CN-680000-HQA23-A1.pdf

AHCA Contract No. HQA023, Amendment No. 1, Page 1 of 1

AHCA CONTRACT NO. HQA023

AMENDMENT NO. 1

THIS CONTRACT, entered into between the State of Florida, AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as the "Agency" and MAXIMUS FEDERAL SERVICES, INC., hereinafter referred to as the "Vendor", is hereby amended as follows:

1. Attachment I, Scope of Services, is hereby deleted in its entirety and replaced with Attachment I-A, Scope of Services. All references in this Agreement to Attachment I, shall hereinafter refer to Attachment I-A.

All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in this Contract.

This Amendment and all its attachments are hereby made a part of this Contract.

This Amendment cannot be executed unless all previous amendments to this Contract have been fully executed.

IN WITNESS THEREOF, the Parties hereto have caused this six (6) page Amendment (including all attachments) to be executed by their officials thereunto duly authorized.

MAXIMUS FEDERAL SERVICES, INC. STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION

SIGNED SIGNED

BY: BY:

NAME: NAME:

TITLE: TITLE:

DATE: DATE:

List of Exhibits/Attachments included as part of this Amendment:

Specify Letter/ Type Number Description Attachment I-A Scope of Services (5 Pages)

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DocuSign Envelope ID: E91799C2-BB42-4853-96F3-311BB2A38C1D

12/14/2017 | 11:31 AM PST

Thomas Naughton

Division President

Molly McKinstry

Deputy Secretary

12/20/2017 | 7:58 AM PST

AHCA Contract No. HQA023, Attachment I-A, Page 1 of 5

ATTACHMENT I-A

SCOPE OF SERVICES

A. Service(s) to be Provided:

Pursuant to Section 408.7507, Florida Statutes, the Agency shall contract with a “qualified independent third-party claim dispute-resolution-entity”, hereinafter referred to as the “Vendor” to provide assistance to contracted and non-contracted health care providers and health care plans for resolution of claims disputes within the parameters of Section 408.7507, Florida Statutes and Rule 59A-12.030, Florida Administrative Codes.

B. Manner of Service(s) Provision:

1. Review and Recommendations

The Vendor shall review all requests for claim(s) dispute resolution within ten (10) days after receipt, to determine whether the request meets the statutory and rule criteria for submission as specified in Section 408.7057(2)(b)1-7 and (d), Florida Statutes, and meet the claim threshold requirements specified in Rule 59A-12.030, Florida Administrative Code. The Vendor shall notify the entity filing the request, the responding party, and the Agency Contract Manager of the determination within three (3) calendar days of such decision.

The Vendor’s procedure shall include a review of the documentation provided and any additional information requested by the resolution organization. The Vendor shall research the claim dispute submission and make a recommendation to the Agency based on findings of fact.

2. Status Updates and Reporting

Pursuant to Section 408.7507(3), Florida Statutes the Vendor shall issue a recommendation, based on findings of fact, within sixty (60) days after the initial claim(s) dispute submission and other prudent information was received by the Vendor. In no event shall the review time exceed ninety (90) days following receipt of the initial claim(s) dispute submission by the health plan or provider.

Submission Deadlines

The Vendor shall submit a monthly report electronically to the Agency Contract Manager within fifteen (15) calendar days after the end of each month to include the following information:

a) All new claim disputes that have been submitted to the Vendor for review including the dates it was received, the filing entity, the respondent, the disputed issue, (including balance billing disputes), non-covered services, claim amount dispute, and product line of business (Medicaid vs Commercial).;

b) Claim disputes that have been dismissed or withdrawn and with the reason;

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AHCA Contract No. HQA023, Attachment I-A, Page 2 of 5

c) All pending claim disputes being reviewed including the case number, the date the claim dispute was accepted for review, the filing entity, the respondent, the disputed issue, and the disputed amount;

d) Claim disputes where a recommendation has been submitted to the Agency including the case number, the date the claim dispute was accepted for review, the date the recommendation was sent to the Agency, disputed issue (including balance billing disputes), non-covered services, claim amount dispute, product line of business (Medicaid vs Commercial), the awarded amount, review fee and the party billed, and the invoice number of the review fee; and,

e) If a reporting due date falls on a weekend or state holiday, the report shall be due to the Agency on the following business day.

Modifications to Reporting Requirements

a) The Agency reserves the right to modify the reporting requirements, with a ninety (90) day notice to allow the Vendor to complete implementation, unless otherwise required by law; and,

b) The Agency shall provide the Vendor with written notification of any modifications to the reporting requirements.

Information shall be provided to the Agency Contract Manager (or designee during absences) via email.

3. Final Orders

The Agency shall issue a final order within thirty (30) days after receipt of the recommendations issued by the Vendor. The Agency will enforce the final order as authorized under Subsection 641.52(1)(e), Florida Statutes.

The Agency’s final order is subject to notice of appeal rights and judicial review pursuant to Section 120. 68, Florida Statutes.

4. Objective/Standards/Performance Measures

1. Quantity and Quality Outcome Objectives:

a) The Vendor shall operate a toll free assistance line equipped with caller identification, automatic call distribution equipment capable of handling the expected volume of calls and access to interpreter services for non-English speaking providers. The Vendor shall operate its Florida Provider Appeals assistance line as part of an inbound call center or similar functional arrangement where agents or operators staff telephones to field incoming calls.

b) The Vendor shall staff the Florida Provider Appeals assistance line Monday through Friday from 8:00 A.M. to 5:00 P.M., EST

AHCA Contract No. HQA023, Attachment I-A, Page 3 of 5

c) The Vendor shall provide information to agents/operators on how to conduct various tasks and procedures for processing arbitration inquiries, such as call scripts, call-handling procedures and escalation protocols.

d) The Vendor may use a voice mail option in an automated phone tree system for callers to leave messages between the hours of 5:00 PM and 8:00 AM, EST, Monday through Friday and at all hours on weekends and holidays.

e) If the Vendor utilizes a voice mailbox option, the Vendor shall ensure that the voice mailbox has adequate capacity to receive all messages. A Vendor’s representative shall respond to all messages on the next business day.

f) The Vendor shall have an emergency operations plan ready to be implemented for any interruptions in service of eight (8) hours or more during normal business hours. The emergency operations plan shall also be implemented for service(s) interruptions of eight (8) hours. The Vendor shall also let the Agency know of any interruptions of service(s).

C. Method of Payment:

This is a no cost Contract. The Agency shall not compensate the Vendor for any services provided under this Contract. The initial review fee is a flat fee required by the Vendor to determine eligibility. The fee is retained by the Vendor whether or not the case qualifies for review. Once eligibility has been determined by the Vendor, the fees will vary based on the complexity of the case. If requested, the Vendor will provide a fee schedule (the hourly fees of professionals and any additional costs including an evidentiary hearing) to both the health plan and the provider prior to beginning any review of the case. The Vendor shall allow for one business day for either or both parties to opt out based upon the fee schedule prior to beginning a review where fees will be incurred. All review fees incurred by the Vendor are paid by the party that does not prevail or both parties if the recommendation and final order provide for an apportionment of the review fees in cases in which both parties prevail in part. All review fees must be paid directly to the Vendor.

Should the Vendor decide to change their fee schedule by either price per hour or to set a flat fee for reviews; they must provide a minimum of thirty (30) days notice to the Agency.

D. Special Provision(s):

1. Corrective Action Plan (CAP)

a) If the Agency determines that the Vendor is out of compliance with any of the provisions of this Contract, the Agency may require the Vendor to submit a Corrective Action Plan (CAP) within a specified timeframe. The CAP shall provide an opportunity for the Vendor to resolve deficiencies without the Agency invoking more serious remedies, up to and including Contract termination.

b) In the event the Agency identifies a violation of this Contract, or other non-compliance with this Contract, the Agency shall notify the Vendor of the

AHCA Contract No. HQA023, Attachment I-A, Page 4 of 5 occurrence in writing. The Agency shall provide the Vendor with a timeframe for corrections to be made.

c) The Vendor shall respond by providing a CAP to the Agency within the timeframe specified by the Agency.

d) The Vendor shall implement the CAP only after approval from the Agency.

e) The Agency may require changes or a complete rewrite of the CAP and provide a specific deadline.

f) If the Vendor does not meet the standards established in the CAP within the agreed upon time frame, the Vendor shall be in violation of the provisions of this Contract and the Contract may be terminated.

2. MyFloridaMarketPlace Vendor Registration

Each Vendor doing business with the State of Florida for the sale of commodities or contractual services as defined in section 287.012, Florida Statutes, shall register in MyFloridaMarketPlace, in compliance with Rule 60A-1.033, Florida Administrative Code, unless exempt under Rule 60A-1.033(3) Florida Administrative Code.

3. MyFloridaMarketPlace Transaction Fee

This is a no-cost Contract; therefore, it is exempt from paying the MyFloridaMarketPlace 1% Transaction Fee.

4. Minority Participation

The Agency for Health Care Administration encourages the Vendor to use Minority and Certified Minority businesses as subcontractors when procuring commodities or services for this Contract.

A minority owned business is defined as any business enterprise owned and operated by the following ethnic groups: African American (Certified Minority Code H or Non-Certified Minority Code N), Hispanic American (Certified Minority Code I or Non-Certified Minority o), Asian American (Certified Minority Code J or Non- Certified Minority P), Native American (Certified Minority Code K or Non-Certified Minority Code Q), or American Woman (Certified Minority Code M or Non-Certified Minority Code R).

5. Public Records Requests

a. To comply with Section 119.0701, F.S., if applicable, and all other applicable parts of the Florida Public Records Act.

b. To keep and maintain public records that ordinarily and necessarily would be required in order to perform services under this Contract.

AHCA Contract No. HQA023, Attachment I-A, Page 5 of 5

c. To provide the public with access to public records on the same terms and conditions that the Agency would provide the records and at a cost that does not exceed the cost provided in Section 119.07, F.S., or as otherwise provided by law.

d. To upon request from the appropriate Agency custodian of public records, provide the Agency with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost in Section 119.07, F.S., or as otherwise provided by law.

e. To ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of this Contract term and following completion of this Contract if the Vendor does not transfer the records to the Agency.

f. To not collect an individual’s social security number unless the Vendor has stated in writing the purpose for its collection. The Vendor collecting an individual’s social security number shall provide a copy of the written statement to the Agency and otherwise comply with applicable portions of Section 119.071(5), F.S.

g. To meet all requirements for retaining public records and transfer, at no cost, to the Agency all public records in possession of the Vendor upon termination of this Contract and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to the Agency in a format that is compatible with the information technology systems of the Agency.

h. If the Vendor does not comply with a public records request, the Agency shall enforce Contract provisions in accordance with this Contract.

i. IF THE VENDOR HAS QUESTIONS REGARDING THE

APPLICATION OF CHAPTER 119, FLORIDA STATUTES,

TO THE VENDOR’S DUTY TO PROVIDE PUBLIC

RECORDS RELATING TO THIS CONTRACT, CONTACT

THE AGENCY CUSTODIAN OF PUBLIC RECORDS FOR

THIS CONTRACT. THE AGENCY CUSTODIAN OF

PUBLIC RECORDS FOR THIS CONTRACT IS THE

CONTRACT MANAGER.

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