Sandata_YH19-0025__Amendment_12_with_CS-066__CS-090__CS-140__CS-187_-_Fully_Executed.pdf

CONTRACT AMENDMENT

1. AMENDMENT #:

2. CONTRACT #:

YH19-0025

3. EFFECTIVE DATE OF AMENDMENT:

Date of Last Signature

4. PROGRAM:

DHCM

5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Sandata Technologies 26 Harbor Park Drive

Port Washington, NY 11050

6. PURPOSE:

To add the effective date to new pricing for Amendment #11 and add four (4) change requests: CS-066, CS-090, CS-140, CS-187.

The total five-year contract value will be increased from $45,165,156.44 to $45,614,986.44

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

A. The updated device pricing added with Contract Amendment #11 is effective September 1, 2022.

B. Four (4) Change Requests are hereby added to the contract and total amounts are as follows:

Change Request Description Amounts

1. CS-066 HI/MedQUEST Addition of Employee Other ID to Visit Maintenance and Existing

$145,200.00

2. CS-090 Addition of Taxonomy in BI Tool $3,600.00

3. CS-140 Addition of Home Health Aid Services $29,755.00

4. CS-187 HI/MedQUEST Resort and Rename SMC Service Listing/DDD

Addition/Deletion of Services/Additional Language Support $271,275.00

Total $449,830.00

C. Therefore, Sandata change orders for increased services are attached.

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

E. Contract Total Amount now is $45,614,986.44 F. This contract amendment is contingent upon CMS approval.

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

AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

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

9. NAME OF CONTRACTOR/PROVIDER:

Sandata

10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

SIGNATURE OF AUTHORIZED INDIVIDUAL:

SIGNATURE:

TYPED NAME:

Akshay Bhandari

TYPED NAME:

Meggan LaPorte

TITLE: TITLE:

Chief Procurement Officer

DATE: DATE:

Meggan LaPorte (Dec 9, 2022 14:28 MST)

Dec 9, 2022

Akshay Bhandari (Dec 9, 2022 20:10 EST)

CFO

Dec 9, 2022 https://azahcccs.na4.echosign.com/verifier?tx=CBJCHBCAABAAfbVWApEJNPNvFv870Uti5bNfgFmb0JXe https://na4.documents.adobe.com/verifier?tx=CBJCHBCAABAAfbVWApEJNPNvFv870Uti5bNfgFmb0JXe

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CS-066 HI/MedQUEST Addition of Employee Other ID to Visit Maintenance and Existing Reports

Change Request Technical Proposal

January 2022 Sandata Technologies, LLC sandata.com

Tessie Austin, Technical Account Manager taustin@sandata.com

516.484.4400 ext. 4202 mailto:taustin@sandata.com mailto:taustin@sandata.com mailto:taustin@sandata.com mailto:taustin@sandata.com

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Revision History Date Version Author Description

02/28/2021 1.0 Paige Gibson Initial Draft

03/17/2021 1.1 Paige Gibson Combined CS-071 into one CR

03/31/2021 1.2 Judy Ross Technical Review

04/07/2021 1.3 Paige Gibson Edits following tech review with

MQD

1/25/2022 1.4 Tessie Austin Update to current form Add SQL information

1/26/2022 1.5 Judy Ross Technical Review & Update

2/14/22 1.6 Paige Gibson/Tessie Austin

Sandata review and updates added

2/24/22 1.7 Paige Gibson Sandata Internal Review

3/9/22 1.8 Paige Gibson/Tessie Austin Updates from Internal Review

3/11/22 1.9 Judy Ross Technical Review

3/17/22 1.10 Paige Gibson/Tessie Austin

Sandata review and updates

3/17/22 1.11 Paige Gibson/Tessie Austin

Update following MQD discussions with MCOs

3/22/22 1.12 Judy Ross Technical Review

3/23/22 1.13 Tessie Austin Technical Response

4/19/22 1.14 Team Finalization Discussions

4/20/22 1.15 Judy Ross/Tessie Austin Update following meeting, accept changes, remove comments, add report visual

4/26/22 1.16 MedQUEST updates Updates to terminology

4/27/22 1.17 Review with Health Plans

Updates to reporting

5/10/22 1.18 Judy Ross Added Development Items

6/7/22 FINAL Brian Lawson Added Pricing and hours to dev items

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Reference Information Reference # Description

CRB Tracking # CR CS-066 Addition of Employee Other ID to Visit Maintenance and Existing Reports

Zendesk 193000

JIRA SEVV-31281

Issue Log #

Customer ID # Hawaii Med-Quest

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Table of Contents

Change Request

Background

Issue:

Enhancement:

Who is Impacted:

Benefits:

Proposed Solution

Detailed Work Items

Assumptions

Customer Responsibilities

Reference Materials

Approval

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Change Request

This change request (this “Change Request”) is being issued pursuant to the Statement of Work, as amended (“SOW”) between AHCCCS/MedQUEST and Sandata Technologies, LLC for the Arizona and Hawaii Program dated November 16, 2018, as amended. The SOW is governed by the terms of the contract (YH19-0025).

Background

Issue:

Hawaii CDS Fiscal Intermediaries (FIs) participating need the ability to automatically generate data to support Ceridian payroll processing. Today, this is supported by manually created spreadsheets using underlying EVV data.

Enhancement:

On behalf of these FIs, Med-QUEST is requesting a custom export matching the Ceridian format as well as updates to existing reports to show the field used to create the ‘timekeeper id’ known as Employee Other ID in the Sandata EVV system. Med QUEST is also requesting a custom report for the program.

All Hawaii Fiscal Intermediaries for the Self-Directed programs use Ceridian to process payroll. The Ceridian ID also known as the Timekeeper ID is stored in the Employee Other ID field and will need to be exportable on a custom export. Additionally, the State has identified

2 reports on which they would like to include the Employee Other ID for on-demand reporting.

Who is Impacted:

Hawaii MedQuest FIs and their associated caregivers. This process may help resolve payroll issues created by the manual generation of payroll files.

Benefits:

For the FIs, this will allow them to save the time they are currently spending to manually create these interface files as well as allow them to report on this information.

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Proposed Solution Report Changes:

To satisfy this request, we would:

• Create a custom version of the Visit Verification Activity Summary (called Custom SD Payroll Report) o Add the field Employee Other ID based on the value shown in the UI

• Add the field ‘EmployeeOtherID’ to the Visit Verification Activity Summary. No additional changes requested for this report.

The Custom SD Report and Export will be run on demand.

Current filters for both reports will apply with the addition of the Visit Status filter which will allow for multiple statuses to be selected.

Custom SD Payroll Report:

The report would be manually generated from the ‘Reports’ screen within Sandata EVV and will be used for validation of visits/payroll for Hawaii. The report can be generated multiple times without negatively impacting visit qualification for either the report or extract.

Report base will be custom but will be based on the Date Range Report - Detail Visit Status

• Type: Detail Visit Status

• Name: Custom SD Payroll Report

• File Specifics o Filters – all current filters for the ‘Detail Visit Status’ report and o Visit Status – multiple status selection will need to be available.

• Columns – as shown below

• Standard column name headers will be used

COLUMN COLUMN NAME INFO

General Header

Account Account In report currently

Provider IDHeader - Client

Client Medicaid

ID

Medicaid ID In report currently

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Client Name Name In report currently (LN, FN)

Header - Employee

Employee Name Name In report currently (LN, FN)

Employee SSN SSN New – full 9-digit SSN

Employee Other

ID

Other ID This will be the Clock ID (4 digit) for the customer

Employee Timekeeper ID

Timekeeper ID Field is the concatenation of the last 6 of the client’s Medicaid ID on the visit plus the Employee Other ID (this field will be 4 characters)

Header - Visit

Payer Payer In report currently – use short version

Service Service In report currently – use the true 5 character service versus the version with _xx.

Modifiers Modifiers Need modifier for service performed. Provided as comma separated within one field (e.g. U1, U2, U3, U4)

Service Description

Service Description

Need description of service performed

Visit Status Status The current status of the visit

Visit Date Date In report currently

Hours Hours Need hours of service performed. Fractional Hours.

If Exists: Adjusted Out – Adjusted In, if not Call Out – Call In.

Units Units Need units of service performed

Header - Call

Call In In In report currently

Call Out Out In report currently

Header - Adjusted

Adjusted In In In report currently

Adjusted Out Out In report currently

Header - Authorization

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Authorization Number

ID Need auth reference number – if no authorization found, the remaining fields should be left blank

Unit Type Unit Type Use the Auth Type Code (single character version of Hourly, Unit, Visit)

Authorized Amount

Units Need hours authorized – updated to Units

Authorized Start Start Date Need start date of auth

Authorized Stop End Date Need end date of auth

Authorization Limit By

Limit Type Need info if limit sent in authorization. Use Auth Limit Type Code (single character version of Non, Day, Week, Month, Year)

Authorization Limit

Limit Need limit amount if sent

Proposed Report Design:

Custom SD Payroll Export:

The export would be manually generated from the ‘Reports’ screen within Sandata EVV and will be used to load (not replace) regular timecard transactions (5500) into the payer’s self-direct payroll system. The export will include a parameter to include selected Visit Status.

• Create a custom export for Hawaii CDS providers

• File Specifics o Since the file will be manually generating, file naming will be controlled by the user. The file name is expected to start with the

Time & Attendance company number followed by an underscore, for example; HL1234_October152005.csv.

o Once exported, visits will no longer qualify for the export unless the visit has been changed post-export.

| 4 o The first row of the file is the header record; this row is required. The names used for each field is row 1 on the Template and Sample contained herein and listed in the 'Column Name' column on the File Details tab. The export will be limited to the fields listed and headers for other fields are not required.

o The generated file will be ASCII and will be a .csv comma (,) delimited format.

o Field will be enclosed in quotes.

o Each row should have a CR/LF at the end.

• No rollup will be done. One record per visit found.

• Calculations on reporting must ‘break’ across weeks/end of month. This requirement is stated below in the Proposed Solution section. If a visit passes midnight, the visit would appear twice with the time split between the 2 days based on the dates selected for the report.

• Each Record represents one transaction for the regular timecard summarizing the employee + client + service for the period in a single record. These transactions will load into the payer’s self-direct payroll system Individual and Multiple Time Entry Pages (ITE/MTE).

• The Export should include all statuses.

• List of fields (DWH field elements have been included for reference only):

Column Name Data Type Length Valid Values & Format Calculation

Notes

SSN Alphanumeric 11

Employee SSN Full 9-digit value (no dashes)

EmployeeNumber Numeric 4

Employee Other

LastName Alphanumeric 30 Employee Last Name

FirstName Alphanumeric 30 Employee First Name

Hours Numeric 7.2 Calculation Adjusted Out Date/Time – Adjusted In Date/Time if available otherwise Call Out Date Time – Call In Date Time

Service Codes LaborField4

Alphanumeric 20 ProcedureCode 5-character service

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Column Name Data Type Length Valid Values & Format Calculation

Notes

Modifiers LaborField5

Alphanumeric 20 Ex. U1 / U2 / U3 / U4

All Visit Modifiers

Concatenation of all modifiers separated by a forward slash Modifier1 / Modifier2 / Modifier3 / Modifier4

TimeKeeper ID

Alphanumeric 10 Calculation Field is the concatenation of the last 6 of the client’s Medicaid ID on the visit plus Employee Other ID (this field will be 4 characters)

ClientMedicaidID

Alphanumeric 64 Client Medicaid

ClientLastName

Alphanumeric 30 Client Last Name

ClientFirstName

Alphanumeric 30 Client First Name

Proposed File Layout:

"SSN","EmployeOtherID","LastName","FirstName","Hours","LaborField4","LaborField5","TimeKeeperID","ClientMedicaidID","ClientLastName","ClientFirstName" "111111111","5555","Test","Employee","4","S9122","U1/U2","1414145555","1234141414","Test","Member"

Visit Maintenance and Visit Review Grids and Visit Details General:

• Add the ability to select Employee Other ID as a new Filter Options within Visit Maintenance and Visit Review. This will be available for all users.

• Add Employee Other ID as an optional column which can be enabled in the Visit Maintenance and Visit Review grids. This will be available for all users.

• Add Employee Other ID on the Visit Details/General page within both EVV and Aggregator. The value should only be shown if populated.

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Data Warehouse Feed

• Ensure that Employee Other ID is included in the Data Warehouse feed. If this information is not currently being provided, this change request will include adding this field to the export and a re-export of all historic data for the program. Note that this field is available on the Employee Segment as EmployeeIDCustom1.

BI Tool

• Employee Other ID will be available in the appropriate datasets within BI and will be available when the users drill down to the lowest tabular level for cards utilizing those data sets.

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Detailed Work Items

The following includes all work items required to implement the proposed solution as defined.

Table 1: Work Item List

Item # Type Description Hours

Product & Engineering

PE1 Reporting New Report: Custom SD Payroll Report for the 5 Hawaii FIs 88

PE2 Reporting Customer Payroll Export – once run, records would only reexport if changes. Generated manually via the reports page.

PE3 Development EVV VM – Add a new optional filter for the Employee Other ID – configurable on/off 56

PE4 Development EVV VM – Add a new optional column Employee Other ID – Available to all

PE5 Development EVV VM Employee Details Tab – Add Employee Other ID – show if populated 56

PE6 Development Aggregator VR – Add a new optional filter for the Employee Other ID – configurable on/off

PE7 Development Aggregator VR – Add a new optional column – Employee Other ID – Available to all 56

PE8 Development Aggregator VR Employee Details Tab – Add Employee Other ID – show if populated 56

PE9 Configuration Validate that EmployeeIDCustom1 is included in the Hawaii DWH Export

PE10 Development Include EmployeeIDCustom1 in the BI Employee Object 32

Project Management / Implementation Support

PM1 Project Management PM/TAM support 40

PM2 UAT UAT Assistance 80

Assumptions

Sandata has made the following assumptions in providing the work items for this Change Request:

• Formats will be exactly as specified for all parties – no variations per MCO.

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Customer Responsibilities

To support the delivery and implementation of this Change Request, the Customer must agree to the following:

• As part of this effort, fiscals will need to edit the Employee Other ID from today’s full TimekeeperID to the 4-digit Ceridian ClockID.

• Hawaii will assist in engaging the MCOs to test the new functionality

Reference Materials

Please specify the current version of each specification below.

Table 2: Reference Information

Reference Specification Version

Addendum Version

Description of Changes

Business Rules Update to include new report/export on list of available reports

Open EVV Update to note the value to be provided in the employee portion of the interface

Pricing

One-Time Fees

Description Fees

Change Request Fee $145,200

Pricing Notes Fees to be invoiced and due 50% upon completion of the Task 1 and 50% due upon completion of the remaining tasks under this Change Request.

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Approval

HI MedQUEST Approved By:

Signature/Title Date

Printed Name

Title

Signature Date

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

Jon Fujii (Sep 9, 2022 10:06 HST) Sep 9, 2022 Sep 13, 2022 https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA_d0yxVYUMEfchT28NI12ItFk4rJIkrb9 https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA_d0yxVYUMEfchT28NI12ItFk4rJIkrb9 https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA_d0yxVYUMEfchT28NI12ItFk4rJIkrb9 https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA_d0yxVYUMEfchT28NI12ItFk4rJIkrb9

August 2021

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

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

HI-MedQUEST

Change Request Technical Requirements

Addition of Taxonomy in BI Tool (CR CS-090) mailto:pgibson@sandata.com mailto:blawson@sandata.com mailto:pgibson@sandata.com mailto:blawson@sandata.com mailto:pgibson@sandata.com mailto:blawson@sandata.com mailto:blawson@sandata.com

Change Request Technical Requirements |

Revision History

Change Request Tracking

Med-QUEST Change Request

Change Request

Background

System/Functionality Enhancement Requested

Sandata Responsibilities

Customer Responsibilities

Pricing

Date Version # Author Description of the Document Updates

Requires Update to Business Rules?

7/22/2021 1.0 Paige Gibson Initial Draft No

7/26/2021 1.1 Judy Ross Technical Review No

8/10/2021 1.2 Paige Gibson Contractual language added

No

8/11/2021 1.3 Judy Ross Including Items for Estimation

No

8/13/2021 1.4 Brian Lawson Pricing and Legal Review

No

Change Request Tracking

Reference Ticket Number Notes

ZenDesk 227470 Tracking item for Change Order

JIRA SEVV-33283 Story for tracking estimates and work

Other CS-090

Med-QUEST Change Request

Change Request

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

Technologies, LLC (“Sandata”) for Electronic Visit Verification.

Med-QUEST transmits Taxonomy Code on the Provider Master File (PMF) when available.

This field needs to be accessible in the Business Intelligence (“BI”) tool to allow the state to analyze data. Changes for the CR are limited to adding this value to the appropriate data sets in BI.

System/Functionality Enhancement Requested

Material changes in the configuration and behavior will include:

Update the information provided from the Sandata Aggregator to the BI environment to include the provider’s Taxonomy Code. Affected datasets will be:

o Provider o Visit

Update all account history to include the Taxonomy Code values provided.

Exclusions:

The Taxonomy will be added to the Exchange, Transform, and Load (“ETL”) process from the Aggregator repository to the BI environment. This does not include changes to existing cards.

The Taxonomy Code is not available on all accounts and no validation is done on the information received in the provider feed.

Sandata Responsibilities

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

# Item Dev (hrs) QA (hrs)

1 Update the BI Integration to populate the Taxonomy code field 16 8

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

Sandata anticipates that this enhancement will be included in the Sandata EVV 8.1.XX release currently scheduled for XXX XXth, 2021. This Change Request must be approved no later than

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

Change Request Fee $3,600

Pricing Notes

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

submission, if applicable).

Jon Fujii (Aug 24, 2022 17:14 HST) Aug 24, 2022 https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA4esyrkKLuFY4qsY7sPi_LPu_5qK8qcsC https://stateofhawaii.na1.adobesign.com/verifier?tx=CBJCHBCAABAA4esyrkKLuFY4qsY7sPi_LPu_5qK8qcsC

Change Request – CS140 | 0

CS-140 AZ AHCCCS

Addition of Home Health Aide Services

July 2022

Paige Gibson Customer Success Manager

516.484.4400 ext. 4022 pgibson@sandata.com

Brian Lawson VP, Sales Solution Design

516.484.4400 ext. 3131 blawson@sandata.com

Change Request – CS140 | 1

Date Version # Author Description of the

Document Updates

Requires Update to Business Rules?

6/7/22 1.0 Paige Gibson Initial Draft Yes

6/24/22 1.1 Paige Gibson Rounding Rule Added Yes

6/29/22 1.2 Judy Ross Technical Review Yes

7/12/22 1.3 Brian Lawson Pricing and General Edits No

8/23/2022 1.4 Brian Lawson

Addition of the milestone table in the customer responsibilities section and payment terms to align to them

No

9/2/2022 1.5 Brian Lawson

Updated release schedule based on delivery of test results instead of formal

UAT

Reference Ticket Number Notes

ZenDesk 372255 Tracking item for Change Order

JIRA SEVV-39386

Other CS140

Change Request – CS140 | 2

Change Request

Background

Issue:

Enhancement:

Service Changes:

Who is Impacted:

Benefits:

Timing:

Proposed Solution

Detailed Work Items

Assumptions

Customer Responsibilities

Reference Materials

Pricing

Approval

Change Request – CS140 | 3

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

AHCCCS needs to add two new modifiers for an existing service to the program. This effort should include the following:

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

-Documentation Updates

• Service Listing Update

• Supplemental Guide Update

-Vendor Communication Required for Alt EVV Agencies

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

• Updated to Alt EVV Addendum will be required

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

Service Changes:

Table 1: All Changes. Notes field indicates action required:

Payer Program HCPCS Modi-fiers

Desc Contingency Plan Default Value

Selection for Mobile/SMC

Telephone Prompt

Telephony Prompt

Billing units of Measure

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS T1021 U4 Home Health Aide (Family Member not residing at home)

CP04 Home Health Aide;

Family (non-res)

Home Health Aide; Family Member not residing at home

Rule 2

Change Request – CS140 | 4

Payer Program HCPCS Modi-fiers

Desc Contingency Plan Default Value

Selection for Mobile/SMC

Telephone Prompt

Telephony Prompt

Billing units of Measure

AZCCCS

,AZDDD

,AZACH

,AZBUFC

,AZCHP

,AZMCC

,AZMYC

,AZSHC

,AZUCP

,AZCDMP

AHCCCS T1021 U5 Home Health Aide (Family Member residing in member’s home)

CP04 Home Health Aide;

Family (home)

Home Health Aide; Family Member resi ding in member's home)

Rule 2

AZ providers and their vendors and AZ AHCCCS users are impacted by this change and the consumption of the data.

AZ providers will be able to use EVV for Home Health Aide services. These combinations are new to the Business Rules and will also need to be billed as recurring costs. Volume is expected to be very low.

Timing:

There is no specific requirement on when this change is needed.

Sandata will add 2 new services to the Arizona program in all 10 languages for the program.

defined.

Table 1: Work Item List – Option 1 – Enable Rejection if Change Log is not Provided for Certain Cases

Item # Type Description Hours

1 Documentation Update Business Rules to include 2 new service/modifier combinations

2 Documentation Update Alt EVV Addendum / Services Listing 2

Change Request – CS140 | 5

Item # Type Description Hours

3 Documentation Update Authorization Addendum to include 2 new service/modifier combinations 2

4 Documentation Update Open EVV Addendum to include 2 new service/modifier combinations 2

5 Documentation Update Call Reference Guide to Include new Services for Newly Created Accounts 4

6 Configuration Update Visit Maintenance Configuration to Include 2 New Services Including Implementation of Existing Units Rules for each

7 Configuration Update Scheduling & Billing Configuration to Include 2 New Services Including Implementation of Existing Units Rules for each

8 Configuration Update Aggregator with 2 new services 12

9 Interface Update Alt EVV Validation to Accept 2 New Services 18

10 Interface Update Authorization Validation to Accept 2 New Services 18

11 Interface Update Open EVV Validation to Accept 2 New Services 18 12 Interface Update Provider Creation with New Call Reference Guide 18 13 SMC Deploy 2 Services in all Arizona Languages to SMC 4 14 IVR Deploy 2 Services in all Arizona Languages to IVR 4 15 Operations Project management and oversight 24

• Work will be scheduled post Arizona final approval.

Change Request – CS140 | 6

• Review and approve this change request.

Sandata anticipates that this enhancement will be included in the UAT release of Sandata EVV

8.14 release currently scheduled for December 14, 2022. This change request will be included in the production release of Sandata EVV 8.15 on January 25, 2023. This Change Request must be approved no later than September 14, 2022, to support the proposed release schedule.

Task Milestone Date(s) Release

1 CR Approval 9/21/2022 -

2 Requirements/Design 10/1/2022 – 10/20/2022 -

3 Development 10/21/2022 – 12/1/2022 -

4 Delivery of Test Results 12/5/2022

5 Outreach / Training - -

6 Production 12/14/2022 EVV 8.14

The release schedule is an estimate only and is subject to change in Sandata’s sole discretion and will be finalized after approval of this Change Request.

Reference Materials

Please specify the current version of each specification below.

Table 2: Reference Information

Reference Item Name Description Version Revision Required?

Addendum_AZ_altEVV v1.10.docx Alt EVV specification 1.10 Yes

Addendum_AZ_DataWarehouse v1.9.2.3.docx Data Warehouse Specification 1.9.2.3 Yes

Addendum_AZ-OpenEVV v1.7.docx OpenEVV Specification 1.9 Yes

Addendum_AZ_Authorization v1.4.docx Authorization Specification 1.4 Yes

Change Request – CS140 | 7

Change Request Fee – Development/Configuration $22,800

Change Request Fee – Translation Services ($535 per language for 13 languages)

$6,955

Pricing Notes Fees to be invoiced based on the completion of deliverables as specified in the milestone table defined in the Customer Responsibilities section:

Task Milestone Percentage

2 Requirements/Design signoff 33%

4 Delivery of Test Results 33%

6 Production deployment 34%

Recurring Fees

Visit captured for this new service will be billed using the Claims Transaction Costs as per the RFP.

AZ AHCCCS

submission, if applicable).

Jakenna L Lebsock (Sep 9, 2022 08:48 PDT) Sep 9, 2022

Sep 9, 2022 https://azahcccs.na1.echosign.com/verifier?tx=CBJCHBCAABAAwFHKoNvpJg45vIptdKr0ag9mf9tGE2L9 https://na1.documents.adobe.com/verifier?tx=CBJCHBCAABAAwFHKoNvpJg45vIptdKr0ag9mf9tGE2L9 https://azahcccs.na1.echosign.com/verifier?tx=CBJCHBCAABAAwFHKoNvpJg45vIptdKr0ag9mf9tGE2L9 https://na1.documents.adobe.com/verifier?tx=CBJCHBCAABAAwFHKoNvpJg45vIptdKr0ag9mf9tGE2L9

CR – CS-187 - HI | 0

CS-187 HI Med-QUEST Resort and Rename SMC Service Listing / DDD Addition/Deletion of Services / Additional Language Support

July 2022

Paige Gibson, CSM pgibson@sandata.com

516.484.4400 ext. 4022

CR – CS-187 - HI | 1

Date Version Author Description

6/15/22 1.0 Paige Gibson Initial Draft

7/5/22 1.1 Paige Gibson New CR assigned/New ZD assigned. Ready for estimation.

7/6/22 1.2 Paige Gibson Acceptance of estimates

7/20/22 1.3 Brian Lawson Pricing and General Edits

8/8/22 1.4 Audrey Hogan Update to documentation

8/17/22 1.5 Brian Lawson Final edits and pricing

Reference # Description

CRB Tracking # CS-187

Zendesk 379919

JIRA SEVV-37437

Issue Log #

Customer ID #

CR – CS-187 - HI | 2

Change Request

Background

Issue:

Enhancement:

Who is Impacted:

Benefits:

Timing:

Proposed Solution

Detailed Work Items

Assumptions

Customer Responsibilities

Reference Materials ............................................... Error! Bookmark not defined.

Technical Proposal Approval ................................. Error! Bookmark not defined.

CR – CS-187 - HI | 3

This change request (this “Change Request”) is being issued pursuant to the Statement of Work, as amended (“SOW”) between AHCCCS and Sandata Technologies, LLC for the Hawaii MedQUEST program dated November 16, 2018, as amended. The SOW is governed by the terms of the contract (YH19-0025).

Hawaii would like to improve service selection on the mobile device. As part of that effort, they need to redefine the sort order. Hawaii is also adding new Service/Modifier combinations for the DDD program and sunsetting a selection of services. Hawaii will also be adding additional languages to the program including documentation to support non-English speaking populations whose languages are not available in Sandata Mobile Connect.

Add and sunset new DDD services to the program. Once completed, resort all services according to the direction provided in this Change Request. Once the sort order is completed and services are enabled, translations and documentation can be updated and added according to the request.

Table 1: Updates and changes to Services are as follows:

Note: New Sort Order is defined in the New Sort Order Column – 185 services to be ordered Items in Red are services to be end dated (see End Date column) – 12 services Items in Green are newly added services – 41 services Service/Modifier combinations without an EVV Service Description will stay as-is in terms of the recordings

Payer Program HCPCS Code

M o d if ie r

M o d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TE na 1 S5125_07

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD na 2 S5125_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD U6 na 3 S5125_18

CR – CS-187 - HI | 4

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5130 na 4 S5130_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 U2 na 5 S9122_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 U2 na 6 S9124_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 U6 na 7 S9124_07

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U2 na 8 S9123_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U6 na 9 S9123_13

HI_DDD AGYP S5120 U2 na 10 S5120_01

HI_DDD AGYP S5120 DD CHORE na 11

HI_DDD

AGYP S5120 UA

DD BI

CHORE

na 12

HI_DDD AGYP S5125 U6 na 13 S5125_10

HI_DDD AGYP S5125 DD PAB 1:1 na 14

HI_DDD AGYP 99509 U6 na 15 99509_01

AGYP S5125 UA

DD BI PAB

1:1 na 16

HI_DDD AGYP 99509 UN na 17 99509_02

AGYP S5125 UN UA

1:2 na 18

HI_DDD AGYP 99509 UP na 19 99509_03

AGYP S5125 UP UA

1:3 na 20

HI_DDD AGYP 99509 U7 na 21 99509_04

AGYP S5125 U7 UA

2:1 na 22

HI_DDD AGYP 99509 U4 na 23 99509_05

AGYP S5125 U8 UA

3:1 na 24

HI_DDD AGYP 99509 HM na 25 99509_06

AGYP S5125 HM UA

RBT 1:1

na 26

HI_DDD AGYP 99509 U9 na 27 99509_07

HI_DDD

AGYP S5125 HM U7 UA

DD BI PAB

RBT 2:1

na 28

HI_DDD AGYP 99509 UD na 29 99509_08

HI_DDD

AGYP S5125 HM U8 UA

DD BI PAB

RBT 3:1

na 30

HI_DDD AGYP T1000 U3 na 31 T1000_09

AGYP S9124 UA

DD BI PDN

LPN 1:1

na 32

CR – CS-187 - HI | 5

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_DDD AGYP T1000 U4 na 33 T1000_10

AGYP S9124 UN UA

LPN 1:2

na 34

HI_DDD AGYP T1000 U1 na 35 T1000_04

AGYP S9123 UA

RN 1:1

na 36

HI_DDD AGYP T1000 U2 na 37 T1000_06

AGYP S9123 UN UA

RN 1:2

na 38

HI_DDD AGYP T1005 U1 na 39 T1005_13

HI_DDD AGYP T1005 UN na 40 T1005_14

HI_DDD AGYP T1005 UP na 41 T1005_15

HI_DDD AGYP T1002 U5 na 42 T1002_09

AGYP T1005 TE UA

RESPITE LPN

1:1 na 43

HI_DDD AGYP T1002 U6 na 44 T1002_11

HI_DDD

AGYP T1005 TE UN

UA

DD BI

RESPITE LPN

1:2 na 45

HI_DDD AGYP T1002 U7 na 46 T1002_13

HI_DDD

AGYP T1005 TE UP

UA

DD BI

RESPITE LPN

1:3 na 47

HI_DDD AGYP T1002 U2 na 48 T1002_03

AGYP T1005 TD UA

RESPITE RN

1:1 na 49

HI_DDD AGYP T1002 U3 na 50 T1002_05

HI_DDD

AGYP T1005 TD UN

UA

DD BI

RESPITE RN

1:2 na 51

HI_DDD AGYP T1002 U4 na 52 T1002_07

HI_DDD

AGYP T1005 TD UP

UA

DD BI

RESPITE RN

1:3 na 53

HI_DDD AGYP S5125 UN na 54 S5125_11

HI_DDD AGYP S5125 UP na 55 S5125_12

HI_DDD AGYP S5125 U7 na 56 S5125_13

HI_DDD AGYP S5125 U4 na 57 S5125_14

HI_DDD AGYP S5125 U8 DD PAB 3:1 na 58

HI_DDD AGYP S5125 HM na 59 S5125_15

HI_DDD AGYP S5125 U9 na 60 S5125_16

AGYP S5125 HM U7

DD PAB RBT

na 61

HI_DDD AGYP S5125 UD na 62 S5125_17

AGYP S5125 HM U8

DD PAB RBT

na 63

HI_DDD AGYP T1000 U7 na 64 T1000_08

AGYP S9124

DD PDN LPN

na 65

HI_DDD AGYP T1000 U8 na 66 T1000_07

AGYP S9124 UN

DD PDN LPN

na 67

HI_DDD AGYP T1000 U5 na 68 T1000_03

CR – CS-187 - HI | 6

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

AGYP S9123

DD PDN RN

na 69

HI_DDD AGYP T1000 U6 na 70 T1000_05

AGYP S9123 UN

DD PDN RN

na 71

HI_DDD AGYP S5150 UP na 72 S5150_07

AGYP S5150 UP UA

RESPITE 1:3

na 73

HI_DDD AGYP T1002 UC na 74 T1002_10

AGYP T1005 TE UN

DD RESPITE

LPN 1:2

na 75

HI_DDD AGYP T1002 UD na 76 T1002_12

AGYP T1005 TE UP

LPN 1:3

na 77

HI_DDD AGYP T1002 U8 na 78 T1002_02

AGYP T1005 TD

RN 1:1

na 79

HI_DDD AGYP T1002 U9 na 80 T1002_04

AGYP T1005 TD UN

RN 1:2

na 81

HI_DDD AGYP S5150 na 82 S5150_01

AGYP S5150 UA

RESPITE 1:1

na 83

HI_DDD AGYP S5150 UN na 84 S5150_02

AGYP S5150 UN UA

RESPITE 1:2

na 85

HI_DDD AGYP T1002 UB na 86 T1002_08

AGYP T1005 TE

LPN 1:1

na 87

HI_DDD AGYP T1002 UA na 88 T1002_06

AGYP T1005 TD UP

RN 1:3

na 89

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0156 U6 na 90 G0156_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI S9129 U6 na 91 S9129_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI S9128 U6 na 92 S9128_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI S9131 U6 na 93 S9131_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5130 UA na 94 S5130_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

AGYP S5130 UN na 95 S5130_02

CR – CS-187 - HI | 7

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5130 UN UA na 96 S5130_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5130 UN U5 na 97 S5130_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5130 U5 na 98 S5130_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5135 na 99 S5135_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5135 UA na 100 S5135_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5135 U5 na 101 S5135_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 U5 U2 na 102 S9122_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 UA U2 na 103 S9122_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 UN U2 na 104 S9122_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 UN UA U2 na 105 S9122_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9122 UN U5 U2 na 106 S9122_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 UA U2 na 107 S9124_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 UN U2 na 108 S9124_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 UN UA U2 na 109 S9124_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

AGYP S9124 UN U5 U2 na 110 S9124_05

CR – CS-187 - HI | 8

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9124 U5 U2 na 111 S9124_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 UA U2 na 112 S9123_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 UN U2 na 113 S9123_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 UN UA U2 na 114 S9123_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 UN U5 U2 na 115 S9123_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 U2 na 116 S9123_10

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 U6 na 117 S9123_14

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 UA U2 na 118 S9123_12

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U4 U5 U2 na 119 S9123_11

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U5 U2 na 120 S9123_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 U2 na 121 S9123_07

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 U6 na 122 S9123_15

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 UA U2 na 123 S9123_09

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S9123 U3 U5 U2 na 124 S9123_08

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

AGYP T1005 TE na 125 T1005_07

CR – CS-187 - HI | 9

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TE UA na 126 T1005_10

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TE UN na 127 T1005_08

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TE UN UA na 128 T1005_12

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TE UN U5 na 129 T1005_11

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TE U5 na 130 T1005_09

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD na 131 T1005_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD UA na 132 T1005_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD UN na 133 T1005_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD UN UA na 134 T1005_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD UN U5 na 135 T1005_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP T1005 TD U5 na 136 T1005_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5150 na 137 S5150_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5150 UA na 138 S5150_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5150 UN na 139 S5150_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

AGYP S5150 UN UA na 140 S5150_06

CR – CS-187 - HI | 10

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5150 UN U5 na 141 S5150_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5150 U5 na 142 S5150_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TE UA na 143 S5125_09

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TE U5 na 144 S5125_08

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD UA na 145 S5125_06

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 TD U5 na 146 S5125_05

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 na 147 S5125_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 UA na 148 S5125_03

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYP S5125 U5 na 149 S5125_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0300 U6 na 150 G0300_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0494 U6 na 151 G0494_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0496 U6 na 152 G0496_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0152 U6 na 153 G0152_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0158 U6 na 154 G0158_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

AGYI G0160 U6 na 155 G0160_61

CR – CS-187 - HI | 11

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0151 U6 na 156 G0151_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0157 U6 na 157 G0157_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0159 U6 na 158 G0159_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0299 U6 na 159 G0299_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0493 U6 na 160 G0493_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0495 U6 na 161 G0495_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI S5181 U6 na 162 S5181_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI S5180 U6 na 163 S5180_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0153 U6 na 164 G0153_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0161 U6 na 165 G0161_01

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

AGYI G0155 U6 na 166 G0155_01

HI_DDD CD 99509 U1 na 167 99509_09

HI_DDD CD 99509 51 na 168 99509_10

HI_DDD CD S5120 U4 na 169 S5120_03

HI_DDD CD S5120 U3 na 170 S5120_04

HI_DDD CD S5125 51 na 171 S5125_19

HI_DDD CD S5150 UA na 172 S5150_08

HI_DDD CD S5150 UB na 173 S5150_09

HI_DDD CD T1005 UA na 174 T1005_16

HI_DDD CD T1005 UB na 175 T1005_17

CD S5120 U1

DD CHORE

CD

na 176

HI_DDD CD S5125 U1 na 177 S5125_18

HI_DDD

CD S5125 UN

U1

DD PAB CD

na 178

CR – CS-187 - HI | 12

M o d if ie d if ie d if ie d if ie r

EVV Service

Description End Date New

Sort Order

Sandata DB Service Code

CD S5150 U1

CD 1:1

na 179

HI_DDD

CD S5150 UN

U1

DD BI

RESPITE CD

1:2 na 180

HI_DDD AGYP S5120 U1 na 181 S5120_02

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

SD S5130 U1

na 182 S5130_07

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

SD S5135 U1

na 183 S5135_04

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

SD S9122 U1

U2 na 184 S9122_07

HI_AC, HI_KP,

HI_HMSA,

HI_OHANA,

HI_UHC

SD S9122 U1

U4 U2 na 185 S9122_08

AGYP T1019 U6

PAB Level 1, 06/30/22 na T1019_01

AGYP T1019 U3

PAB Level 3, 06/30/22 na T1019_010

AGYP T1019 U4

06/30/22 na T1019_011

AGYP T1019 U5

4:1 06/30/22 na T1019_012

AGYP T1019 U7

06/30/22 na T1019_02

AGYP T1019 U8

06/30/22 na T1019_03

AGYP T1019 U9

06/30/22 na T1019_04

AGYP T1019 UA

PAB Level 2, 06/30/22 na T1019_05

AGYP T1019 UB

06/30/22 na T1019_06

AGYP T1019 UC

06/30/22 na T1019_07

AGYP T1019 UD

06/30/22 na T1019_08

AGYP T1019 U2

06/30/22 na T1019_09

Table 2: List of current Tasks for translation services:

Task ID (*) Task Description (**) Char length Include?

0099 Patient Refused Personal Care 29 Yes

0100 Temperature 11 Yes

0105 Pulse 5 Yes

0110 Respiration 11 Yes

0115 Blood pressure 14 Yes

CR – CS-187 - HI | 13

Char length Include?

0120 Oxygen Saturation 17 Yes

0125 Height/Weight 13 Yes

0200 Clean Bathroom 14 Yes

0205 Clean Kitchen 13 Yes

0210 Clean Bedroom 13 Yes

0215 Change Linen 12 Yes

0220 Make bed 8 Yes

0225 Empty Trash 11 Yes

0230 Laundry - Washing 17 Yes

0235 Laundry - Drying 16 Yes

0240 Laundry - Ironing 17 Yes

0245 Laundry - Mending 17 Yes

0250 Shopping/Errands 16 Yes

0255 Transportation/Escort 21 Yes

0260 Meal Preparation 16 Yes

0300 Prepare/Serve Meal(s) 21 Yes

0305 Assist/Feed 11 Yes

0310 Record Oral Intake 18 Yes

0315 Bed Bath 8 Yes

0320 Shower 6 Yes

0325 Shampoo 7 Yes

0330 Dressing - Upper Body 21 Yes

0335 Dressing - Lower Body 21 Yes

0340 Grooming - Oral Care 20 Yes

0345 Grooming - Shave 16 Yes

0350 Brush Hair 10 Yes

0355 Comb Hair 9 Yes

0360 Nail Care 9 Yes

0365 Foot Care 9 Yes

0367 Skin Care 9 Yes

0370 Toileting 9 Yes

0375 Bed Mobility/Transfers 22 Yes

0377 Manual WC Mobility 18 Yes

0380 Medication Assistance 21 Yes

0385 Medication Reminder 19 Yes

0450 Record Tube Fding Intake 24 Yes

0455 Tube Feeding 12 Yes

0460 G-Tube Care 11 Yes

CR – CS-187 - HI | 14

length Include?

0465 Check Skin for Hydration 24 Yes

0500 Check Oxygen 12 Yes

0505 Oral Suctioning 15 Yes

0510 Suctioning (non-oral) 21 Yes

0515 Neb/Aerosol Treatment 21 Yes

0520 Check Humidifier 16 Yes

0525 Check Apnea Monitor 19 Yes

0530 Check Pulse Oximeter 20 Yes

0535 Tracheostomy Care 17 Yes

0540 Ventilator Care 15 Yes

0545 Check Ventilator Settings 25 Yes

0550 Check Oxygen Concentrator 25 Yes

0555 Check Resuscit/Ambu Bag 23 Yes

0560 Chest Physiotherapy 19 Yes

0565 Cough Stimulator 16 Yes

0600 Decubitus Care 14 Yes

0605 Dressing (Wound) 16 Yes

0610 Dressing Change - Clean 23 Yes

0615 Dressing Change - Sterile 25 Yes

0700 Administer Medication(s) 24 Yes

0705 Update Medication List 22 Yes

0710 Blood Glucose Monitoring 24 Yes

0800 Diaper Change/Skin Care 23 Yes

0805 Bedpan 6 Yes

0810 Urinal 6 Yes

0815 Commode 7 Yes

0820 Toilet 6 Yes

0825 Urinary Catheterization 23 Yes

0830 Catheter Care 13 Yes

0835 Catheter Irrigation 19 Yes

0840 Condom Care 11 Yes

0845 Empty Urine Drainage Bag 24 Yes

0850 Record Urine Output 19 Yes

0855 Drain urine bag 1/2 full 24 Yes

0860 Check for Bowel Movement 24 Yes

0865 Digital Stimulation 19 Yes

0870 Suppository 11 Yes

0875 Enema 5 Yes

CR – CS-187 - HI | 15

length Include?

0880 Fleets Enema 12 Yes

0900 Turn/Reposition 15 Yes

0905 Transfer(s) 11 Yes

0910 Up in Chair 11 Yes

0915 Manual Wheelchair 17 Yes

0920 Front Wheeled Walker 20 Yes

0925 Transfer - Patient Lift 23 Yes

0930 Walk 4 Yes

0935 Exercise 8 Yes

0940 Safety Belt w/ Mobility 23 Yes

0945 Check Side Rails 16 Yes

0955 Habilitation 12 Yes

Add the following Sandata-supported languages to both the Agency and Self Direct Program:

• Arabic

• Burmese

• Laotian

• Portuguese

• Russian

Table 3: The order of language prompts will be:

Language Presentation Order (Mobile)

English (US) 1

Ilokano 2

Filipino (Philippines) 3

Traditional Chinese 4

Simplified Chinese 5

Hawaiian 6

Korean 7

Japanese 8

Vietnamese 9

Spanish 10

French 11

Arabic 12

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Burmese 13

Laotian 14

Portuguese 15

Russian 16

Existing documentation to update and translate include the Call Reference Guides, Service Listings, Task Listings and Welcome Kits.

In addition, Med-QUEST requests that Sandata create written documentation of step-by-step instructions to log an SMC visit, an SMC Group Visit and an FVV visit that supports both Agency and Self Direct. These documents will be produced and offered with a one-time edit for Med-QUEST. Thereafter, Med-QUEST will manage any changes, updates and translations. The English version will be available to agencies and health plans. The State of Hawaii’s language services is available to help with the translation effort for Chuukese and Marshallese.

Documents to be created:

1. Logging a mobile visit

2. Logging a Group Visit on the mobile device

3. Logging an FVV visit and filling in a timesheet

Translations for the following documents would also be required for all program languages (including the 5 new languages:

1. Logging a mobile visit

2. Logging a Group Visit on the mobile device

3. Logging an FVV visit and filling in a timesheet.

4. Basic Toolkit

5. FVV Toolkit

6. Group Visit Toolkit

All Hawaii agencies and self-direct health plans.

Benefits include improved efficiency when using the mobile device for caregivers and for non-English speaking clients/caregivers.

Timing:

Timing of this Change Request should follow logically to ensure that translation and documentation reflect the new/changed services and should ensure that no duplication of effort in translation and documentation occurs.

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To be completed by product management and solution engineering.

Sandata Product/Engineering will perform the following work:

1. 41 New Services will be translated for SMC, recorded for TVV and deployed in the following languages:

a. English

b. Ilokano

c. Tagalog

d. Traditional Chinese

e. Simplified Chinese

f. Hawaiian

g. Korean

h. Japanese

i. Vietnamese

j. Spanish

k. French

2. 12 Services will be end-dated at a mutually agreed upon date

a. Visits for these 12 services will be rejected for Alt EVV vendors after the specified date

b. Authorizations for these 12 services will be rejected for Alt EVV vendors after the specified date

c. Any authorization in the system for these services will be end dated as of the specified date.

3. For SMC, all 185 services including existing and new will be reordered per the order provided.

4. Sandata will enable 5 additional standard languages. All 185 services and 93 tasks included in the program will be translated into each of these languages. Languages will follow existing languages as follows:

a. Arabic (12)

b. Burmese (13)

c. Laotian (14)

d. Portuguese (15)

e. Russian (16)

5. A new Welcome Kit will be deployed and will be distributed and will be created for all newly created accounts including all new materials.

Sandata Customer Enablement will perform the following work:

1. Update one service list to include 41 new services and remove 12 end-dated services

2. Update 5 tool kits with 41 new services and remove 12 end-dated services

3. Update 2 CRGs with 5 additional standard languages:

a. Arabic (12)

b. Burmese (13)

c. Laotian (14)

d. Portuguese (15)

e. Russian (16)

4. Translate updated service list for 15 standard languages:

a. Ilokano

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b. Tagalog

c. Traditional Chinese

d. Simplified Chinese

e. Hawaiian

f. Korean

g. Japanese

h. Vietnamese

i. Spanish

j. French

k. Arabic

l. Burmese

m. Laotian

n. Portuguese

o. Russian

5. Translate 5 updated tool kits into 15 standard languages

a. Ilokano

b. Tagalog

c. Traditional Chinese

d. Simplified Chinese

e. Hawaiian

f. Korean

g. Japanese

h. Vietnamese

i. Spanish

j. French

k. Arabic

l. Burmese

m. Laotian

n. Portuguese

o. Russian

6. Translate 2 updated CRGs into 15 standard languages

a. Ilokano

b. Tagalog

c. Traditional Chinese

d. Simplified Chinese

e. Hawaiian

f. Korean

g. Japanese

h. Vietnamese

i. Spanish

j. French

k. Arabic

l. Burmese

m. Laotian

n. Portuguese

o. Russian

7. Record 41 new services for IVR deployment into the 11 original standard languages

a. English

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b. Ilokano

c. Tagalog

d. Traditional Chinese

e. Simplified Chinese

f. Hawaiian

g. Korean

h. Japanese

i. Vietnamese

j. Spanish

k. French

8. Record the entire 185 services and 93 tasks into the 5 new languages

a. Arabic

b. Burmese

c. Laotian

d. Portuguese

e. Russian

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defined.

Table 1: Work Item List

Item # Type Description Hours Product & Engineering

PE1 Business Rules Update business rules to update services and service order, add 5 new languages and language order.

PE2 Alt EVV Addendum Update addendum to update services available. 8

PE3 Authorization Addendum Update addendum to update services available. 8

PE4 POC Addendum Update addendum to update services available. 8

PE5 SMC Deploy 41 new service translations in original 11 languages 116

PE6 Telephony Deploy 41 new service recordings in original 11 languages 116

PE7 SMC Deploy 185 new services in 5 new languages 235 PE8 Telephony Deploy 185 new services in 5 new languages 235 PE9 SMC Deploy 93 new tasks in 5 new languages 120 PE10 Telephony Deploy 93 new tasks in 5 new languages 120 PE11 Welcome Kit Deploy updated welcome kit materials 20

PE12 Configuration Add 41 new services to Sandata EVV, Sandata EVV Scheduling and Billing and Sandata Aggregator

PE13 Configuration End Date 12 Services from Sandata EVV, Sandata EVV Scheduling and Billing and Sandata Aggregator

PE14 Configuration Add new languages per order defined to Hawaii template and all existing phones 44

PE15 Configuration Define order of final 185 services for SMC display 36 PE16 Configuration Define order of final 185 services for UI display 16 PE19 Alt EVV Interface Update validation on services 28

PE20 Authorization Interface Update validation on services 28

PE21 POC Interface Update validation on services 28

Translation Services

TS1 Current 11 Languages

Translate and Record 41 New Services for SMC and Telephony

TS2 New 5 Languages Translate and Record 185 New Services for SMC and Telephony

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TS3 New 5 Languages Translate and Record 93 Tasks for SMC and Telephony

Project Management / Implementation Support PM1 PM Project Management Support 160 PM2 UAT UAT Support 60 PM3 SIT Interface Testing Support 60

Documentation & Translation Services

DO1 Document Update 1 service list to include 41 new services and to remove the 12 end-dated services

D02 Document Update 5 tool kits to include 41 new services and to remove the 12 end-dated services

D03 Document Update 2 CRGs to add 5 additional languages D04 Translation Translate new service list for 15 languages D05 Translation Translate 5 updated tool kits into for 15 languages D06 Translation Translate 2 updated CRGs into 15 languages DO7 Translation Translate existing task list into 5 new languages

D08 Translation Record 41 new services for IVR deployment into 11 languages, including English

D09 Translation Record the 185 services & 93 tasks into the 5 new languages

• It is assumed that there are no changes to the task list

• Med-QUEST will maintain and distribute the custom documents referenced in this

Change Request.

This section will be updated with the appropriate release…