Request as described within.

Acceptance and approval of this Change Request will initiate the described work (and invoice submission, if applicable).

July 2021

516-484-4400 ext.3131

Table of Contents

Revision History

Change Request Tracking

Med-QUEST Change Request

Change Request

Background

System/Functionality Enhancement Requested

Customer Responsibilities

Other Considerations/Deliverables

Reference Materials

Pricing

Date Version # Author Description of the Document Updates

Requires Update to Business Rules?

05/14/21 1.0 Paige Gibson Initial Draft Yes

05/19/21 1.1 Judy Ross Technical Review Yes

5/24/21 1.2 Douglas Forsell

Client Review Yes

6/1/21 1.3 Paige Gibson Addition of New Task Yes

6/2/21 1.4 Paige Gibson Addition of changes to existing codes with a new modifier (originally CS- 073)

Yes

7/1/21 1.5 Paige Gibson Separation of new Service/Modifier addition from remaining work

Yes

7/6/21 1.6 Judy Ross Addition Review & Estimation

Yes

7/7/21 1.7 Paige Gibson Remove Extraneous Row/Define Translations and Specification

Yes

7/7/21 1.8 Brian Lawson Pricing and Legal Review No

Reference Ticket Number Notes

ZenDesk 209590 Tracking item for Change Order

JIRA SEVV-33884 Replaces SEVV-33065 including all estimates provided under the earlier CR (CS-086)

Med-QUEST would like to rename services on the mobile device to improve selection by caregivers in the Agency portion of the program. Med-QUEST has also added a new modifier to select services to indicate a visit instead of units. In addition, a new task has been added to the program.

Additional Task:

Table 1: New task to be added

Task ID Task Description Char Length

0367 Skin Care 9

Service Changes:

Values to be deleted are in red.

Values to be added are in green. These will require recordings and translations in all supported languages.

Services that need to be renamed are highlighted in yellow. These will require recordings and translations in all supported languages.

Table 2: Service Code Changes

Values requiring Change: CHANGED VALUES TO

BE UPDATED

Changed Values to be

Added

Units Rule

Payer Program HCPCS Code

M1 M2 M3 M4 EVV Svc Description

Selection for Mobile

Telephony Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD ATTND RN ATTND RN UNIT 44 Rule 1

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD U6 ATTND RN VISIT Rule 2

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 U2 PDN LPN PDN LPN UNIT 35 Rule 1

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 U6 PDN LPN VISIT Rule 2

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U2 PDN RN PDN RN UNIT 7 Rule 1

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U6 PDN RN VISIT Rule 2

HI-DDD AGYP T1002 22 Respite Daily 1:1

DDD RESPITE DAILY 1:1 168

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 U2 PDN RN ND PDN RN ND UNIT 32 Rule 1

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 U6 PDN RN ND VISIT Rule 2

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 U2 PDN RN SV PDN RN SV UNIT 29 Rule 1

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 U6 PDN RN SV VISIT Rule 2

Development / Configuration - 276 Hours total

Task

# Description Dev (Hrs)

QA

(Hrs)

1 Update Business Rules to reflect all new configuration values 4 4

2a Update Hawaii Account Configurations including Sandata EVV w/Scheduling & Billing, Alt EVV and CDS to reflect changes (tasks, service, description and History)

12 8

2b .. Add new task (0367 Skin Care) (EVV, SMC, Telephony) 12 4

2c .. Add 6 Services with Descriptions and Modifiers (EVV, SMC, Telephony) 12 4

2d .. Update 6 services - add new information to service name 12 4

2e .. End Date 1 service as of date TBD 10 4

2f .. Assumes no new units calculation rules 8 4

3 Update all telephony recordings 8 8

4 Update all SMC translations 4 4

5 Create new service prompt keys 12 8

6 Update Alt EVV middleware to accept new services and tasks 20 12

7 Update Authorization middleware to accept new services and tasks 20 12

8 Update Open EVV middleware to accept new services and tasks 8 8

9 Update POC middleware to accept new services and tasks 20 12

10 Update Call Reference Guides 2

Extract Tasks List from Alt EVV Addendum and create a separate reference guide to be published with new task addition

Extract Services List from Alt EVV Addendum and create a separate reference guide to be published with new service information

Update Alt EVV Addendum to remove tasks, payers, programs, services, modifiers and reference external documents

Update DWH Addendum to remove tasks, payers, programs, services, modifiers and reference external documents

Update Open EVV Addendum used by FI to remove tasks, payers, programs, services, modifiers and reference external documents

Update POC Addendum used by FI to remove tasks, payers, programs, services, modifiers and reference external documents

Translation Services

Includes: Chinese - Cantonese/Traditional, Chinese Mandarin, French, Hawaiian, Ilokano, Japanese, Korean, Spanish, Tagalog, Vietnamese

17 Translations in all HI Languages for new task, 5 new services and 5 updated descriptions

18 Recordings for telephony in all HI Languages for new task, 5 new services and 5 updated descriptions

To support the activities and deliverables defined in this change request, AHCCCS will be required to provide the following:

• Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.46 release currently scheduled for November 3rd, 2021. This Change Request must be approved no later than September 1st, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this

• Provide the date when the service to be removed should be end-dated.

This section elaborates any other pertinent facts regarding the delivery of this change request. This may include timing dependencies, completion deadlines, responsible parties or activities associated with the realization of this change request.

Recording/Translation for Telephony (TVV) and Mobile Device (SMC)

• Translation of new Task

• Translations of new Service/Modifier combination and renamed Service/Modifier combination

Documentation Updates

• Task and Service Listing Update

• Supplemental Guide Update

Vendor Communication Required for Alt EVV Agencies

• Vendors/Agencies will need notification of the effective date of the Task

• Updated to Alt EVV Addendum will be required

• Vendors may require time to configure their systems for changes.

This section contains any external documentation or reference materials that support the change request, or are

Reference Item Name Description Version Revision

Required?

Addendum_HI_altEVV v1.6.docx

Alt EVV specification 1.6 Yes

Addundum_HI_DataWarehouse v1.5.docx

Data Warehouse Specification

1.5 Yes

Addundum_HI-OpenEVV v1.5.docx

OpenEVV Specification 1.5 Yes

Reference Item Name Description Version Revision Required?

Addendum_HI_PlanofCare v1.3.docx

Plan of Care Specification 1.3 Yes

Change Request Fee – Development/Configuration $41,400

Change Request Fee – Translation Services ($950 per language for 10 languages)

$9,500

Pricing Notes

Fees to be invoiced and due 50% upon completion of the Business Rules update (Task 1) and 50% due upon completion of the remaining tasks under this Change Request.

May 17, 2021

Hawaii Med-QUEST

Change Request Technical Requirements

Config change to Visit Entry to 365 days (CR CS-078) mailto:blawson@sandata.com

Revision History

Change Request Tracking

Med-QUEST Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Pricing

4/16/2021 1.0 Paige Gibson Initial Draft Yes

5/7/21 1.1 Paige Gibson Removal of BI Items Yes

5/11/21 1.2 Judy Ross Technical Review Yes

5/17/21 1.3 Brian Lawson Legal review and Pricing

No

7/14/21 1.4 Brian Lawson Updated Approval/Release

ZenDesk 215758 Tracking item for Change Order

JIRA SEVV-32727 JIRA to track estimates and work

Other CS-078

Med-QUEST needs to reconfigure the visit entry value to match their filing deadlines.

Currently, the setting for visit entry is set to 30 days. Med-QUEST must allow visit entry up to and including their filing deadline (365 days).

Change the visit entry value configuration to match the Med-QUEST claims filing deadline. The value needs to be changed to 365 days. This value should be changed in all agency/Self Direct fiscal accounts.

This section defines the aspects of this change that are the responsibility of Sandata to perform or deliver. These may include functional alterations to the EVV system, updates to the program parameters or configurations for this customer, as well as training and support considerations that would fall under Sandata’s responsibilities for the program as defined in the contract.

(hrs)

QA

(hrs)

1 Update all Hawaii accounts to have the Visit Maintenance back days parameter set to 365 including QA and Deployment to production

16 8

• Internal QA testing to ensure change is made appropriately.

This section defines the aspects of this change that are the responsibility of the payer program customer, their MMIS vendor, or other related program stakeholder entity. These may include policy updates, system alterations, provider outreach items, or other activities that may be required to have this change request realized. Where possible, the dependencies between Sandata responsibilities and the customer responsibilities should be defined.

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.44 release currently scheduled for September 8th, 2021. This Change Request must be approved no later than July 26th, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

Change Request Fee $3,600

Pricing Notes

One-time Fees will be due 50% upon execution of the Change Request and 50% upon completion of the Change Request as described within.

June, 2021

AZ/AHCCCS

Change Request Technical Requirements

Magellan/Molina SFTP Changes (CR CS-087)

Revision History

Change Request Tracking

AHCCCS/Customer Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Reference Materials

Pricing

05/24/2021 1.0 Paige Gibson Initial Draft Yes

6/21/21 1.1 Paige Gibson Move to Sandata hosted SFTP

6/22/21 1.2 Judy Ross Technical Review

6/24/21 1.3 Brian Lawson Pricing and Legal Review

ZenDesk 227606 Tracking item for Change Order

JIRA SEVV-33312 Epic to track estimates and work between the Arizona Health Care Cost Containment System Administration (“AHCCCS”) and

Sandata Technologies, LLC (“Sandata”). Magellan Health, an AHCCCS MCO, is transitioning their EVV program to Molina Complete. This will require a change of SFTP site for interfaces.

At the request of AHCCCS, Molina Complete will need an update to move from the current (Magellan Health) SFTP to a Molina Complete SFTP. This effort will require changes to code, testing and a coordinated release to production. Sandata will move this SFTP to an internal, Sandata-hosted site, utilize already existing folders for Magellan Health, grant access and test the connection. Sandata will work with Molina to establish a cut over date and work in coordination with Molina Complete to complete the move.

• Update the configuration for the location of the Magellan/Molina SFTP Site

• Testing with Magellan to ensure that files are properly received and processed

(hrs)

QA

(hrs)

1 Reconfiguration of all interfaces to the new SFTP location as well as issuing updated credentials

4 4

2 Testing/Setup of internal SFTP 12 8

Alt EVV (3rd Party) Considerations

• None

Operational Considerations

• Support Considerations – None post testing and implementation of the change

• Report Considerations - None

This section defines the aspects of this change that are the responsibility of the payer program customer, their MMIS vendor, or other related program stakeholder entity. These may include policy updates, system alterations, provider outreach items, or other activities that may be required to have this change request realized. Where possible, the

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.X.XX release currently scheduled for XXX XX, 2021. This Change Request must be approved no later than XXX XX, 2021 to support the proposed release schedule. The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

This section contains any external documentation or reference materials that support the change request, or are

Addendum_AZ_Authorization v1.4.docx

Current AZ Authorization Addendum

1.4 No

OpenEVV-Authorization –

7.3 FINAL.pdf

Current OpenEVV Authorization Specification

7.3 No

Change Request Fee $4,200

Pricing Notes

Fees to be invoiced and due upon completion of work (sFTP site is configured and credentials verified) under this Change Request.

September 2021

Arizona Health Care Cost Containment System

Change Request Technical Requirements

Alignment of Service/Modifier Combinations/Addition of Modifier Combinations (CR CS-096) mailto:blawson@sandata.com

Table of Contents

Revision History

Change Request Tracking

Change Request

Background

System/Functionality Enhancement Requested

Customer Responsibilities

Reference Materials

Pricing

Date Rev # Author Description of the Document Updates

Requires Update to Business Rules?

7/20/2021 1.0 Paige Gibson Initial Draft Yes

9/7/2021 1.1 Paige Gibson Revised List of Changes provided by Dara

Yes

9/9/2021 1.2 Paige Gibson Revised list of Changes provided by Dara

Yes

9/13/2021 1.3 Judy Ross Technical Review Yes

9/17/2021 1.4 Brian Lawson General edits and pricing No

9/22/2021 1.5 Brian Lawson Legal Review and Product Schedule

No

9/22/2021 1.6 Brian Lawson Updated Release Schedule Verbiage per AZ request

Reference Ticket Number Notes

ZenDesk 260531 Tracking item for Change Order

JIRA SEVV-35335

Epic to track estimates and work

Other CS-096 Change Order tracking item between the Arizona Health Care Cost Containment System Administration (“AHCCCS”) and

Sandata Technologies, LLC (“Sandata”).

AHCCSS is requesting new Service/Modifier combinations added to the EVV program.

AHCCCS needs to add additional Service/Modifier combinations to their EVV program.

Service Changes:

Table 1: New Service Additions

# Payer Program HCPCS Mod 1 Mod 2 Description Cont Plan Def Value

Selection for Mobile/SMC

Telephone Prompt

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U2 U4

[S5125]:

Attendant care services; per 15 minutes;

Unskilled Self-directed care;

Family member or non-spouse not residing at home

CP01

Attendant Care;

Self (Unskilled);

Family (non-res)

Attendant Care;

Unskilled Self Directed Care;

Family member or non-spouse not residing at home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U2 U5

[S5125]:

Attendant care services; per 15 minutes;

Unskilled Self-directed care;

Family member or non-spouse residing in member's home

CP01

Attendant Care;

Self (Unskilled);

Family (home)

Attendant Care;

Unskilled Self Directed Care;

Family member or non-spouse residing in the member’s home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U6 U4

[S5125]:

Attendant care services; per 15 minutes; Skilled Self-directed care; Family member or non-spouse not residing at home

CP01

Attendant Care;

Self (Skilled);

Family (non-res)

Attendant Care;

Skilled Self Directed Care;

Family member or non-spouse not residing at home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U6 U5

[S5125]:

Attendant care services; per 15 minutes; Skilled Self-directed care; Family member or non-spouse residing in member's home

CP01

Attendant Care;

Self (Skilled);

Family (home)

Attendant Care;

Skilled Self Directed Care;

Family member or non-spouse residing in member's home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U7 U4

[S5125]:

Attendant care services; per 15 minutes; Agency with Choice;

Family member or non-spouse not residing at home

CP01

Attendant Care;

AWC; Family (non-res)

Attendant Care;

Agency with Choice; Family member or non-spouse not residing at home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U7 U5

[S5125]:

Attendant care services; per 15 minutes; Agency with Choice;

Family member or non-spouse residing in member's home

CP01

Attendant Care;

AWC; Family (home)

Attendant Care;

Agency with Choice; Family member or non-spouse residing in member's home

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S5125 U7 U3

[S5125]:

Attendant care services; per 15 minutes; Agency with Choice;

Spouse - limit to 160 units per week

CP01

Attendant Care;

AWC; Spouse

Attendant Care;

Agency with Choice; Spouse -limit to 160 units per week

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS S9123 UF

[S9123]: Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when cpt codes 99500- 99602 can be used); Services provided, Morning

CP01

Private Duty – RN (Morning)

Private Duty Nursing, Registered Nurse;

Morning Service

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

AHCCCS S9123 UG

[S9123]: Nursing care, in the home; by registered nurse, per hour (use for

CP01

Private Duty – RN (Afternoon)

Private Duty Nursing, Registered Nurse;

Afternoon Service

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

general nursing care only, not to be used when cpt codes 99500- 99602 can be used); Services provided, Afternoon

*All Service Code/modifiers assumed to use an existing rounding rule. If new rounding rules are determined to be needed, they will be quoted separately via the change order process.

(Hrs)

QA

(Hrs)

Update Business Rules to include 90 new service/modifier combinations

4 4

2 Update Alt EVV Addendum / Services Listing 2 2

Update Authorization Addendum to include 90 new service/modifier combinations

2 2

Update Open EVV Addendum to include 90 new service/modifier combinations

2 2

Update Call Reference Guide to Include new Services for Newly Created Accounts

2 2

Update Visit Maintenance Configuration to Include 90 New Services Including Implementation of Existing Units Rules for each

26 26

7a Update Scheduling & Billing Configuration to Include 90 New Services Including Implementation of Existing Units Rules for each

20 20

7b Update aggregator with 90 new services 24 24

8 Update Alt EVV Validation to Accept 90 New Services 10 10

9 Update Authorization Validation to Accept 90 New Services 10 10

10 Update Open EVV Validation to Accept 90 New Services 10 10

11 Update Provider Creation with New Call Reference Guide 10 10

12 Deploy 9 Services across 10 payers in all Arizona Languages to SMC 48 40

13 Deploy 9 Services across 10 payers in all Arizona Languages to IVR 48 40

To support the activities and deliverables defined in this change request, AHCCCS will be required to provide the following:

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.2.2 release currently scheduled for February 23rd, 2022. This Change Request must be approved no later than

November 1st, 2021, to support the proposed release schedule. The release schedule is based on current availability and is subject to change. Any changes to the release schedule would be reviewed and discussed with the Customer.

This section contains any external documentation or reference materials that support the change request, or are

Documentation Updates

• Service Listing Update

• Supplemental Guide Update

Vendor Communication Required for Alt EVV Agencies

• Vendors/Agencies will need notification of the effective date of the new services.

• Updated to Alt EVV Addendum will be required.

• Vendors may require time to configure their systems for changes.

Reference Item Name Description Version Revision Required?

Addendum_AZ_altEVV v1.10.docx Alt EVV specification

1.10 Yes

Addendum_AZ_DataWarehouse v1.9.2.3.docx Data Warehouse Specification

1.9.2.3 Yes

Addendum_AZ-OpenEVV v1.7.docx OpenEVV Specification

1.7 Yes

Addendum_A_Authorization v1.4.docx Authorization Specification

1.4 Yes

Change Request Fee $67,950

Pricing Notes

Fees to be invoiced and due 50% once available in UAT and 50% due once completed and available in Production.