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CORONADO DENTAL SERVICE

Fee Schedule Overview Proc Code Description UCR Fee D0120 Periodic Evaluation 69.00$ D0140 Limited Evaluation-problem focused 117.00$ D0150 Comprehensive Evaluation 106.00$ D0160 Detailed & Extensive Evaluation 134.00$ D0171 Re-eval - Post-op Office Visit 52.00$ D0210 Intraoral – comprehensive series of radiographic images 159.00$ D0220 Intraoral Periapical Images 38.00$ D0230 Intraoral Periapical Add'l 28.00$ D0240 Intraoral Occlusal Image 50.00$ D0250 Extraoral 2D projection image 42.00$ D0270 Bitewing Single Image 32.00$ D0272 Bitewing Two Images 42.00$ D0274 Bitewing Four Images 89.00$ D0330 Panoramic Image 178.00$ D1110 Prophylaxis - Adult 125.00$ D1206 Topical Applic Fluoride Varnish 42.00$ D1208 Topical Application of Fluoride 38.00$ D1330 Oral Hygiene Instructions 32.00$ D1351 Sealant 70.00$ D1354 Interim caries arresting medicament application - per tooth 22.00$ D1510 Space maintainer - fixed, unilateral – per quadrant 467.00$ D1516 Space maintainer - fixed - bilateral, maxillary 599.00$ D1517 Space maintainer - fixed - bilateral, mandibular 599.00$ D1520 Space maintainer - removable, unilateral - per quadrant 528.00$ D1526 Space maintainer - removable - bilateral, maxillary 660.00$ D1527 Space maintainer - removable - bilateral, mandibular 660.00$ D2140 Amalgam 1 Surface 167.00$ D2150 Amalgam 2 Surface 205.00$ D2160 Amalgam 3 Surface 242.00$ D2161 Amalgam 4 Surface 289.00$ D2330 Anterior Resin Composite 1s 187.00$ D2331 Anterior Resin Composite 2s 252.00$ D2332 Anterior Resin Composite 3s 302.00$ D2335 Anterior Resin Composite 4+s 364.00$ D2390 Anterior Resin Composite Crown 612.00$ D2391 Posterior Resin Composite 1s 205.00$ D2392 Posterior Resin Composite 2s 299.00$ D2393 Posterior Resin Composite 3s 337.00$ D2394 Posterior Resin Composite 4+s 444.00$ D2510 Metallic Inlay 1 Surface 1,035.00$

BEST AND FINAL CDS FEE SCHEDULE

D2520 Metallic Inlay 2 Surface 1,146.00$ D2530 Metallic Inlay 3+ Surface 1,231.00$ D2542 Metallic Onlay 2 Surface 1,273.00$ D2543 Metallic Onlay 3 Surface 1,315.00$ D2544 Metallic Onlay 4+ Surface 1,400.00$ D2610 Full Porcelain/Ceramic Inlay 1s 1,188.00$ D2620 Full Porcelain/Ceramic Inlay 2s 1,231.00$ D2630 Full Porcelain/Ceram Inlay 3+s 1,315.00$ D2642 Full Porcelain/Ceramic Onlay 2s 1,358.00$ D2643 Full Porcelain/Ceramic Onlay 3s 1,400.00$ D2644 Full Porcelain/Ceram Onlay 4+s 1,400.00$ D2650 Resin Composite Inlay 1s 1,104.00$ D2651 Resin Composite Inlay 2s 1,146.00$ D2652 Resin Composite Inlay 3+s 1,188.00$ D2662 Resin Composite Onlay 2s 1,231.00$ D2663 Resin Composite Onlay 3s 1,273.00$ D2664 Resin Composite Onlay 4+s 1,315.00$ D2710 Indirect Resin-Based Crown 1,188.00$ D2720 Resin/HNM Crown 1,315.00$ D2721 Resin/Base Crown 1,273.00$ D2722 Resin/Noble Crown 1,315.00$ D2740 Full Porcelain/Ceramic Crown 1,315.00$ D2750 Porcelain/HNM Crown 1,248.00$ D2751 Porcelain/Base Crown 1,212.00$ D2752 Porcelain/Noble Crown 1,371.00$ D2780 3/4 Cast HNM Crown 1,358.00$ D2781 3/4 Cast Base Crown 1,315.00$ D2782 3/4 Cast Noble Crown 1,358.00$ D2783 Crown - 3/4 porcelain/ceramic 1,400.00$ D2790 Full Cast HNM Crown 1,352.00$ D2791 Full Cast Base Crown 1,250.00$ D2792 Full Cast Noble Crown 1,285.00$ D2794 Crown - titanium and titanium alloys 477.00$ D2799 Provisional Crown 766.00$ D2910 Recement/bnd inlay/onlay/part 145.00$ D2920 Re-cement or re-bond crown 121.00$ D2930 Prefabricated Steel Crown-Prim 333.00$ D2931 Prefabricated Steel Crown-Perm 402.00$ D2932 Prefabricated Resin Crown 429.00$ D2933 Steel Crown w/ Resin Window 417.00$ D2940 Protective Restoration 136.00$ D2950 Core Buildup w/ Any Pins 337.00$ D2951 Pin Retention 103.00$ D2952 Post & Core Added to Crown 543.00$ D2954 Prefabricated Post & Core 355.00$ D2960 Direct Resin Veneer 726.00$

D2961 Indirect Resin Veneer 1,112.00$ D2962 Full Porcelain Veneer 1,295.00$ D2980 Crown Repair, Material Failure 341.00$ D3110 Direct Pulp Cap 98.00$ D3120 Indirect Pulp Cap 98.00$ D3220 Therapeutic Pulpotomy 238.00$ D3221 Pulpal Debridement 256.00$ D3230 Pulpal Therapy on Anterior 323.00$ D3240 Pulpal Therapy on Posterior 369.00$ D3310 Root Canal Therapy on Anterior 851.00$ D3320 Root Canal Therapy on Premolar 1,011.00$ D3330 Root Canal Therapy on Molar Tooth 1,020.00$ D3331 Treat Root Canal Obstruction 449.00$ D3332 Incomplete Endodontic Therapy 472.00$ D3346 Retreat, prev RCT - anterior 1,071.00$ D3347 Retreat, prev RCT - premolar 1,131.00$ D4341 Scaling & Root Planing (4-8) 370.00$ D4346 Scaling in presence of generalized gingival inflammation, full mouth 370.00$ D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and 275.00$ D4910 Periodontal Maintenance 181.00$ D4999 Other Periodontal Procedure 42.00$ D5110 Full Upper Denture 1,890.00$ D5120 Full Lower Denture 1,890.00$ D5130 Immediate denture - maxillary 1,625.00$ D5140 Immediate denture - mandibular 1,625.00$ D5211 Upper Partial w/ Resin Base 2,082.00$ D5212 Lower Partial w/ Resin Base 2,082.00$ D5213 Maxillary partial denture - cast metal framework with resin denture bases (includ 2,213.00$ D5214 Mandibular partial denture - cast metal framework with resin denture bases 2,213.00$ D5282 Removable unilateral partial denture - cast metal, maxillary 1,198.00$ D5283 Removable unilateral partial denture - cast metal, mandibular 1,198.00$ D5410 Adjust Full Upper Denture 107.00$ D5411 Adjust Full Lower Denture 107.00$ D5421 Adjust Partial Upper Denture 107.00$ D5422 Adjust Partial Lower Denture 107.00$ D5511 Repair broken complete denture base, mandibular 257.00$ D5512 Repair broken complete denture base, maxillary 257.00$ D5520 Replace Tooth on Full Denture 201.00$ D5520.5520 Replace Tooth on Full Denture 201.00$ D5611 Repair resin partial denture base, mandibular 245.00$ D5612 Repair resin partial denture base, maxillary 248.00$ D5621 Repair cast partial framework, mandibular 190.00$ D5622 Repair cast partial framework, maxillary 190.00$ D5630 Repair/replace broken retentive/clasping materials - per tooth 341.00$ D5640 Replace Broken Tooth on Partial 215.00$ D5640.d5640 Replace Broken Tooth on Partial 215.00$

D5650 Add Tooth to Existing Partial 248.00$ D5650.5650 Add Tooth to Existing Partial 248.00$ D5660 Add clasp to existing partial - per tooth 284.00$ D5710 Rebase Full Upper Denture 711.00$ D5711 Rebase Full Lower Denture 711.00$ D5720 Rebase Partial Upper Denture 683.00$ D5721 Rebase Partial Lower Denture 683.00$ D5730 Reline Full Upper Denture 472.00$ D5731 Reline Full Lower Denture 472.00$ D5740 Reline Partial Upper Denture 458.00$ D5741 Reline Partial Lower Denture 458.00$ D5750 Lab Reline Full Upper Denture 537.00$ D5751 Lab Reline Full Lower Denture 537.00$ D5760 Lab Reline Upper Partial 571.00$ D5761 Lab Reline Lower Partial 571.00$ D5810 Interim Full Upper Denture 1,026.00$ D5811 Interim Full Lower Denture 1,026.00$ D5820 Interim Upper Partial Denture 838.00$ D5821 Interim Lower Partial Denture 838.00$ D5850 Upper Tissue Conditioning 256.00$ D5851 Lower Tissue Conditioning 256.00$ D5867 Replacement of Attachment Part 299.00$ D5899 Other Removable Procedure 149.00$ D6210 Full Cast HNM Pontic 1,342.00$ D6211 Full Cast Base Pontic 1,230.00$ D6212 Full Cast Noble Pontic 1,285.00$ D6240 Porcelain/HNM Pontic 1,362.00$ D6241 Porcelain/Base Pontic 1,267.00$ D6242 Porcelain/Noble Pontic 1,319.00$ D6245 Full Porcelain/Ceramic Pontic 1,369.00$ D6720 Retainer crown - resin with high noble metal 1,329.00$ D6721 Retainer crown - resin with predominantly base metal 1,281.00$ D6740 Retainer crown - porcelain/ceramic 1,313.00$ D6750 Retainer crown - porcelain fused to high noble metal 1,376.00$ D6751 Retainer crown - porcelain fused to predominantly base metal 1,254.00$ D6752 Retainer crown - porcelain fused to noble metal 1,313.00$ D6780 Retainer crown - 3/4 cast high noble metal 1,338.00$ D6790 Retainer crown - full cast high noble metal 1,352.00$ D6791 Retainer crown - full cast predominantly base metal 1,220.00$ D6792 Retainer crown - full cast noble metal 1,369.00$ D6930 Recement/bnd fxd part denture 201.00$ D7140 Routine Extraction 172.00$ D7210 Extraction of Erupted Tooth with Bone Removal 317.00$ D7241 Extraction Complications 514.00$ D7250 Removal of Residual Tooth Roots 336.00$ D7310 Alveoloplasty with extractions 4+ teeth, per quadrant 351.00$

D7320 Alveoloplasty (4-8) 537.00$ D7321 Alveoloplasty (1-3) 376.00$ D7321.7321 Alveoloplasty (1-3) 376.00$ D9110 Palliative treatment of dental pain – per visit 153.00$ D9310 Professional Consultation 230.00$ D9410 House Call 230.00$ D9932 Cleaning and inspection of removable complete denture, maxillary 62.00$ D9933 Cleaning and inspection of removable complete denture, mandibular 62.00$ D9934 Cleaning and inspection of removable partial denture, maxillary 22.00$ D9935 Cleaning and inspection of removable partial denture, mandibular 22.00$ D9941 Soft Night Guard 768.00$ D9943 Occlusal guard adjustment 64.00$ D9944 Occlusal guard - hard appliance, full arch 768.00$ D9945 Occlusal guard - soft appliance, full arch 768.00$ D9946 Occlusal guard - hard appliance, partial arch 768.00$ D9951 Limited Occlusal Adjustment 64.00$

CDS

Revision: 11/1/2021

BUSINESS ASSOCIATE ADDENDUM

This Addendum is made part of this Contract between the State of Arizona System ("STATE" or “Covered Entity”) and Coronado Dental Services, Inc. (“Business Associate”).

STATE and Business Associate agree that the underlying Contract, by which Business Associate provides services to STATE, shall comply with the Administrative Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as set forth in Title 45, Parts 160 and 164 of the Code of Federal Regulations (the "CFR"), as amended. In the event of conflicting terms or conditions, this Addendum shall supersede the underlying Contract.

1. DEFINITIONS

The following terms used in this Addendum shall have the same meaning as those terms in the HIPAA rules set forth in Title 45, Parts 160 and 164 of the CFR: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required by Law, Secretary, Security Incident, Subcontractor, and Unsecured Protected Health Information, and Use.

2. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE

Business Associate agrees to:

2.1. Not use or disclose Protected Health Information (“PHI”) other than as permitted, required by this Addendum, or as Required by Law;

2.2. Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic Protected Health Information (ePHI), to prevent use or disclosure of PHI/ePHI other than as provided for by this Addendum;

2.3. Report to STATE any use or disclosure of PHI/ePHI not provided for by this Addendum of which it becomes aware, including Breaches of Unsecured Protected Health Information as required at 45 CFR §164.410, and any Security Incident of which it becomes aware, in the following manner;

2.3.1. Reporting. Business Associate shall report to STATE any use or disclosure of

PHI/ePHI that is not authorized by the Contract, by law, or in writing by STATE. Business Associate shall make an initial report to the STATE not more than seventy-two (72) business hours after Business Associate learns of such unauthorized use or disclosure. The initial report shall include all of the following information to the extent known to the Business Associate at the time of the initial report:

A. A description of the nature of the unauthorized use or disclosure, including the number of individuals affected by the unauthorized use or disclosure;

B. A description of the PHI/ePHI used or disclosed;

C. The date(s) on which the unauthorized use or disclosure occurred;

D. The date(s) on which the unauthorized use or disclosure was discovered;

E. Identify the person(s) who used or disclosed the PHI/ePHI in an unauthorized manner;

F. Identify the person(s) who received PHI/ePHI disclosed in an unauthorized manner;

G. A description of actions, efforts, or plans undertaken by the Business associate to mitigate the harm of the unauthorized disclosure;

H. A description of corrective actions undertaken or planned to prevent future similar unauthorized use or disclosure;

I. An assessment of whether a breach, as defined in 45 CFR 164.402, has occurred, including, if necessary, an assessment of the probability of harm, and

J. Such other information, as may be reasonably requested by the STATE Privacy Official.

Business Associate shall provide STATE with supplemental reports promptly as new information becomes available and as needed, as assessments and action plans are developed, and as action plans are implemented. In any event, Business Associate shall provide a comprehensive written report including all of the information listed above no later than thirty (30) days after discovery of the unauthorized use or disclosure.

2.3.2. Mitigation. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of PHI/ePHI by Business Associate in violation of the requirements of the Contract.

2.3.3. Sanctions. Business Associate shall have and apply appropriate sanctions against any employee, Subcontractor or agent who uses or discloses STATE PHI/ePHI in violation of this Addendum or applicable law.

2.4. In accordance with 45 CFR §164.502(e)(1)(ii) and §164.308(b)(2), if applicable, ensure that any STATE approved subcontractors that create, receive, maintain or transmit PHI/ePHI on behalf of the Business Associate agree to the same restrictions, conditions and requirements that apply to the Business Associate with respect to such information;

2.5. Make available PHI/ePHI in a designated record set to STATE as necessary to satisfy STATE's obligations under 45 CFR §164.524;

2.6. Make any amendment(s) to PHI/ePHI in a designated record set as directed or agreed to by STATE pursuant to 45 CFR §164.526, or take other measures as necessary to satisfy STATE's obligations under 45 CFR §164.526;

2.7. Maintain and make available the information required to provide an Accounting of

Disclosures to STATE as necessary to satisfy STATE's obligations under 45 CFR §164.528;

2.8. To the extent Business Associate is to carry out one of more of STATE's obligations under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to STATE in the performance of such obligation(s); and

2.9. Make its internal practices, books and records available to STATE and the Secretary for purposes of determining compliance with the HIPAA rules within ten (10) business days of a written request by STATE.

3. PERMITTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE

3.1. Business Associate may only use or disclose PHI/ePHI as necessary to perform the services and obligations set forth in the underlying Contract;

3.2. Business Associate may use or disclose protected health information as required by law;

3.3. Business Associate agrees to make uses and disclosures and requests for PHI/ePHI consistent with minimum necessary requirements;

3.4. Business Associate may not use or disclose PHI/ePHI in a manner that would violate Subpart E of 45 CFR Part 164 if done by STATE, except for the specific uses and disclosures set forth below in (3.5 and 3.6);

3.5. Business Associate may use protected health information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate; and

3.6. Business Associate may provide data aggregation services relating to the health care operations of STATE.

4. PROVISIONS FOR STATE TO INFORM BUSINESS ASSOCIATE OF PRIVACY PRACTICES AND

RESTRICTIONS

4.1. STATE shall notify Business Associate of any limitation(s) in the STATE Notice of Privacy

Practices under 45 CFR §164.520, to the extent that such limitation may affect Business Associate’s use or disclosure of PHI;

4.2. STATE shall notify Business Associate of any changes in, or revocation of, the permission by an individual to use or disclose his or her PHI/ePHI, to the extent that such changes may affect Business Associate’s use or disclosure of PHI/ePHI; and

4.3. STATE shall notify Business Associate of any restriction on the use or disclosure of PHI/ePHI that STATE has agreed to or is required to abide by under 45 CFR 164.522, to the extent that such restriction may affect Business Associate’s use or disclosure of PHI/ePHI.

5. TERM AND TERMINATION

5.1. Term: This Addendum is effective upon the effective date of the underlying Contract and shall terminate on the date STATE terminates the contract for cause as authorized in Section 5.2, or for any other reason permitted under the contract, whichever is sooner.

5.2. Termination for Cause: Business Associate authorizes termination of the Contract by STATE if STATE determines that Business Associate has breached a material term of this Addendum and Business Associate has not cured the breach or ended the violation within the time specified by STATE.

5.3. Obligations of Business Associate Upon Termination: Upon termination, cancellation, expiration or other conclusion of the Contract, Business Associate, with respect to PHI/ePHI received from STATE, or created, maintained, or received by Business Associate on behalf of STATE, shall:

5.3.1. Retain only that PHI/ePHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;

5.3.2. Destroy or return to STATE all remaining PHI/ePHI that the Business Associate still maintains in any form;

5.3.3. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part

164 with respect to ePHI to prevent use or disclosure of the PHI, other than as provided for in this Section, for as long as Business Associate retains the PHI/ePHI;

5.3.4. Not use or disclose the PHI/ePHI retained by Business Associate other than for the purposes for which such information was retained and subject to the same conditions set out in this Addendum that applied prior to termination; and

5.3.5. Destroy or return to STATE the PHI/ePHI retained by Business Associate when it is no longer needed by Business Associate for its proper management and administration or to carry out its legal and contractual responsibilities.

5.4. Survival: The obligations of Business Associate under this Section shall survive the termination of the Contract.

6. INDEMNIFICATION AND MISCELLANEOUS

6.1. Indemnification: Business Associate shall indemnify, hold harmless and defend STATE from and against any and all claims, losses, liabilities, costs, including, but not limited to, reasonable attorney fees and court costs (including, but not limited to, primary loss investigation, judgment costs, expert witness fees, and any and all fees and costs from appellate proceedings), civil and criminal penalties, and any and all other expenses resulting from, or relating to, the acts or omissions of Business Associate, its employees, agents, and approved sub-contractors in connection with the representations, duties and obligations of Business Associate under this Addendum. The parties’ respective rights and obligations under this Section shall survive termination of the Contract.

6.2. Regulatory References: A reference in this Addendum to a section in the HIPAA rules means the section as in effect or as amended.

6.3. Amendment: The parties agree to take such action as is necessary to amend this Addendum from time to time as is necessary for compliance with the requirements of the HIPAA rules or any other applicable law.

6.4. Interpretation: Any ambiguity in this Addendum shall be interpreted to permit compliance with the HIPAA rules.

6.5. Governing Law: This Addendum and any action related thereto shall be governed by and interpreted under the laws of the State of Arizona. The parties expressly consent to the jurisdiction and venue of the state and federal courts of Phoenix, Arizona for any action arising from or related to this Addendum.

Contractor hereby acknowledges receipt and acceptance of this HIPAA Business Associate

Addendum and that a signed copy must be filed with the ADOA Procurement and ASET Enterprise

Security Offices.

Signature Date

Printed Name

Title

Company/Vendor Name

The above referenced HIPAA Business

Associate Addendum is hereby executed this

_June day of 29th 2023 by the

Department of Administration on behalf of the State of Arizona.

State Representative Date

Teena Ziegler_________

Printed Name

Procurement Manager

Title

6/23/2023

Felipe Dest

Administrative Director

Coronado Dental Services, Inc.

151243

Underline

151243

Underline

2023-06-29T15:38:12-0700

Teena Ziegler

Notice of Award under A.R.S. § 41- 2534 Notice Page

Arizona Department of Administration State Procurement Office

100 N 15th Avenue, Suite 305 Phoenix, AZ 85007

Contract Number: CTR066401

Description: Dental Services for Phoenix and Tucson Veteran Homes

Offeror Award to: Coronado Dental Service, Inc.

Proposals will only be accepted online in the “State’s eProcurement System”, Arizona Procurement Portal (APP), at https://app.az.gov until the “Bid/Offer Due Date” indicated in the “State’s eProcurement System” for the Solicitation No. shown at the top of this page. Proposals must be in the State Procurement Office’s possession online no later than that deadline.

Submit technical inquiries about navigating and/or submitting proposals in the State’s eProcurement System to the State’s eProcurement System Help Desk by phone at (602) 542-7600, option 2; or by email to app@azdoa.gov.

LATE PROPOSALS WILL NOT BE CONSIDERED. No extension or grace period will be given for delays or incomplete proposals caused by internet connectivity problems, file uploading difficulties, or misunderstanding of the requirements or procedures for online submission in the “State’s eProcurement System”.

It is the responsibility of the Prospective Offeror to routinely check the APP website for Solicitation Amendments. Additional instructions for preparing an Offer are included in this solicitation.

Persons with a disability may request a reasonable accommodation, such as a sign language interpreter, by contacting the Solicitation contact person. Requests shall be made as early as possible to allow time to arrange for the accommodation.

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 1 of 70 https://app.az.gov/ mailto:app@azdoa.gov

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 2 of 73 Click here to return to the Table of Contents

Table of Contents

CTR#066401

Coronado Dental Service, Inc.

Dental, Vision and Audiology Services for Veteran Homes

100 N 15th Avenue, Suite 305

Notice Page

Table of Contents

Solicitation Summary 3

Scope of Work 5 Special Terms and Conditions 20 Addendum A to the Special Terms and Conditions 48

Uniform Terms and Conditions 54 Exhibit A 14 Exhibit B 15

Best and Final Prices are attached

Business Agreement is attached

Offer and Acceptance attached

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 4 of 73

Contract Summary

CTR066401

100 N 15th Avenue

1. What is the State Soliciting?

The Arizona Department of Administration, State Procurement Office (the State), as authorized under A.R.S. § 41-2501 et seq. is seeking to establish one or more Contracts in the areas of Dental, Vision and Audiology Services for the Department of Veteran Services (ADVS)

The State anticipates awarding contract(s) with the intent to secure service coverage statewide.

Whether or not it actually enters into any contracts, how many contracts it enters into, and how the work is awarded between those contracts are all at the State’s discretion. Furthermore, the State will use any awarded contracts on an as-needed basis, with no guarantee as to its actual spending under them.

The State reserves the right to accept any item or combination of items specified in the Solicitation, unless the Offeror expressly restricts an item or combination of items in its Offer, and conditions its response on receiving all items for which it provided a proposal. In the event of such restriction, the State will evaluate if an award on such a basis will result in the best value and is in the best interest for the State. The State may otherwise determine, at its sole discretion, that such restriction is non-responsive and deem the Offeror ineligible for further evaluation.

2. What is in the Solicitation?

2.1. At the time of publication, the following documents are included in the Solicitation:

2.1.1. Attachment: BPM005257 Solicitation Requirements

2.1.1.1. Notice / Cover Page

2.1.1.2. Table of Contents

2.1.1.3. Solicitation Summary

2.1.1.4. Scope of Work

2.1.1.5. Special Terms and Conditions

2.1.1.6. Addendum A to the Special Terms and Conditions

2.1.1.7. Addendum B to the Special Terms and Conditions

2.1.1.8. Uniform Terms and Conditions

2.1.1.9. Exhibits A Price Sheet

2.1.1.10. Exhibit B Vaccination and Exemptions

2.1.2. Attachment: BPM005257 Solicitation Instructions

2.1.2.1. Special Instructions to Offerors

2.1.2.2. Uniform Instructions to Offerors

2.1.3. Solicitation Attachments

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 5 of 73

2.1.3.1. Offer and Acceptance;

2.1.3.2. Boycott of Israel Disclosure;

2.1.3.3. Forced Labor of Ethnic Uyghurs Ban;

2.1.3.4. Confidential Information Designation;

2.1.3.5. Confidential Information Designation (for reference only);

2.1.3.6. Conformance Statements;

2.1.3.7. Supplement – Conformance Statements - Exceptions to

Instructions;

2.1.3.8. Supplement – Conformance Statements - Exceptions to Scope of

Work;

2.1.3.9. Supplement – Conformance Statements - Exceptions to Contract

Terms and Conditions;

2.1.3.10. Key Personnel;

2.1.3.11. Letter of Insurability;

2.1.3.12. Organization Profile;

2.1.3.13. Proposed Subcontractors;

2.1.3.14. Experience and Capacity Response;

2.1.3.15. References

2.1.3.16. Method of Approach

2.1.3.17. Price Sheet

2.1.3.18. Check List

2.2. The State may issue a Solicitation Amendment at any time after Solicitation publication and before the Offer due date. It is the responsibility of the Prospective Offeror to routinely check the APP website for any Solicitation Amendments and revised documents.

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 6 of 73

Scope of Work Coronado Dental Service for the AZ Department of Veteran Services

1. Purpose

1.1. The purpose of this Solicitation is to establish Dental Services with Coronado Dental Service, Inc., exclusively for residents who live in Arizona Veteran Homes in Phoenix and Tucson, Arizona. The Veterans are not required to participate, but the services will be offered in each of the homes.

2. Background:

2.1 The Arizona Department of Veterans’ Services (ADVS) is seeking a contract to provide Dental, Auditory, and Vision Services for the Arizona State Veteran Homes – Phoenix (ASVH-P), Arizona State Veterans’ Home- Tucson (ASVH-T), Arizona State Veterans’ Home - Flagstaff (ASVH-F) and Arizona State Veterans’ Home - Yuma (ASVH-Y).

2.2 All ASVHs are state owned and built to serve the long-term needs of the

Veterans/Residents in Arizona. These services will be used on an as needed, if needed basis. Consequently, ADVS does not guarantee the use of any resultant contract or the need for performance of services at the level indicated with the number of residents or beds..

2.3 The Agency will offer a room at each location to provide the service. Depending on the facility, the rooms are different in size and accommodations. See Exhibit A. The three services will share the same room, therefore the contractor(s) will have to share the room and not conflict on time or day with the other services.

2.4 This contract is eligible for multiple awards and each category will have a separate evaluation based on that category requirements. The State is seeking licensed and board qualified practitioners in the field of Dentistry, Audiology and Vision.

2.5 The operation for each practice is to be a turn key type of operation. There are no unique furniture or tools for the contractor. The room will be bare and water will be available, but the location is different for each building. See Exhibit A.

3. Background about the Homes:

3.1 The services provided by all ASVHs must adapt to meet the ever-changing health care needs of the population served. Care provided is based on the most currently accepted knowledge, practices, and technologies implemented through skilled personnel. In all levels of care, interdisciplinary approaches are planned with the resident and/or family to meet his or her needs. Programs are aimed at meeting

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 7 of 73

Coronado Dental Service long-term health care needs and encouraging wellness through preventive and rehabilitative services offered to assist in attaining and maintaining optimal functioning. Person Centered Care is practiced daily.

3.1. ASVH-P is a skilled nursing facility located at 4141 North S. Herrera Way, Phoenix, AZ 85012. The ASVH-P operates seven (7) days a week, twenty-four (24) hours a day. This facility has 4 units, with fifty (50) beds in each unit to total two hundred (200) beds. The facility has one hundred-fifty beds

(150) beds that are considered skilled/long-term care beds and fifty (50) beds located in a memory care unit. This facility is approved to accept Medicare and Medicaid benefits.

3.2. ASVH-T is a skilled nursing facility located at 555 East Ajo Way, Tucson, AZ 85723. The ASVH-T operates seven (7) days a week, twenty-four (24) hours a day. This facility has 4 units, with thirty

(30) beds in each unit to total one hundred twenty (120) beds. The facility has ninety (90) beds that are considered skilled/long-term care beds and thirty (30) beds located in a memory care unit. This facility is approved to accept Medicare and Medicaid benefits.

3.3. ASVH-F is a skilled nursing facility located at 2100 N. Gemini Drive, Flagstaff, AZ 86001. This ASVH- F will operate seven (7) days a week, twenty-four (24) hours a day. This facility will offer 4 units, with twenty (20) beds in each unit to total eighty (80) beds. The facility has sixty (60) beds that are considered skilled/long-term care beds and twenty (20) beds located in a memory care unit.

3.4. ASVH-Y is a skilled nursing facility located at 6051 E. 34th Street, Yuma, AZ 85365. This ASVH-Y will operate seven (7) days a week, twenty-four (24) hours a day. This facility will offer 4 units, with twenty

(20) beds in each unit to total eighty (80) beds. The facility has sixty (60) beds that are considered skilled/long-term care beds and twenty (20) beds located in a memory care unit.

3.5. Age, disability, or terminal illness should not limit the individual's right to experience life to the fullest extent possible. Despite the complexity of care required and the degree of disability, the ASVHs Homes strives to provide care that promotes the resident's dignity, self-determination, happiness, and well-being in a home-like environment. Basic to this emphasis is fostering the individual to be as self-determining and independent as possible.

3.6. The ASVHs are committed to quality care. It is important to anticipate trends in care needs and plan services to meet those trends, evaluate the care provided, research new approaches, and update programming. The ASVHs have the responsibility to share findings with others involved in long-term health care services.

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SCOPE OF WORK

Coronado Dental Services

Dental, Visual, Audiology Services

4. SPECIFIC REQUIREMENTS FOR EACH SERVICE

4.1 Dental Services/Requirements

4.1.1 The intent of this category is to enter into a contract with qualified individuals or organizations to provide Dental Services for the residents of the ASVHs. The Department is opening one room at each location to provide the services to the residents. See Exhibit A.

4.1.2 Dental Services shall be defined as services provided by the following professionals within their regulated scope of practice in accordance with the Arizona State Board of Dental Examiners:

4.1.2.1 Licensed Dentist;

4.1.2.2 Licensed Dental Hygienist;

4.1.2.3 Registered Dental Assistant; and

4.1.2.4 Practical Dental Assistant.

4.1.3 Treatment duties of the Contractor shall include, but are not limited to the following:

4.1.3.1 Perform extractions as necessary

4.1.3.2 Treat impactions when possible

4.1.3.3 Provide prosthetic devices as needed to include full and partial dentures.

4.2 Vision Care Services/Requirements - REMOVED

4.3 Audiology Services/Requirements - REMOVED

4.4 REQUIREMENTS GENERAL FOR DENTAL

4.4.1 All category of services will be used on an as needed, if needed basis.

Consequently, ADVS does not guarantee the use of any resultant contract or the need for performance of services at the level indicated below.

4.4.2 Report to Traffic Control upon entering the ASVHs. When leaving the ASVHs, the Contractor shall sign out prior to leaving the facility.

4.4.3 Provide labor, equipment and supplies suitable for required tasks.

4.4.4 Be available for scheduled appointments during normal working hours, Monday – Friday, 8:00am to 5:00pm.

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4.4.5 Provide a timetable for delivery of the devices/glasses and contact the Facility Medical Records office when a delay occurs.

4.4.6 Contractor, or manufacturer, shall allow the return of a prescribed piece of equipment within sixty (60) days of purchase and provide credit to the ASVH if the patient/resident is unable to adapt to or use the device. Provide a copy of the manufacturer’s warranty for every item ordered for the patient.

4.4.7 The Services rendered under this contract shall be performed within the guidelines established by the CDC and within the requirements recommended by the state and local government for the professional services sought in the scope of work.

4.4.8 All Services will take direction from the doctor writing the order at the ASVHs.

The ASVH representative for the Doctor will be the Medical Record Clerk or Unit Clerk.

All requests for service shall originate at the Arizona State Veteran Home.

4.4.9 Meet with patients/residents at the ASVHs to provide devices, evaluations, assessments, and if needed, determine the expected improvement from use of a recommended device or service. The Contractor shall conduct audiometric tests before.

5. Licenses/Certifications Requirements

5.1 Contractors providing service shall possess current business licenses and certifications as required by law, State, Federal, and City regulations to provide the required Dental Services.

5.2 The Contractor shall be responsible for verifying current license/certifications and obtain copies for the personnel file.

5.3 Present licenses and/or certification within twenty-four (24) hours of the ASVHs request.

5.4 The Contractor shall present licenses and/ or certification on a yearly basis to the Administrator for each respective Home.

5.5 Providing an employee to ADVS who has a probationary or suspended license may be cause for contract termination. The Agency will be notified within 24 hours if an employee is placed on probation or is on a suspended license. If a suspension happens over a weekend, notice will be provided by the first available weekday work morning.

5.6 The Contractor shall be responsible for Credentialing and Privileging.

Credentialing is the process of obtaining, verifying, and assessing the qualifications of

Solicitation Requirements | Revision No. 3.2 | Revised 02-23 | Page 10 of 73 a health care practitioner, which may include, podiatrists, dentists, physicians, physician assistants, to provide patient care services in or for a healthcare organization. Privileging is the process whereby a specific scope and content of patient care services are authorized for health care practitioners by the Contractor, based on evaluation of the individual’s credentials and performance.

5.7 The Contractor must uniformly apply credentialing criteria to licensed practitioners applying to provide resident care or treatment under the facility’s care.

5.8 The Contractor must verify and uniformly apply the following core criteria:

a.) Current licensure; current certification, b.) If applicable, relevant education, training, and experience;

c.) Current competence; and d.) A statement that the individual is able to perform the services he or she is applying to provide.

5.9 The Contractor must decide whether to authorize the independent practitioner to provide resident care or treatment, and each credentials file must indicate that these criteria are uniformly and individually applied.

5.10 The Contractor must maintain documentation of current credentials for each licensed independent practitioner providing services to residents residing at ASVH.

5.11 Contractor shall as requested provide the current credentials when/as requested by the Department within twenty-four (24) hours from the time of the request.

5.12 When reappointing a licensed independent practitioner, the Contractor must review the individual’s record of experience.

5.13 The Contractor systematically must assess whether individuals with clinical privileges act within the scope of work.

5.14 Provide a Plan of Correction (POC) as requested by the Quality Resource Management (QRM) Administrator or designee when deficiencies have been identified by the ASVHs or an external regulatory agency.

6 The Contractor shall provide qualified and trained service personnel to perform all the required services. The ASVHs will provide a safe environment in which to examine and provide services to patients and residents. Personnel provided by the Contractor must follow ADVS rules, including;

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6.1 ASVHs grounds are drug-, alcohol- and tobacco-free. Smoking is permitted only in the designated smoking areas.

6.2 Signing in and presenting positive identification upon reporting for duty.

6.3 Interacting cordially with ADVS personnel.

6.4 Responding professionally to ADVS supervisory personnel.

6.5 Following other State/ADVS rules as required.

6.6 Park in ADVS assigned locations when reporting for duty and obey all speed limits.

6.7 Referred personnel shall be immediately productive, requiring minimal training and orientation.

6.8 Communicate and cooperate with the ASVHs staff in the treatment of the patients and residents.

6.9 Taking images of residents is prohibited on all ASVH property. Taking pictures inside a facility is prohibited.

6.10 No firearms are permitted on ASVHs property.

6.11 Work policies, standards and procedures as established by the ADVS shall be followed at all times. The Contractor and his/her employee(s) shall conform in all respects with regard to physical, fire and security regulations while on the premises of the ADVS. Link to Policies will be provided upon award.

6.12 Follow “Procedures for Vaccination Status Verification”, see Exhibit B.

7 Tuberculosis –

7.1 The Contractor shall ensure that all employees assigned to work at each of the ASVH’s Statewide have a negative T.B. tuberculin screening within the last twelve (12) months before commencing work and yearly thereafter.

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8. Offeror Shall:

8.1 Onboarding New Patients:

• Upon review of the census, each new patient will be onboarded by one of Coronado Dental’s Care Coordinators and added to our Electronic Health Record (EHR) system to ensure a complete profile, inclusive of patient demographic, medical history, and insurance information. It is at this point that all key billing information and documentation of Responsible Parties are noted in the EHR.

• As stated in our Method of Approach, each new patient will receive a comprehensive dental exam with one of our doctors. This visit includes full-mouth x-rays and an extensive evaluation of the patient’s oral health. During this initial appointment, each patient receives a personalized treatment plan that outlines the next steps in providing preventive and restorative services, as deemed medically necessary.

• Preventive: Patient will be placed on a routine oral hygiene schedule that is reviewed with the patient and Responsible Parties to provide a clear understanding of care and obtain consent.

• Restorative: Dental care that focuses on repairing or replacing damaged teeth to restore function and aesthetics. This includes a range of procedures, including fillings, crowns, periodontal treatment, extractions, and dentures. Each individualized care plan will undergo a financial review and consent process with the appropriate parties prior to rendering services.

8.2 The Contractor shall provide care services in accordance with the requirements for that profession and to include but not limited to the following; the Arizona Revised Statutes, Arizona Administrative Code and any other law that maintains the integrity and safety of the patient and practice.

8.2.1 Agency prefers a business practice that can accept a preferred provider contract with Medicaid to ensure proper billing (i.e. Banner University Family Care, Mercy Care, and Cigna Long Term Care).

8.2.2 Provide documentation of evidence of compliance, such as, but not limited to:

history including complaint and relevant symptoms, dental, ocular or audiology health, medication usage, medical and family history, current vision aide if applicable, and any other pertinent data, patient progress notes and other required patient related documentation per the ASVHs medical records guidelines, with applicable regulations enforced by the federal, state and local regulatory agencies, including the ASVHs Policies and Procedure.

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Onboarding New Patients

Upon review of the census, each new patient will be onboarded by one of Coronado Dental’s Care Coordinators and added to our Electronic Health Record (EHR) system to ensure a complete profile, inclusive of patient demographic, medical history, and insurance information. It is at this point that all key billing information and documentation of Responsible Parties are noted in the EHR.

As stated in our Method of Approach, each new patient will receive a comprehensive dental exam with one of our doctors.

This visit includes full-mouth x-rays and an extensive evaluation of the patient’s oral health. During this initial appointment, each patient receives a personalized treatment plan that outlines the next steps in providing preventive and restorative services, as deemed medically necessary.

• Preventive: Patient will be placed on a routine oral hygiene schedule that is reviewed with the patient and Responsible Parties to provide a clear understanding of care and obtain consent.

• Restorative: Dental care that focuses on repairing or replacing damaged teeth to restore function and aesthetics.

This includes a range of procedures, including fillings, crowns, periodontal treatment, extractions, and dentures.

Each individualized care plan will undergo a financial review and consent process with the appropriate parties prior to rendering services.

Billing Structure

The following is an outline of Coronado Dental’s proposed billing and claims processing practices for patients based on insurance type. This is consistent with our current operations and will rely on clear communication regarding the patient’s benefits and consent for treatment. All pricing structures are based on our UCR fee schedule (see attached) and confirmed prior to rendering care.

• Medicaid (AHCCCS): Continue billing practices through the patient’s Medicaid insurance plan.

• Private Pay: Review total cost-of-care along with a signed treatment plan and collect money directly from patient or

Responsible Party.

• 70% - 90% Disability Rating: Review total cost-of-care along with a signed treatment plan and collect money from the AZ State Veteran’s Home.

• 100% Disability Rating or Rated for Dental Issue: Authorize services and billing process with the U.S. Department of

Veterans Affairs (VA) prior to performing services. Coronado Dental will maintain an active status with regards to their Veterans Care Agreement, last renewed 3/17/2023 and awarded on June 26th, 2023, effective July 1, 2023.

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9. Pricing:

9.1 Comply with all requirements of applicable standards of the, Centers for Medicare and Medicaid Services (CMS), OSHA, National Fire Protection Agency (NFPA), Environmental Protection Agency (EPA), Center for Disease Control and Prevention (CDC) and any other federal, state and local regulatory agencies.

9.2 The Contractor will be paid in accordance with the Contract amount, as accepted by ASVHs.

9.3 Billing Structure:

9.3.1 The following is an outline of Coronado Dental’s proposed billing and claims processing practices for patients based on insurance type. This is consistent with our current operations and will rely on clear communication regarding the patient’s benefits and consent for treatment.

9.3.2 All pricing structures are based on our UCR fee schedule and confirmed prior to rendering care.

9.3.3 Medicaid (AHCCCS): Continue billing practices through the patient’s Medicaid insurance plan.

9.3.4 Private Pay: Review total cost-of-care along with a signed treatment plan and collect money directly from patient or responsible party.

9.3.5 70%-90 to 99.9% Disability Rating: Review total cost-of-care along with a signed treatment plan and collect money from the AZ State Veteran’s Home.

9.3.6 100% Disability Rating: Authorize services and billing process with the U.S. Department of Veterans Affairs (VA) prior to performing services. Coronado Dental will maintain an active status with regards to their Veterans Care Agreement, last renewed 3/17/2023.

9.4 The State will not pay for services, any travel expenses, and/or products in advance. Payments will be made monthly for completion of services as shown by an itemized invoice, submitted by the Contractor by the thirtieth (30th) day of the month following service. Payments will not be authorized if the invoice submitted is incomplete or does not contain the necessary information needed to properly review.

9.5 Offeror is asked to submit a Pricing Plan that will cover all efforts to perform the work. Whether that work is per individual, a group, location or 3rd party payment system, the solution offered for payment, must be simple, consistent and provide a service that will cover the needs of our Veteran’s. “Work” means all fees to accomplish the service.

9.6 Provide pricing to include all labor for the initial appointments with the patient or resident, appointment for fitting the device and follow-up adjustments, as necessary. The agency is encouraging pricing plans suggested by Contractor that will be simple, easily administered and financially explicit with no surprises for the patient or the Agency.

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9.7 Some price solutions, might be a total charge or lump sum per diem to include all services provided the resident(s) on the day of service, if that is preferred, use Table 1, to list location, service and lump sum.

A menu of treatments is required with offer.

9.8 Other price solutions, might be rate charges for treatments, with the patient/Agency responsible for what Medicare does not cover. The Agency expects the Offeror to provide what the patient/Agency would cover for those services. Use Table 2, or something similar in the offer.

9.9 Regardless of the price plan offered, each Medical Specialty that is being offered, the Offeror must submit a menu of services offered to the patient. With each service, describe simply, the work to be completed, with a rate charge for the treatment. See Exhibit A.

9.10 New or Different Products or Services:

The State, at its sole discretion may allow new or services identified by the Contractor or ADVS to be incorporated. The request may be submitted at any time during the Contract period. The requested products or services shall align with the current Scope of Work and Price List.

9.11 The Contractor must demonstrate the ability to bill third party insurance, where applicable, based on the individual resident payer situation and provide a list of those insurances i.e. AHCCCS, Medicare B, Delta Dental, etc… Further, any co-pays, co- insurance or deductibles will be billed to the resident, where applicable, based on the individual resident payer situation, if not applicable these charges will be billed to the Facility.

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EXHIBIT B Vaccination Status Verification

Arizona Department of Veterans’ Services

Procedures for Vaccination Status Verification/ Mitigation/ Reasonable Accommodations/ Exemptions (medical, delayed vaccination and religious)

These procedures are subject to change at any time

I. Vaccination Status Verification

a. Facility Staff: must present COVID-19 Immunization Record Card to the Infection Preventionist

i. Vaccination logs must be retained/ maintained by the facility in a secure location

ii. Physical copies of the staff COVID-19 Immunization Card or HR's approval letter for exemptions with the approved COVID-19 mitigation strategy are retained/ maintained by the Infection Preventionist

iii. Staff will utilize the vaccination logs to update and maintain National Health Safety Network (NHSN) database

b. Volunteers/ Contracted Services/ Students/ Interns/ Trainees: must present COVID-19 Immunization Record Card to the Infection Preventionist

i. Vaccination logs must be retained/ maintained by the facility in a secure location

ii. Physical copies of the COVID-19 Immunization Card or approved exemptions with the approved COVID-19 mitigation strategy are retained/maintained by the Infection…