Mercy_Care_Final_contract_Revised_for_amendment_1.pdf

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Contract CTR050520

State of Arizona

Department of Child Safety

Office of Procurement & Contracts

3003 N. Central Ave., 20th Fl.

Phoenix, AZ 85012 Integrated Healthcare Delivery

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Integrated Healthcare Delivery Services

Office of Procurement & Contracts

3003 N. Central Ave., 20th Fl.

Phoenix, AZ 85012 TABLE OF CONTENTS

CONTENTS

SECTION B: CONTRACTOR FUNDING ARRANGEMENT AND CONTRACTOR

REQUIREMENTS

SECTION C: DEFINITIONS

SECTION D: SCOPE OF WORK

1. PURPOSE, APPLICABILITY AND INTRODUCTION

2. ELIGIBILITY CATEGORIES

3. ENROLLMENT AND DISENROLLMENT

4. RESERVED

5. RESERVED

6. RESERVED

7. ACCOMODATING MEMBERS

8. TRANSITION ACTIVITIES

9. SCOPE OF SERVICES

10. SPECIAL HEALTH CARE NEEDS

11. BEHAVIORAL HEALTH SERVICE DELIVERY

12. DCS CHP AND AHCCCS GUIDELINES, POLICIES AND MANUALS

13. MEDICAID SCHOOL BASED CLAIMING

14. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM

15. STAFFING REQUIREMENTS

16. WRITTEN POLICIES AND PROCEDURES

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17. MEMBER INFORMATION

18. SURVEYS

19. CULTURAL COMPETENCY

20. MEDICAL RECORDS

21. RESERVED

22. QUALITY MANAGEMENT AND PERFORMANCE IMPROVEMENT

23. MEDICAL MANAGEMENT

24. TELEPHONE PERFORMANCE STANDARDS

25. GRIEVANCE AND APPEAL SYSTEM REQUIREMENTS

26. NETWORK DEVELOPMENT

27. PROVIDER AFFILIATION TRANSMISSION

28. NETWORK MANAGEMENT

29. PRIMARY CARE PROVIDER STANDARDS

30. MATERNITY CARE PROVIDER REQUIREMENTS

31. REFERRAL MANAGEMENT

32. APPOINTMENT STANDARDS

33. FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS

34. PROVIDER MANUAL

35. PROVIDER REGISTRATION/TERMINATION

36. SUBCONTRACTS

37. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM

38. SPECIALTY CONTRACTS

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Phoenix, AZ 85012 TABLE OF CONTENTS

39. HOSPITAL SUBCONTRACTING AND REIMBURSEMENT

40. RESPONSIBILITY FOR NURSING FACILITY REIMBURSEMENT

41. PHYSICIAN INCENTIVES

42. MATERIAL CHANGE TO BUSINESS OPERATIONS

43. RESERVED

44. RESERVED

45. RESERVED

46. RESERVED

47. RESERVED

48. RESERVED

49. RESERVED

50. CHANGE IN CONTRACTOR ORGANIZATION STRUCTURE

51. COMPENSATION

52. RESERVED

53. RESERVED

54. MEMBER BILLING AND LIABILITY FOR PAYMENT

55. REINSURANCE

56. COORDINATION OF BENEFITS AND THIRD PARTY LIABILITY

57. RESERVED

58. MEDICARE SERVICES AND COST SHARING

59. RESERVED

60. CORPORATE COMPLIANCE

61. RECORD RETENTION

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Phoenix, AZ 85012 TABLE OF CONTENTS

62. SYSTEMS DATA EXCHANGE REQUIREMENTS

63. ENCOUNTER DATA REPORTING

64. ENROLLMENT AND CAPITATION TRANSACTION UPDATES

65. PERIODIC REPORTING REQUIREMENTS

66. REQUESTS FOR INFORMATION

67. DISSEMINATION OF INFORMATION

68. READINESS REVIEWS

69. MONITORING AND OPERATIONAL REVIEWS

70. ADMINISTRATIVE ACTIONS

71. CONTINUITY OF OPERATIONS AND RECOVERY PLAN

72. RESERVED

73. PENDING ISSUES

74. VALUE BASED PURCHASING

EXHIBITS

EXHIBIT 1: MEMBER GRIEVANCE AND APPEAL SYSTEM STANDARDS

EXHIBIT 2: PROVIDER CLAIM DISPUTE STANDARDS

EXHIBIT 3: OFFEROR’S RESOURCE LIST

EXHIBIT 4: CHART OF DELIVERABLES

SPECIAL TERMS AND CONDITONS

UNIFORM TERMS AND CONDITIONS

Contract CTR505620

Office of Procurement & Contracts

3003 N. Central Ave., 20the Fl.

Phoenix, AZ 85012

CONTRACTOR FUNDING AND

CONTRACTOR-SPECIFIC REQUIREMENTS

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SECTION B: CONTRACTOR FUNDING

ARRANGEMENT AND CONTRACTOR

REQUIREMENTS

Contractor – Funding Arrangement:

Contractor Service Fees shall be in accordance with the terms of this Contract as provided under

Section D, Paragraph 51, Compensation. Contractor Specific Requirements:

Geographic Service Area: The Contractor shall serve eligible members statewide.

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Phoenix, AZ 85012 DEFINITIONS

SECTION C: DEFINITIONS

638 TRIBAL FACILITY A facility that is owned and/or Operated by a Federally recognized

American Indian/Alaskan Native Tribe and that is authorized to provide services pursuant to Public Law 93-638, as amended. Also referred to as:

tribally owned and/or operated 638 facility, tribally owned and/or operated facility, 638 tribal facility, and tribally- operated 638 health program.

ABUSE (OF A MEMBER) Abuse of a child who is a member is specified in A.R.S. § 8-201(2) and means the infliction or allowing of physical injury, impairment of bodily function or disfigurement or the infliction of or allowing another person to cause serious emotional damage as evidenced by severe anxiety, depression, withdrawal or untoward aggressive behavior and which emotional damage is diagnosed by a medical doctor or psychologist and is caused by the acts or omissions of an individual who has the care, custody and control of a child. Abuse includes:

a. Inflicting or allowing sexual abuse pursuant to A.R.S. §13-1404, sexual conduct with a minor pursuant to A.R.S. § 13-1405, sexual assault pursuant to A.R.S. § 13-1406, molestation of a child pursuant to A.R.S.

§ 3-1410, commercial sexual exploitation of a minor pursuant to

A.R.S. § 13-3552, sexual exploitation of a minor pursuant to A.R.S. §

13-3553, incest pursuant to A.R.S. § 13-3608 or child sex trafficking pursuant to

A.R.S. § 13-3212;

b. Physical injury that results from permitting a child to enter or remain in any structure or vehicle in which volatile, toxic or flammable chemicals are found or equipment is possessed by any person for the purpose of manufacturing a dangerous drug as defined in A.R.S. § 13-3401; and,

c. Unreasonable confinement of a child.

ABUSE (BY A PROVIDER) Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program as defined by 42 CFR 455.2.

ACTIVE TREATMENT Related to standards that apply to members with Children’s

Rehabilitative Services (CRS) qualifying condition(s): Means there is a current need for treatment of the CRS qualifying condition(s) or it is

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Phoenix, AZ 85012 DEFINITIONS anticipated that treatment or evaluation for continuing treatment of the

CRS qualifying condition(s) will be needed within the next 18 months from the last date of service for treatment of any CRS qualifying condition

(A.A.C. R9-22-1301).

Related to standards that apply to members receiving services in

Intermediate Care Facilities for Individuals with Intellectual Disabilities

(ICF/IID): Means that each client must receive a comprehensive functional assessment within 30 days after admission that is reviewed at least annually by the interdisciplinary team for its relevancy, and updated, as needed, and a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and related services that is directed toward the acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible and the prevention or deceleration of regression or loss of current optimal functional status (42 C.F.R. 483.440).

ADJUDICATED CLAIM A claim that has been received and processed by the Contractor which resulted in a payment or denial of payment.

ADMINISTRATIVE OFFICE OF The Arizona Constitution authorizes an administrative director and staff

THE COURTS (AOC) to assist the Chief Justice with administrative duties. Under the direction of the Chief Justice, the administrative director and the staff of the AOC provide the necessary support for the supervision and administration of all State courts.

ADMINISTRATIVE SERVICES An agreement that delegates any of the requirements of the Contract with

SUBCONTRACT/ DCS/CHP, including, but not limited to the following:

SUBCONTRACTOR

a. Claims processing, including pharmacy claims;

b. Credentialing, including those for only primary source verification

(i.e., Credential Verification Organization);

c. Management Service Agreements; and

d. Service Level Agreements with any Division or Subsidiary of a corporate parent owner.

Providers are not Administrative Services Subcontractors.

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ADULT A person 18 years of age or older, unless the term is given a different definition by statute, rule, or policies adopted by the DCS/CHP or

Arizona Health Care Cost Containment System (AHCCCS).

AGENT Any person who has been delegated the authority to obligate or act on behalf of another.

AHCCCS (ARIZONA HEALTH See “ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM.”

CARE COST CONTAINMENT

SYSTEM)

AHCCCS COMPLETE CARE A contracted Managed Care Organization, also referred to herein as

(ACC) CONTRACTOR “health plan,” that, except in limited circumstances, is responsible for the provision of both physical and behavioral health services to eligible Title

XIX/XXI persons enrolled with ACC.

AHCCCS CONTRACTOR The ACOM provides information related to AHCCCS Contractor

OPERATIONS MANUAL (ACOM) operations and is available on the AHCCCS website at www.azahcccs.gov.

AHCCCS MEDICAL POLICY The AMPM provides information regarding covered health care

MANUAL (AMPM) services and is available on the AHCCCS website at www.azahcccs.gov.

AHCCCS MEMBER An eligible individual who is enrolled in AHCCCS, as defined in A.R.S. §

36-2931, § 36-2901, § 36-2901.01 and § 36-2981.

AHCCCS RULES See “ARIZONA ADMINISTRATIVE CODE.” AHCCCS Rules are State regulations which have been promulgated by the AHCCCS

Administration and published by the Arizona Secretary of State.

AMBULATORY CARE Preventive, diagnostic and treatment services provided on an outpatient basis by physicians, nurse practitioners, physician assistants and/or other health care providers.

AMERICAN INDIAN HEALTH Indian Health Service Facilities, Tribally-Operated 638 Health Programs

FACILITY (ITUs) and Urban Indian Health Programs may be referred to as American Indian

Health Facilities (ITUs) (ARRA Section 5006(d), SMD letter 10-001).

http://www.azahcccs.gov/

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AMERICAN INDIAN An acute care fee-for-service (FFS) program administered by AHCCCS

HEALTH PLAN (AIHP) for Title XIX/XXI eligible American Indians which reimburses for physical and behavioral health services provided by or through the Indian

Health Services (IHS), tribal health programs operated under 638 or any other AHCCCS registered provider.

AMERICANS WITH DISABILITIES See “ADA Act of 1990, as amended, in 42 U.S.C. 126 and 47 U.S.C.

ACT OF 1990 (ADA) 5.” The ADA prohibits discrimination on the basis of disability and ensures equal opportunity for persons with disabilities in employment, State and local government services, public accommodations, commercial facilities transportation and telecommunications.

APPEAL The request for review of an Adverse Benefit Determination.

APPEAL RESOLUTION The written determination by DCS/CHP concerning an appeal.

ARIZONA ADMINISTRATIVE State regulations established pursuant to relevant statutes. Referred to

CODE (A.A.C.) in this Contract as “Rules.”

ARIZONA DEPARTMENT OF The State agency established pursuant to A.R.S. § 8-451.

CHILD SAFETY (DCS)

ARIZONA DEPARTMENT OF The State agency established under A.R.S. § 36-101 et. seq. responsible for

HEALTH SERVICES (ADHS) leading Arizona’s public health system including responding to disease outbreaks, licensing health and childcare facilities, operating the

Arizona State Hospital (AzSH), and improving the overall health and wellness of all Arizonans.

ARIZONA DEPARTMENT OF The State agency established under A.R.S. § 48-2801 et. seq. responsible for all

JUVENILE CORRECTIONS (ADJC) juveniles adjudicated as delinquent and committed to its jurisdiction by the county juvenile courts.

ARIZONA EARLY INTERVENTION A program established by Part C of the Individuals with Disabilities

Education

PROGRAM (AzEIP) Act within ADES/DDD which provides eligible children and their families’ access to services to enhance the capacity of families and caregivers to support the child’s development between the ages of birth to three years old.

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ARIZONA HEALTH CARE The State agency responsible for Arizona’s Medicaid Program, COST CONTAINMENT SYSTEM approved by the Centers for Medicare and Medicaid Services (CMS) as

(AHCCCS) a Section 1115 Waiver Demonstration Program and described in A.R.S.

Title 36, Chapter 29. In Arizona, AHCCCS is used interchangeably with

Medicaid.

ARIZONA LONG TERM CARE An AHCCCS program which delivers long-term, acute, behavioral

SYSTEM (ALTCS) health and support coordination (case management) services as authorized by A.R.S. § 36-2931 et seq., to eligible members who are either elderly and/or have physical disabilities, and to members with developmental disabilities (DD), through contractual agreements and other arrangements.

ARIZONA REVISED STATUTES Laws of the State of Arizona.

(A.R.S.)

ARIZONA STATE IMMUNIZATION ` Arizona’s information system that is the repository for immunization

INFORMATION SYSTEM (ASIIS) information.

AUTHORIZED REPRESENTATIVE Authorized representative means a person who is authorized to apply for medical assistance or act on behalf of another person (A.A.C. R9-

22-101).

BALANCED BUDGET ACT See “MEDICAID MANAGED CARE REGULATIONS.”

(BBA) OF 1997

BED HOLD A 24 hour per day unit of service that is authorized by the Contractor which may be billed despite the member’s absence from the facility for the purposes of short term hospitalization leave and therapeutic leave.

Refer to the Arizona Medicaid State Plan [42 CFR 447.40, 42 CFR

483.15(c), 9 A.A.C. 28 and AMPM Chapter 100].

BEHAVIORAL HEALTH (BH) Term used to describe mental health (MH) and substance use collectively.

BEHAVIORAL HEALTH Any behavioral disturbance or MH condition that affects a person’s

CONDITION thinking, feeling or mood, and/or substance use diagnosis found in the most current version of the Diagnostic and Statistical Manual of Mental

Disorders or International Classification of Disorders and Related

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Health Problems.

BEHAVIORAL HEALTH DISORDER Any behavioral, MH, and/or substance use diagnoses found in the most current version of the Diagnostic and Statistical Manual of International

Classification of Disorders (DSM) excluding those diagnoses such as intellectual disability, learning disorders and dementia, which are not typically responsive to MH or substance use treatment.

BEHAVIORAL HEALTH As specified in A.A.C. R9-10-101, an individual who is not a BH

PARAPROFESSIONAL (BHPP) professional who provides BH services at or for a health care institution according to the health care institution’s policies and procedures that:

a. If the BH services were provided in a setting other than a licensed health care institution, the individual would be required to be licensed as a behavioral professional under A.R.S. Title 32, Chapter 33, and

b. Are provided with clinical oversight by a BH professional.

BEHAVIORAL HEALTH A behavioral health professional is:

PROFESSIONAL (BHP) a. An individual licensed under A.R.S. Title 32, Chapter 33, whose scope of practice allows the individual to:

i. Independently engage in the practice of BH as defined in

A.R.S. § 32-3251; or

ii. Except for a licensed substance abuse technician, engage in the practice of BH as defined in A.R.S. § 32-3251 under direct supervision as defined in A.A.C. R4-6-101;

b. A psychiatrist as defined in A.R.S. § 36-501;

c. A psychologist as defined in A.R.S. § 32-2061;

d. A physician;

e. A behavior analyst as defined in A.R.S. § 32-2091;

f. A registered nurse practitioner licensed as an adult psychiatric and

MH nurse; or

g. A registered nurse.

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Phoenix, AZ 85012 DEFINITIONS BEHAVIORAL HEALTH As specified in A.A.C. R9-10-101, health care institution that provides

RESIDENTIAL FACILITY treatment to an individual experiencing a BH issue that:

a. Limits the individual’s ability to be independent; or

b. Causes the individual to require treatment to maintain or enhance independence.

BEHAVIORAL HEALTH Physician or practitioner services, nursing services, health-related

SERVICES services, or ancillary services provided to an individual to address the individual’s BH issue. See also “COVERED SERVICES.”

BENEFITS COORDINATION AND CMS resource dedicated to the coordination of benefits for individuals

RECOVERY CENTER dually eligible for Medicaid and Medicare for States that have entered into a Coordination of Benefits Agreement.

BOARD CERTIFIED An individual who has successfully completed all prerequisites of the respective medical specialty board and successfully passed the required examination for certification and when applicable, requirements for maintenance of certification.

BORDER COMMUNITIES Cities, towns or municipalities located in Arizona whose residents typically receive primary or emergency care in neighboring states, excluding neighboring countries, due to service availability or distance.

CARE MANAGEMENT A group of activities performed by the Contractor to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost and help achieve better health care outcomes.

Distinct from case management, care management does not include the day-to-day duties of service delivery.

CARE MANAGEMENT Program activities to identify the top tier of high need/high cost

PROGRAM DCS CHP members receiving services; including the design of clinical interventions or alternative treatments to reduce risk, cost and help members achieve better health care outcomes. The Care Management

Program is a care coordination function performed by the Contractor.

Distinct from case management, Contractor care management does not involve the day- to-day duties of service delivery.

CARE MANAGER A Contractor employed Care Manager performs care management activities to identify and manage clinical interventions or alternative treatments for identified members to reduce risk, cost and help achieve better health care outcomes. Distinct from a Case Manager, a Care

Manager does not perform the day-to-day duties of service delivery.

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CASE MANAGEMENT A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.

CENTERS OF EXCELLENCE A facility and/or program that supplies exceptionally high concentrations of expertise and related resources centered on particular medical areas, delivered in a comprehensive, interdisciplinary fashion. It delivers the highest levels of leadership, quality and services. Centers of Excellence align physicians and other providers to achieve higher value through greater focus on appropriateness of care, clinical excellence and patient satisfaction.

CENTERS FOR MEDICARE AND An organization within the United States Department of Health and

MEDICAID SERVICES (CMS) Human Services (DHHS), which administers the Medicare and

Medicaid programs and the State Children’s Health Insurance Program

(CHIP).

CHILD A person under the age of 18, unless the term is given a different definition by statute, rule or policies adopted by DCS CHP or AHCCCS.

CHILD AND FAMILY TEAM (CFT) A defined group of individuals that includes, at a minimum, the child and his or her family, a BH representative, the DCS Case Manager and any individuals important in the child’s life that are identified and invited to participate by the child and family. This may include teachers, extended family members, friends, family support partners, healthcare providers, coaches, and community resource providers, representatives from the faith community, and agents from other service systems. The size, scope, and intensity of involvement of the team members are determined by the objectives established for the child, the needs of the family in providing for the child, and by who is needed to develop an effective service plan, and can therefore expand and contract as necessary to be successful on behalf of the child

CHILDREN’S REHABILITATIVE A designation of Title XIX and Title XXI members who have completed

SERVICES (CRS) the CRS application and have met the eligibility criteria to receive services as specified in A.A.C. R9-22.

CRS SERVICE PLAN A complete written description of all covered health services and other informal supports which includes individualized goals, family support

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Phoenix, AZ 85012 DEFINITIONS services, care coordination activities and strategies to assist the member in achieving an improved quality of life.

CLAIM DISPUTE A dispute, filed by a provider or Contractor, whichever is applicable, involving a payment of a claim, denial of a claim, imposition of a sanction, or reinsurance.

CLEAN CLAIM A claim that may be processed without obtaining additional information from the provider of service or from a third party but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by A.R.S. § 36-2904.

CLIENT INFORMATION SYSTEM The centralized processing system for files from each Tribal Regional

(CIS) Behavioral Health Authority (TRBHA)/Regional Behavioral Health

Authority (RBHA) to AHCCCS as well as an informational repository for a variety of BH related reporting. The CIS system includes Member

Enrollment and Eligibility, Encounter processing data, Demographics and Serious Mental Illness (SMI) determination processes.

CODE OF FEDERAL The general and permanent rules published in the Federal Register by

REGULATIONS (CFR) the departments and agencies of the Federal Government.

CONTRACT SERVICES See “COVERED SERVICES.”

CONTRACT YEAR A Contract Year is October 1 through September 30.

CONTRACTOR The organization or entity that has a contract with DCS CHP to provide the benefits and services to members through subcontracts with providers and perform the administrative functions described herein, in conformance with contractual requirements, State Statute and Rules, and Federal law and regulations.

CONTRACTOR SERVICE FEES An all-inclusive firm, fixed price for the Contractor’s performance under the Contract.

CONVICTED A judgment of conviction has been entered by a Federal, State or local court, regardless of whether an appeal from that judgment is pending.

CORRECTIVE ACTION PLAN (CAP) A written work plan that identifies the root cause(s) of a deficiency, includes goals and objectives, actions/tasks to be taken to facilitate an expedient return to compliance, methodologies to be used to accomplish CAP goals and objectives, and staff responsible to carry out

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Phoenix, AZ 85012 DEFINITIONS the CAP within established timelines. CAPs are generally used to improve performance of the Contractor and/or its providers, to enhance

Quality Management/Process Improvement activities and the outcomes of the activities, or to resolve a deficiency.

COST AVOIDANCE The process of identifying and utilizing all confirmed sources of first or third party benefits before payment is made by the Contractor.

COVERED SERVICES The health care services to be delivered by the Contractor as described in Section D, Paragraph 9, Scope of Services.

CREDENTIALING The process of obtaining, verifying and evaluating information regarding applicable licensure, accreditation, certification, educational and practice requirements to determine whether a provider has the required credentials to deliver specific covered services to members.

CULTURE The integrated pattern of human behavior that includes language, thought, communication, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group. Culture defines the preferred ways for meeting needs, and may be influenced by factors such as geographic location, lifestyle and age.

CULTURAL COMPETENCY A set of congruent behaviors, attitudes and policies that come together in a system, agency, or among professionals, which enables that system, agency or those professionals to work effectively in cross-cultural situations. Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs beliefs, values, and institutions of racial, ethnic, religious or social groups. Competency means having the capacity to function effectively as an individual and an organization with the context of the cultural beliefs, behaviors and needs presented by members and their communities.

DAY A day means a calendar day unless otherwise specified.

DAY — BUSINESS/WORKING A “business” or “working” day means a Monday, Tuesday, Wednesday, Thursday or Friday unless a State legal holiday falls on Monday, Tuesday, Wednesday, Thursday or Friday.

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DEPARTMENT OF ECONOMIC The Division within the Department of Economic Security (DES), as

SECURITY/DIVISION OF defined in A.R.S. Title 36, Chapter 5.1, which is responsible for serving

DEVELOPMENTAL DISABILITIES Arizona residents with a developmental/intellectual disability. AHCCCS

(DES/DDD OR DIVISION) eligible contracts with DES/DDD to serve Medicaid eligible individuals with a developmental/intellectual disability.

DISENROLLMENT The discontinuance of a member’s eligibility to receive covered services through DCS/CHP or another AHCCCS Contractor.

DIVISION OF HEALTH CARE The division within AHCCCS responsible for AHCCCS Contractor

MANAGEMENT (DHCM) oversight regarding AHCCCS Contractor operations, quality, maternal and child health, BH, medical management, case management, rate setting, encounters and financial/operational oversight.

DIVISION OF MEMBER The division within AHCCCS responsible for providing Member Services

SERVICES (DMS) for AHCCCS and determining eligibility for CRS.

DUAL ELIGIBLE A member who is eligible for both Medicare and Medicaid.

DUAL ELIGIBLE SPECIAL A Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare

NEEDS PLAN (D-SNP) Advantage plan that enrolls beneficiaries who are entitled to both Medicare

(Title XVIII) and Medical Assistance from a State Plan under Title XIX

(Medicaid), and offers the opportunity of enhanced benefits by combining those available through Medicare and Medicaid.

DURABLE MEDICAL Equipment that provides therapeutic benefits; is designed primarily for a

EQUIPMENT (DME) medical purpose; is ordered by a physician/provider; is able to withstand repeated use; and is appropriate for use in the home.

See also, Medical Equipment and Appliances.

EARLY AND PERIODIC A comprehensive child health program of prevention, treatment, SCREENING DIAGNOSTIC, correction, and improvement of physical and BH conditions for

AND TREATMENT (EPSDT) AHCCCS members under the age of 21. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services

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Phoenix, AZ 85012 DEFINITIONS listed in Federal Law 42 U.S.C. 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the

AHCCCS State Plan. Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

ELECTRONIC HEALTH An EHR, or electronic medical record (EMR), refers to the

RECORDS (EHR) systematized collection of patient and population electronically- stored health information in a digital format. These records can be shared across different health care settings.

ELECTRONIC MEDICAL See ELECTRONIC HEALTH RECORDS.

RECORD (EMR)

ELECTRONIC VISIT EVV is an in-home visit and tracking system that employs controls

VERIFICATION (EVV) within the delivery of home based services to ensure client's access to care.

EMERGENCY MEDICAL A medical condition manifesting itself by acute symptoms of sufficient

CONDITION severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: a) placing the patient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part [42 CFR 438.114(a)].

EMERGENCY MEDICAL Covered inpatient and outpatient services provided after the sudden

SERVICE onset of an emergency medical condition as defined above. These services must be furnished by a qualified provider, and must be necessary to evaluate or stabilize the emergency medical condition [42

CFR 438.114(a)].

EMERGENCY SERVICES Medical or BH services provided for the treatment of an emergency medical or BH condition.

ENCOUNTER A record of a health care-related service rendered by a provider or providers registered with AHCCCS to a member who is enrolled in DCS

CHP on the date of service.

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Phoenix, AZ 85012 DEFINITIONS ENROLLEE A Medicaid recipient who is currently enrolled with DCS CHP [42 CFR

438.2].

ENROLLMENT The process by which an eligible person becomes a member of DCS

CHP.

EVIDENCE-BASED PRACTICE An intervention that is recognized as effective in treating a specific

Health-related condition based on scientific research; the skill and judgment of health care professionals; and the unique needs, concerns and preferences of the person receiving services.

EXCLUDED SERVICES Services not covered under the State Plan or the 1115 Waiver, including but not limited to, services that are above a prescribed limit, experimental services, or services that are not medically necessary.

Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness, do not apply to EPSDT services.

FAMILY-CENTERED Care that recognizes and respects the pivotal role of the family in the lives of members. It supports families in their natural care- giving roles, promotes normal patterns of living, and ensures family collaboration and choice in the provision of services to the member. When appropriate, the member directs the involvement of the family to ensure person-centered care.

FAMILY OR FAMILY MEMBER A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction, or other member representative responsible for making health care decisions on behalf of the member. Family members (kin) may also include siblings, grandparents, aunts, uncles and person(s) who have a significant relationship with the child (fictive kin).

FEDERAL FINANCIAL FFP refers to the contribution that the Federal government makes to the

PARTICIPATION (FFP) Title XIX and Title XXI program portions of AHCCCS, as defined in 42

CFR 400.203.

FEDERALLY QUALIFIED A public or private non-profit health care organization that has been

HEALTH CENTER (FQHC) identified by the Health Resources & Services Administration (HRSA) and certified by CMS as meeting criteria under Sections 1861(aa)(4)

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and 1905(l)(2)(B) of the Social Security Act.

FEE-FOR-SERVICE (FFS) A method of payment to an AHCCCS registered provider on an amount‒ per‒service basis for services reimbursed directly by AHCCCS for members not enrolled with a managed care contractor.

FIELD CLINIC A “clinic” consisting of single specialty health care providers who travel to health care delivery settings closer to members and their families than the Multi‒Specialty Interdisciplinary Clinics to provide a specific set of services including evaluation, monitoring, and treatment for CRS‒ related conditions on a periodic basis.

FISCAL AGENT A contractor that processes or pays vendor claims on behalf of the

Medicaid agency [42 CFR 455.101].

FISCAL YEAR See STATE FISCAL YEAR

FQHC LOOK‒ALIKE A public or private non-profit health care organization that has been identified by the HRSA and certified by CMS as meeting the definition of “health center” under Section 330 of the Public Health Service Act, but does not receive grant funding under Section 330.

FRAUD An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable State or Federal law, as defined in 42

CFR 455.2.

GEOGRAPHIC SERVICE An area designated by AHCCCS within which an AHCCCS Contractor

AREA (GSA) provides, directly or through subcontract, covered health care service to a member enrolled with the Contractor.

GRIEVANCE A member’s expression of dissatisfaction with any matter, other than an

Adverse Benefit Determination.

GRIEVANCE AND APPEAL The system that includes a process for member grievances and appeals

SYSTEM including provider claim disputes. The Grievance and Appeal System provides access to the State fair hearing process.

HEALTH CARE PROFESSIONAL A physician, podiatrist, optometrist, chiropractor, psychologist, dentist, 16 | P a g e

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Phoenix, AZ 85012 DEFINITIONS physician assistant, physical or occupational therapist, therapist assistant, speech language pathologist, audiologist, registered or practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse midwife), licensed social worker, registered respiratory therapist, licensed marriage and family therapist and licensed professional counselor.

HEALTH CARE SERVICES Covered services and treatment provided by a Primary Care Provider

(PCP), attending physician or dentist or by a nurse or other health care professional and technical personnel at the direction/order of a licensed physician or dentist.

HEALTH INFORMATION Electronic information system that allows health care providers to

EXCHANGE (HIE) appropriately access and securely share patient medical information.

HEALTH INSURANCE Insurance coverage against expenses incurred through illness or injury of the person whose life or physical well-being is the subject of coverage.

HEALTH INSURANCE An annual fee on the health insurance industry nationwide, including most

PROVIDER FEE (HIPF) Medicaid health plans effective January 1, 2014, pursuant to the

Affordable Care Act (A.C.A.)

HEALTH INSURANCE HIPAA (P.L. 104-191); also known as the Kennedy-Kassebaum Act, PORTABILITY AND signed August 21, 1996 as amended and as reflected in the

ACCOUNTABILITY ACT (HIPAA) implementing regulations at 45 CFR Parts 160, 162, and 164.

HEALTH PLAN An AHCCCS contracted MCO. See also “ACC CONTRACTOR” and

RBHA.

HOME A residential dwelling that is owned, rented, leased, or occupied, including a house, a mobile home, an apartment or other similar shelter.

A home is not a facility, a setting or an institution, or a portion of any of these, licensed or certified by a regulatory agency of the State as defined in A.A.C. R9-28-101.

HOME HEALTH CARE See “HOME HEALTH SERVICES”.

HOME- AND HCBS, as defined in A.R.S. § 36-2931 and A.R.S. § 36-2939(B)(2) and

COMMUNITY-BASED (C).

SERVICES (HCBS)

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HOME HEALTH SERVICES Nursing services, home health aide services, therapy services, and medical supplies, equipment, and appliances as described in 42 CFR

440.70 when provided to a member at his or her place of residence and on his or her physician's orders as part of a written plan of care [42 CFR

440.70].

HOMEMAKER A direct care service in which assistance is provided for the performance of routine household activities, such as shopping, cooking and cleaning within a member’s own or family home.

HOSPICE SERVICES Palliative and support care for members who are certified by a physician as being terminally ill and having six months or less to live.

HOSPITALIZATION Admission to, or period of stay in, a health care institution that is licensed as a hospital as defined in R9-22-101.

INCURRED BUT NOT Liability for services rendered for which claims have not been received.

REPORTED (IBNR)

INDIAN HEALTH SERVICES (IHS) The operating division within the U.S. DHHS, responsible for providing medical and public health services to members of federally recognized

Tribes and Alaska Natives as outlined in 25 U.S.C. 1661.

INFORMATION SYSTEMS The component of the Contractor’s organization which supports the

Information Systems, whether the systems themselves are internal to the organization (full spectrum of systems staffing), or externally contracted

(internal oversight and support).

IN-NETWORK PROVIDER A person or entity which has signed a provider agreement as specified in A.R.S. § 36-2904 and that has a subcontract with a Contractor to provide services prescribed in A.R.S. § 36-2901 et seq.

INSTITUTION FOR MENTAL A hospital, NF, or other institution of more than 16 beds that is primarily

DISEASES (IMD) engaged in providing diagnosis, treatment or care of persons with mental diseases (including substance use disorders), including medical attention, nursing care and related services.

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Whether an institution is an IMD is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for Individuals with Intellectual

Disabilities is not an IMD. [42 CFR 435.1010].

INTEGRATED CLINICS (ICS) Providers registered with AHCCCS as ICS and licensed by the ADHS as

Outpatient Treatment Centers which provide both BH services and physical health (PH) services.

INTEGRATED MEDICAL RECORD A single document in which all of the medical information listed in Chapter

900 of the AMPM is recorded to facilitate the coordination and quality of care (QOC) delivered by multiple providers serving a single patient in multiple locations and at varying times.

INTEGRATED RAPID RESPONSE An in-person assessment of a child’s immediate behavioral and PH needs by health care provider(s) including referral(s) for further assessments or ongoing care, as needed. The Integrated Rapid Response is initiated when a child enters DCS out of home care and is completed within 72 hours of notification. Virtual Integrated Rapid Response

Assessments (e.g. simultaneous live video with audio) are permitted for exceptional circumstances.

INTERDISCIPLINARY CARE Meetings of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the member based on the most current information available.

INTERGOVERNMENTAL When authorized by legislative or other governing bodies, two or more

AGREEMENT (IGA) public agencies or public procurement units by direct contract or agreement may contract for services or jointly exercise any powers common to the contracting parties and may enter into agreements with one another for joint or cooperative action or may form a separate legal entity, including a non-profit corporation to contract for or perform some or all of the services specified in the contract or agreement or exercise those powers jointly held by the contracting parties. A.R.S. Title 11, Chapter 7, Article 3 (A.R.S. § 11-952(A)).

KIDSCARE Federal and State Title XXI ─ CHIP administered by AHCCCS. The

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Phoenix, AZ 85012 DEFINITIONS KidsCare program offers comprehensive medical, preventive, treatment services, and BH care services statewide to eligible children under the age of 19, in households with income between 133% and 200% of the

Federal Poverty Level (FPL).

LIABLE PARTY An individual, insurer, entity, or program that is or may be liable to pay all or part of the medical cost of injury, disease or disability of a member as defined in A.A.C. R9-22-1001.

LIEN A legal claim, filed with the County Recorder’s office in which a member resides and in the county an injury was sustained for the purpose of ensuring that AHCCCS receives reimbursement for health care services paid. The lien is attached to any settlement the member may receive as a result of an injury.

LIMITED ENGLISH Individuals who do not speak English as their primary language and who

PROFICIENCY (LEP) have a limited ability to read, write, speak or understand English may have LEP and may be eligible to receive language assistance for a particular type of service, benefit or encounter.

MAJOR UPGRADE Any systems upgrade or changes to a major business component that may result in a disruption to the following: loading of contracts, providers or members, issuing prior authorizations or the adjudication of claims.

MANAGED CARE Systems that integrate the financing and delivery of health care services to covered individuals by means of arrangements with selected providers to furnish comprehensive services to members; establish explicit criteria for the selection of health care providers; have financial incentives for members to use providers and procedures associated with the plan; and have formal programs for quality, MM and the coordination of care.

MANAGED CARE ORGANIZATION An entity that has, or is seeking to qualify for, a

(MCO) comprehensive risk contract under 42 CFR Part 438 and that is [42 CFR

438.2]:

a. A Federally qualified health maintenance organization that meets the advance directives and requirements of Subpart I of 42 CFR Part 489;

or

b. Any public or private entity that meets the advance directives requirements and is determined by the DHHS Secretary to also meet the following conditions:

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i. Makes the services it provides to its Medicaid enrollees as accessible (in terms of timeliness, amount, duration and scope) as those services are to other Medicaid beneficiaries within the area served by the entity.

ii. Meets the solvency standards of 42 CFR 438.116.

MANAGED CARE PROGRAM A managed care delivery system operated by a state as authorized under section 1915(a), 1915(b), 1932(a), or 1115(a) of the Act [42 CFR 438.2].

MANAGEMENT SERVICES A type of subcontract with an entity in which the owner of the Contractor

AGREEMENT (MSA) delegates all or substantially all management and administrative services necessary for the operation of the Contractor.

MANAGING EMPLOYEE A general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over or who directly or indirectly conducts the day-to-day operation of an institution, organization or agency [42 CFR 455.101].

MATERIAL CHANGE TO Any change in overall operations that affects, or can reasonably be

BUSINESS OPERATIONS foreseen to affect, the Contractor’s ability to meet the performance standards as required in the Contract including, but not limited to, any change that would impact or is likely to impact more than 5% of total membership or Contractor’s ability to meet network adequacy or access to care requirements (including access to care in rural regions) as described in this Contract. Changes to business operations may include, but are not limited to, policy, process and protocol, such as prior authorization or retrospective review.

Additional changes may also include the addition or change in:

a. Dental Benefit Manager;

b. Transportation vendor;

c. Claims processing system;

d. System changes and upgrades;

e. Call center system;

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Phoenix, AZ 85012 DEFINITIONS

f. Covered benefits delivered exclusively through the mail, such as the delivery of medical equipment;

g. MSA; and

h. Any other Administrative Services Subcontract.

MATERIAL CHANGE TO Any change in composition of, or payments to, a Contractor’s provider

PROVIDER NETWORK network that affects, or can reasonably be foreseen to affect, the

Contractor’s adequacy of capacity and services necessary to meet the performance and/or provider network standards as required in the

Contract. Changes to provider network may include, but are not limited to:

a. Any change that would cause or is likely to cause more than 5% of the members to change the location where services are received or rendered.

b. Any change impacting 5% or less of the membership but involving a provider or provider group who is the sole provider of a service in a service area, or operates in an area with limited alternate sources of the service.

MATERIAL OMISSION A fact, data or other information excluded from a report, contract, etc., the absence of which could lead to erroneous conclusions following reasonable review of such report, contract, etc.

MEDICAID A Federal/State program authorized by Title XIX of the Social Security Act, as amended. Known in Arizona as AHCCCS.

MEDICAID MANAGED The Federal law mandating, in part, that States ensure the accessibility and

CARE REGULATIONS delivery of quality health care by their managed care Contractors. These regulations were promulgated pursuant to the BBA.

MEDICAL EQUIPMENT AND Any item, appliance, or piece of equipment (pursuant to 42 CFR

440.70) that

APPLIANCES is not a prosthetic or orthotic; and

a. Is customarily used to serve a medical purpose, and is generally not useful to an individual in the absence of an illness, disability, or injury;

b. Can withstand repeated use; and

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c. Can be reusable by others or removable.

Medical equipment and appliances may also be referred to as DME.

MEDICAL INSTITUTION For purposes of the Institutional Status Reporting for Medicare Part

D Copays, medical institutions are defined as:

a. Acute hospitals;

b. Psychiatric hospital – Non IMD;

c. Psychiatric hospital – IMD;

d. Residential treatment center – Non IMD;

e. Residential treatment center – IMD;

f. Skilled nursing facilities; and

g. Intermediate Care Facilities for Individuals with Intellectual

Disabilities.

MEDICAL MANAGEMENT (MM) An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the continuum of care (from prevention to hospice).

MEDICAL RECORDS A chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the provider's physical findings, BH findings, the results of diagnostic tests and procedures, medications and therapeutic procedures, referrals and treatment plans.

MEDICAL SUPPLIES Health care related items that are consumable or disposable, or cannot withstand repeated use by more than one individual that are required to address an individual medical disability, illness or injury [42 CFR

440.70].

MEDICALLY NECESSARY As defined in A.A.C. R9-22-101, means a covered service provided by a physician or other licensed practitioner of the health arts within the scope of practice under State law to prevent disease, disability or other

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adverse conditions or their progression, or to prolong life.

MEDICALLY NECESSARY Those covered services provided by qualified service providers within

SERVICES the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life.

MEDICARE A Federal program authorized by Title XVIII of the Social Security Act, as amended.

MEDICATION ASSISTED The use of medications in combination with counseling and behavioral

TREATMENT (MAT) therapies for the treatment of substance use disorders.

MEMBER In this Contract, “member” means an individual enrolled to receive services through DCS CHP, unless explicitly referenced otherwise.

MEMBER INFORMATION Any materials given to DCS CHP’s membership. This includes, but is

MATERIALS not limited to: member handbooks, member newsletters, provider directories, surveys, on hold messages and health related brochures/reminders and videos, form letter templates, and website content. It also includes the use of other mass communication technology such as email and voice recorded information messages delivered to a member’s phone.

MULTI-SPECIALTY An established facility where specialists from multiple specialties meet

INTERDISCIPLINARY CLINIC with members and their families for the purpose of providing

(MSIC) interdisciplinary services to treat members.

NATIONAL PROVIDER A unique identification number for covered health care providers, IDENTIFIER (NPI) assigned by the CMS contracted national enumerator.

NETWORK A list of doctors or other health care providers, nursing facilities and hospitals that the Contractor contracts with directly, or employs through a subcontractor, to provide care to its members.

NON-CONTRACTING PROVIDER A person or entity that provides services under the scope of this Contract

LIMIT (NQTL) who does not have a subcontract with the Contractor.

NON-QUANTITATIVE TREATMENT A limitation on the scope or duration of benefit coverage for treatment that is not expressed numerically. Examples include, but are not limited to: MM standards that apply to deny or limit coverage; fail-first policies or step therapy protocols; provider participation requirements; network

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restrictions and formulary design.

NURSING FACILITY (NF) A facility that is licensed and Medicare/Medicaid certified by the ADHS in accordance with 42 CFR 483 to provide inpatient room, board and nursing services to members who require these services on a continuous basis, but who do not require hospital care or direct daily care from a physician (AMPM Policy 1210).

O…