Current assets

EX-10.6.5 2 w99373exv10w6w5.htm EX-10.6.5 exv10w6w5

Exhibit 10.6.5

State of New Jersey

DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

PO Box 712


JAMES E. MCGREEVEY	TRENTON, NJ ###-###-####	JAMES M. DAVY
Governor	TELEPHONE ###-###-####	Commissioner

		ANN CLEMENCY KOHLER
		Director

June 1, 2004

Norine Yukon
President & CEO
AMERIGROUP New Jersey, Inc.
399 Thornall Street, 9th Floor
Edison, NJ 08837

Dear Ms. Yukon:

Enclosed is your copy of a recently processed contract amendment.

The amendment will extend the NJ Care 2000+ managed care contract through June 30, 2005. This amendment has been approved by the Centers for Medicare and Medicaid Services (CMS).

Thank you.


		Sincerely,

		Rita Hemingway
		Director, Contract Relations
		Office of Managed Health Care

RH:dv
Enclosure
c: Jill Simone, MD
John Koehn

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties agree that the contract shall be amended, effective July 1, 2004 , as follows:

Article 1, “Definitions”, the definition of Complaint shall be amended as reflected in the relevant page of Article 1 attached hereto and incorporated herein.

2.		Article 4, “Provision of Health Care Services” Sections 4.1.1.Q (new); 4.1.2(A)24; 4.1.4(A); 4.1.4(B); 4.1.5(A); 4.2.1(E); 4.2.6(B)7(d)ii; 4.2.6(B)7(f)ii.1; 4.4(B)1; 4.6.1(C)5; 4.6.2(P); 4.6.2(Q)1; 4.8.3(B) (new); 4.8.5; 4.8.8(H)7; 4.8.8(1); 4.8.8(M)3(c); 4.8.8(M)3(j); 4.8.8(M)3(n); 4.8.8(M)3(q); 4.8.8(M)3(s) and 4.9.2 shall be amended as reflected in Article 4, Sections 4:1.1.Q, 4.1.2(A)24, 4.1.4(A), 4.1.4(B), 4.1.5(A), 4.2.1(E), 4.2.6(B)7(d)ii, 4.2.6(B)7(f)ii.1, 4.4(B)1, 4.6.1(C)5, 4.6.2(P), 4.6.2(0)1, 4.8.3(B), 4.8.5, 4.8.8(H)7, 4.8.8(1), 4.8.8(M)3(c), 4.8.8(M)3(j), 4.8.8(M)3(n), 4.8.8(M)3(q), 4.8.8(M)3(s) and 4.9.2 attached hereto and incorporated herein.

3.		Article 5, “Enrollee Services” Sections 5.5(G); 5.8.2(S) and 5.15.1(A) shall be amended as reflected in Article 5, Sections 5.5(G), 5.8.2(S) and 5.15.1(A) attached hereto and incorporated herein.

4.		Article 6, “Provider Information” Section 6.2(D) shall be amended as reflected in Article 6, Section 6.2(D) attached hereto and incorporated herein.

5.		Article 7, “Terms and Conditions” Sections 7.16.7(A)1; 7.16.7(B)1; 7.20.2(C); 7.26(F) and 7.26(L) (new) shall be amended as reflected in Article 7, Sections 7.16.7(A)1, 7.16.7(B)1, 7.20.2(C), 7.26(F) and 7.26(L) attached hereto and incorporated herein.

6.		Article 8, “Financial Provisions” Sections 8.5.4; 8.8(0) and 8.10(B) shall be amended as reflected in Article 8, Sections 8.5.4, 8.8(0) and 8.10(B) attached hereto and incorporated herein.

7.		Appendix, Section A, “Reports”

•		A.4.1 - Provider Network File: Attachment E (revised);

•		A.4.2 - Organ Transplant Procedure (new);

•		A.4.4 - Certification of Provider Network Report;

•		A.7.1 - Certifications: 1) Certification of Enrollment Information Relating to Payment Under The Medicaid/NJ FamilyCare Programs; 2) Certification of Encounter Information Relating to Payment Under the Medicaid/NJ FamilyCare Programs; 3) Certification of .Any Information Required By the State and Contained in Contracts Proposals and Related Documents Relating to Payments Under the Medicaid/NJ FamilyCare Programs;

•		A. 7.8 - Table 6D: Revenue and Expenses, Summary of MCSA Groups on. Claims Paid During Current Quarter (new); .

•		A. 7.8 - Table 6E: Revenue and Expenses, Summary of MCSA Groups on Claims Paid Year to Date (new);

•		A.7.20 - Table 18B: Federally Qualified Health Center Encounters (new);

•		A.7.21 - Table 19: Income Statement By Rate Cell Grouping, Table 19A thru V;

•		A.7.22 - Table 20: Lag Reports

•		A.7.24 - Table 22: Plan H Invoice Form

shall be amended as reflected in Appendix, Section A, A.4.1, A.4.2, A.4.4, A.7.1, A.7.8, A.7.20, A.7.21, A.7.22 and A.7.24 attached hereto and incorporated herein.

8. Appendix, Section B, “Reference Materials”

•		B.5.2 - Cost-Sharing Requirements for NJ FamilyCare Plan C, Plan D and Plan H Beneficiaries;

•		B.7.3 - Financial Guide for Reporting Medicaid/NJ FamilyCare Rate Cell Grouping Costs; and

•		B.7.5 - EPSDT Codes;

shall be amended as reflected in Appendix, Section B, B.5.2, B.7.3, and B.7.5 attached hereto and incorporated herein.

Appendix, Section C, “Capitation Rates,” shall be revised as reflected in SFY 2005 Capitation Rates attached hereto and incorporated herein

All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.


		AMERIGROUP	State of New Jersey

		New Jersey, Inc.	Department of Human Services

BY:	/s/ Norine Yukon		BY:

				Ann Clemency Kohler

TITLE: President & CEO			TITLE: Director, DMAHS

DATE: March 23, 2004			DATE: April 13, 2004

APPROVED AS TO FORM ONLY

Attorney General

State of New Jersey

BY:

Deputy Attorney General

DATE: April 2, 2004

with the contractor. Marketing by an employee of the contractor is considered direct; marketing by an agent is considered indirect.

Commissioner—the Commissioner of the New Jersey Department of Human Services or a duly authorized representative.

Complaint—a protest by an enrollee as to the conduct by the contractor or any agent of the contractor, or an act or failure to act by the contractor or any agent of the contractor, or any other matter in which an enrollee feels aggrieved by the contractor, that is communicated to the contractor and that could be resolved by the contractor within five (5) business days, except for urgent situations, and as required by the exigencies of the situation.

Complaint Resolution-completed actions taken to fully settle a complaint to the DMAHS’ satisfaction.

Comprehensive Risk Contract—a risk contract that covers comprehensive services, that is, inpatient hospital services and any of the following services, or any three or more of the following services:

1. Outpatient hospital services.

2. Rural health clinic services.

3. FQHC services.

4. Other laboratory and X-ray services.

5. Nursing facility (NF) services.

6. Early and periodic screening, diagnosis and treatment (EPSDT) services.

7. Family planning services.

8. Physician services.

9. Home health services.

Condition—a disease, illness, injury, disorder, or biological or psychological condition or status for which treatment is indicated.

Contested Claim—a claim that is denied because the claim is an ineligible claim, the claim submission is incomplete, the coding or other required information to be submitted is incorrect, the amount claimed is in dispute, or the claim requires special treatment.

Continuity of Care—the plan of care for a particular enrollee that should assure progress without unreasonable interruption.

Contract—the written agreement between the State and the contractor, and comprises the contract, any addenda, appendices, attachments, or amendments thereto.

Contracting Officer—the individual empowered to act and respond for the State throughout the life of any contract entered into with the State.

Contractor—the Health Maintenance Organization with a valid Certificate of Authority in New Jersey that contracts hereunder with the State for the provision of comprehensive


Amended as of *July 1, 2004*		I-5

N.		Protection of Enrollee-Provider Communications. Health care professionals may not be prohibited from advising their patients about their health status or medical care or treatment, regardless of whether this care is covered as a benefit under the contract.

O.		Medical or Dental Procedures. For procedures that may be considered either medical or dental such as surgical procedures for fractured jaw or removal of cysts, the contractor shall establish written policies and procedures clearly and definitively delineated for all providers and administrative staff, indicating that either a physician specialist or oral surgeon may perform the procedure and, when, where, and how authorization, if needed, shall be promptly obtained.

P.		Out-of-Network Services. If the contractor is unable to provide in-network necessary services, covered under the contract to a particular enrollee, the contractor must adequately and timely cover those services out-of-network for the enrollee, for as long as the contractor is unable to provide them in-network.

Q.		Termination of Benefits. For benefits terminated at the direction of the State, the contractor shall be responsible for previously authorized services for a period of sixty (60) days after the effective date of termination.

4.1.2 BENEFIT PACKAGE

The following categories of services shall be provided by the contractor for all Medicaid and NJ FamilyCare Plans A, B, and C enrollees, except where indicated. See Section B.4.1 of the Appendices for complete definitions of the covered services.


1.		Primary and Specialty Care by physicians and, within the scope of practice and in accordance with State certification/licensure requirements, standards and practices, by Certified Nurse Midwives, Certified Nurse Practitioners, Clinical Nurse Specialists, and Physician Assistants


2.		Preventive Health Care and Counseling and Health Promotion


3.		Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program Services


		For NJ FamilyCare Plans B and C participants, coverage includes early and periodic screening and diagnosis medical examinations, dental, vision, hearing, and lead screening services. It includes only those treatment services identified through the examination that are available under the contractor’s benefit package or specified services under the FFS program.

4.		Emergency Medical Care


Amended as of *July 1, 2004*		IV-4

21.		Medical Supplies

22.		Prosthetics and Orthotics including certified shoe provider.

23.		Dental Services

24.		Organ Transplants - includes donor and recipient costs. Exception: The contractor will not be responsible for transplant-related donor and recipient inpatient hospital costs for an individual placed on a transplant list while in the Medicaid FFS program prior to initial enrollment into the contractor’s plan.

25.		Transportation Services for any contractor-covered service or non-contractor covered service including ambulance, mobile intensive care units (MICUs) and invalid coach (including lift equipped vehicles)

26.		Post-acute Care

27.		Mental Health/Substance Abuse Services for enrollees who are clients of the Division of Developmental Disabilities

Conditions Altering Mental Status. Those diagnoses which are categorized as altering the mental status of an individual but are of organic origin shall be part of the contractor’s medical, financial and care management responsibilities for all categories of enrollees. These include the diagnoses in the following ICD-9-CM Series:

1.		290.0 Senile dementia, simple type

2.		290.1 Presenile dementia

3.		290.10 Presenile dementia, uncomplicated

4.		290.11 Presenile dementia with delerium

5.		290.12 Presenile dementia with delusional features

6.		290.13 Presenile dementia with depressive features

7.		290.2 Senile dementia with delusional or depressive features

8.		290.20 Senile dementia with delusional features

9.		290.21 Senile dementia with depressive features

10.		290.3 Senile dementia with delerium

11.		290.4 Arteriosclerotic dementia

12.		290.40 Arteriosclerotic dementia, uncomplicated

13.		290.41 Arteriosclerotic dementia with delirium

14.		290.42 Arteriosclerotic dementia with delusional features

15.		290.43 Arteriosclerotic dementia with depressive features

16.		290.8 Other specific senile psychotic conditions

17.		290.9 Unspecified senile psychotic condition

18.		291.1 Alcohol amnestic syndrome


Amended as of *July 1, 2004*		IV-6


02721	02952	05120
02722	O254	05211
02750	03310	05211-52
02751	03320	05212
02752	03330	05212-52
02790	03410-22	05213
02791	03411	05214

Procedure Codes to be paid by Medicaid FFS up to 120 days from date of last preliminary extractions after patient enrolls in New Jersey Care 2000+ (applies to tooth codes 5 - 12 and 21 - 28 only):

05130
05130-22
05140
05140-22

Extraction Procedure Codes to be paid by Medicaid FFS up to 120 days from last date of preliminary extractions after first time New Jersey Care 2000+ enrollment in conjunction with the following codes (05130, 05130-22, 05140, 05140-22):

07110
07130
07210

4.1.4 MEDICAID COVERED SERVICES NOT PROVIDED BY CONTRACTOR

Mental Health/Substance Abuse. The following mental health/substance abuse services (except for the conditions listed in 4.1.2.B) will be managed by the State or its agent for non-DDD enrollees, including all NJ FamilyCare enrollees. (The contractor will retain responsibility for furnishing mental health/substance abuse services, excluding the cost of the drugs listed below, to Medicaid enrollees who are clients of the Division of Developmental Disabilities).

•		Substance Abuse Services-diagnosis, treatment, and detoxification

•		Costs for Methadone maintenance and its administration

•		Mental Health Services

Drugs. The following drugs will be paid fee-for-service by the Medicaid program for all DMAHS enrollees:

•

Atypical antipsychotic drugs within the Specific Therapeutic Drug Classes H7T and H7X


Amended as of *July 1, 2004*		IV-9-

•		Methadone maintenance - cost and its administration. Except as provided in Article 4.4, the contractor will remain responsible for the medical care of enrollees requiring substance abuse treatment

•		Generically-equivalent drug products of the drugs listed in this section.

C.		Up to twelve (12) inpatient hospital days required for social necessity in accordance with Medicaid regulations.

D.		DDD/CCW waiver services: individual supports (which includes personal care and training), habilitation, case management, respite, and Personal Emergency Response Systems (PERS).

4.1.5 INSTITUTIONAL FEE-FOR-SERVICE BENEFITS - NO COORDINATION BY THE CONTRACTOR

The following institutional services shall remain in the fee-for-service program without requiring coordination by the contractor. In addition, Medicaid beneficiaries participating in a waiver (except the Division of Developmental Disabilities Community Care Waiver) or demonstration program or admitted for long term care treatment in one of the following shall be disenrolled from the contractor’s plan on the date of admission to institutionalized care.

A.		Nursing Facility care (Exception: if the admission is only for inpatient rehabilitation/postacute care services and is 30 days or less, the enrollee will not be disenrolled. The contractor remains financially responsible for rehabilitation/postacute services in this setting for 30 days. Thereafter, if the enrollee continues to receive rehabilitation/postacute services in this setting, the enrollee will be disenrolled. The contractor will no longer be financially responsible.) Not covered for NJ FamilyCare Plans B and C.

B.		Inpatient psychiatric services (except for RTCs) for individuals under age 21 and 65 and over - Services that are provided:

1.		Under the direction of a physician;

2.		In a facility or program accredited by the Joint Commission on Accreditation of Health Care Organizations; and

3.		Meet the federal and State requirements.

C.		Intermediate Care Facility/Mental Retardation Services - Items and services furnished in an intermediate care facility for the mentally retarded. Covered for NJ FamilyCare Plan A only.

D.		Waiver (except Division of Developmental Disabilities Community Care Waiver) and demonstration program services. Covered for NJ FamilyCare Plan A only.


*Amended as of July 1, 2004*		1V-10

C.		Access Standards. The contractor shall ensure that all covered services, that are required oh an emergency basis are available to all its enrollees, twenty-four (24) hours per day, seven (7) days per week, either in the contractor’s own provider network or through arrangements approved by DMAHS. The contractor shall maintain twenty-four (24) hours per day, seven (7) days per week on-call telephone coverage, including Telecommunication Device for the Deaf (TDD)/Tech Telephone (TT) systems, to advise enrollees of procedures for emergency and urgent care and explain procedures for obtaining non-emergent/non-urgent care during regular business hours within the enrollment area as well as outside the enrollment area.

D.		Non-Participating Providers.

1.		The contractor shall be responsible for developing and advising its enrollees and where applicable, authorized persons of procedures for obtaining emergency services, including emergency dental services, when it is not medically feasible for enrollees to receive emergency services from or through a participating provider, or when the time required to reach the participating provider would mean risk of permanent damage to the enrollee’s health. The contractor shall bear the cost of providing emergency service through non-participating providers.

2.		Non-contracted hospitals providing emergency services to Medicaid or NJ FamilyCare members enrolled in the managed care program shall accept, as payment in full, the amounts that the non-contracted hospitals would receive from Medicaid for the emergency services and/or any related hospitalization as if the beneficiary were enrolled in fee-for-service Medicaid.

E.		Emergency Care Prior Authorization. Prior authorization shall not be required for emergency services through stabilization. This applies to out-of-network as well as to in-network providers.

F.		Medical Screenings/Urgent Care. Prior authorization shall not be required for medical screenings or for providing services in urgent care situations at the hospital emergency room. The hospital emergency room physician may determine the necessity for contacting the PCP or the contractor for information about an enrollee. who presents with an urgent condition.

G.		The contractor shall pay for all medical screening services rendered to its enrollees by hospitals and emergency room physicians regardless of the admitting symptoms or discharge diagnosis. The amount and method of reimbursement for medical screenings shall be subject to negotiation between the contractor and the hospital and directly with non-hospital salaried emergency room physicians and shall include reimbursement for urgent care and non-urgent care rates. Non-participating hospitals may be reimbursed for hospital costs at Medicaid rates or other mutually agreeable rates for medical screening services. Additional fees for


Amended ..as of *July* 1, *2004*		N-21

i.		The contractor shall provide to DMAHS documentation as to the efforts made to educate providers with low screening rates.

ii.		The contractor shall implement plans for corrective action with those identified PCPs that describe interventions to be taken to identify and correct deficiencies and impediments to the screening and how the effectiveness of its interventions will be measured.

e.		On a quarterly basis, the contractor shall submit to DMAHS a report of all lead-burdened children who are receiving treatment and case management services.

f.		Lead Case Management Program. The contractor shall establish a Lead Case Management Program (LCMP) and have written policies and procedures for the enrollment of children with blood lead levels ³ 10 µg/dl and members of the same household who are between six months and six years of age, into the contractor’s LCMP.

Lead Case Management shall consist of, at a minimum:

Follow-up of a child in need of lead screening, or who has been identified with an elevated blood lead level ³ 10 µg/dl. At minimum, follow-up shall include:

A)		For a child with an elevated blood lead level ³ 10 µg/dl, the Plan’s LCM shall ascertain if the blood lead level has been confirmed by a venous blood determination. In the absence of confirmatory test results, the LCM will arrange for a test.

B)		For a child with a confirmed blood (venous) lead level of ³ 10 µg/dl the contractor’s LCM shall notify and provide to the local health department the child’s name, primary health care provider’s name, the confirmed blood lead level, and any other pertinent information.

Education of the family about all aspects of lead hazard and toxicity. Materials shall explain the sources of lead exposure, the consequences of


Amended as of July 1, 2004		IV-35

		elevated blood levels, preventive measures. including housekeeping, hygiene, and appropriate nutrition. The reasons why it is necessary to follow a prescribed medical regimen shall also be explained.

3)		Communication among all interested parties.

4)		Development of a written case management plan with the PCP and the child’s family and other interested parties. The case management plan shall be reviewed and updated on an ongoing basis.

5)		Coordination of the various aspects of the affected child’s care, e.g., WIC, support groups, and community resources, and

6)		Aggressively pursuing non-compliance with follow-up tests and appointments, and document these activities in the LCMP.

ii.

Active case management may be discontinued if one of the following criteria has been met:

1)		The child has one confirmed blood lead levels < 10 µg/dl drawn and all other children under the age of six years living in the household who have been tested and their blood levels are < 10 µg/dl, and the sources of lead have been identified and reduced, or

2)		The family has been permanently relocated to a lead-safe house, or

3)		The parent/guardian has given a written refusal of service, or

4)		The LCM is unable to locate the child after a minimum of three documented attempts, using the assistance of County Board of Social Services, and the LHD. The child’s PCP will be notified in writing.

4.2.7 IMMUNIZATIONS


Amended as of *July 1, 2004*		IV-36

		with the administration of Methadone, which will .remain FFS), neurological evaluations, laboratory testing and radiologic examinations, and any other diagnostic procedures that are necessary to make the diagnostic determination between a primary MH/SA disorder and an underlying physical disorder, as well as for medical work-ups required for medical clearances prior to the provision of psychiatric medication or electroconvulsive therapy (ECT), or for transfer to a psychiatric/SA facility. Routine laboratory procedures ordered by treating MH/SA providers in conjunction with MH/SA treatment, for routine blood testing performed in conjunction with the administration of atypical antipsychotics (see Article 4.1.4B for non-DDD enrollees, are not the responsibility of the contractor.

2.		The contractor shall develop a referral process to be used by its providers which shall include providing a copy of the medical consultation and diagnostic results to the MH/SA provider. The contractor shall develop procedures to allow for notification of an enrollee’s MHH/SA provider of the findings of his/her physical examination and laboratory/radiological tests within twenty-four (24) hours of receipt for urgent cases and within five business days in non-urgent cases. This notification shall be made by phone with follow-up in writing when feasible.

Pharmacy Services. Except for the drugs specified in Article 4.1.4 (Clozapine, Risperidone, Olanzapine, etc.), all pharmacy services are covered by the contractor. This includes drugs prescribed by the contractor or MH/SA providers. The contractor shall only restrict or require a prior authorization for prescriptions or pharmacy services prescribed by MH/SA providers if one of the following exceptions is demonstrated:

1.		The drug prescribed is not related to the treatment of substance abuse/dependency/addiction or mental illness or to any side effects of the psychopharmacological agents. These drugs are to be prescribed by the contractor’s PCP or specialists in the contractor’s network.

2.		The prescribed drug does not conform to standard rules of the contractor’s pharmacy plan.

3)		The contractor, at its option, may require a prior authorization (PA) process if the number of prescriptions written by the MH-1/SA provider for MH/SA-related conditions exceed four (4) per month per enrollee. For drugs that require weekly prescriptions, these prescriptions shall be counted as one per month and not as four separate prescriptions. The contractor’s PA process for the purposes of this section shall require review and prior approval by DMAHS.


Amended as of *July 1, 2004*		IV-45

g.		Serving as Chairperson of Quality Management Committee; [Note: the medical director may designate another physician to serve as chairperson with prior approval from DMAHS.]

h.		Oversight of provider education, in-service training and orientation;

i.		Assuring that adequate staff and resources are available for the provision of proper medical care to enrollees; and

j.		The review and approval of studies and responses to DMAHS concerning QM matters.

3.		Enrollee Rights and Responsibilities. Shall include the right to the Medicaid Fair Hearing Process for Medicaid enrollees.

4.		Medical Record standards shall address both Medical and Dental records. Records shall also contain notation of any cultural/linguistic needs of the enrollee.

5.		Provider Credentialing. Before any provider may become part of the contractor’s network, that provider shall be credentialed by the contractor. The contractor must comply with N.J.A.C. 8:38C-1 et seq. and Standard IX of NJ modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the contractor’s credentialing procedures shall include verification that providers and subcontractors have not been suspended, debarred, disqualified, terminated or otherwise excluded from Medicaid, Medicare, or any other federal or state health care program. The contractor shall obtain federal and State lists of suspended/debarred providers from the appropriate agencies.

6.		Institutional and Agency Provider Credentialing. The contractor shall have written policies and procedures for the initial quality assessment of institutional and agency providers with which it intends to contract. At a minimum, such procedures shall include confirmation that a provider has been reviewed and approved by a recognized accrediting body and is in good standing with State and federal regulatory bodies. If a provider has not been approved by a recognized accrediting body, the contractor shall develop and implement standards of participation. For home health agency and hospice agency providers, the contractor shall verify that the providers are licensed and meet Medicare certification participation requirements.

7.		Delegation/subcontracting of QAPI activities shall not relieve the contractor of its obligation to perform all QAPI functions. The contractor shall submit a written request and a plan for active oversight of the QAPI


Amended as of July 1, *2004*		IV-61

its aggregate, enrolled commercial and Medicare population in the State or region (if these data are collected and 1..ported to DHSS, a copy of the report should be submitted also to DMAHS) the following clinical indicator measures:


HEDIS		Report Period
Reporting Set Measures		by Contract Year
Childhood Immunization Status		annually
Adolescent Immunization Status		annually
Well-Child Visits in first 15 months of life		annually
Well-Child Visits in the 3rd, 4th, 5th and 6th year of life		annually
Adolescent Well-Care Visits		annually
Prenatal and Postpartum Care		annually
Breast Cancer Screening		annually
Cervical Cancer Screening		annually
Medical Assistance with Smoking Cessation		annually

Childhood & Adolescent Immunization HEDIS data for NJ FamilyCare enrollees up to the age of 19 years must be reported separately.


Q.		Quality Improvement Projects (QIPs). The contractor shall participate in QIPs defined annually by the State with input from the contractor. The State will, with input from the contractor and possibly other MCEs, define measurable improvement goals and QIP-specific measures which shall serve as the focus for each QIP. The contractor shall be responsible for designing and implementing strategies for achieving each QIP’s objectives. At the beginning of each contract year the contractor shall present a plan for designing and implementing such strategies, which shall receive approval from the State prior to implementation. The contractor shall then submit semiannual progress reports summarizing performance relative to each of the objectives of each contract year.

		The QIPs shall be completed annually and shall include the areas identified below. The external review organization (ERO) under contract with DHS shall prepare a final report for year one that will contain data, using State-approved sampling and measurement methodologies, for each of the measures below. Changes in required QIPs shall be defined by the DHS and incorporated into the contract by amendment.

		For each measure the DHS will identify a baseline and a compliance standard. Baseline data, target standards, and compliance standards shall be established or updated by the State.

		If DHS determines that the contractor is not in compliance with the requirements of the annual QIP objectives, either based on the contractor’s progress report or


Amended as *July 1, 2004*	IV-64

the ERO’s report, the contractor shall prepare and submit a corrective action plan for DHS approval.

Well-Child Care (EPSDT)

The QIP for Well-Child Care shall focus upon achieving compliance with the EPSDT periodicity schedule (See Article 4.2.6) in the following priority areas:


				Minimum
	Performance			Compliance			Discretionary
Clinical Area	Standard			Standard			Sanction
Age-appropriate Comprehensive exams (CMS-specified age groups)
		80	%		60	%		60 - 70	%
< 1 year old		80	%		60	%		60 - 70	%
1 - 2 years old		80	%		65	%		60 - 70	%
3 - 5 years old (at least 1 visit)		80	%		60	%		60 - 70	%
6 - 9 years old (at least 1 visit)		80	%		60	%		60 - 70	%
10 - 14 years old (at least 1 visit)		80	%		60	%		60 - 70	%
15 - 18 years old (at least 1 visit)		80	%		60	%		60 - 70	%
19 - 20 years old (at least 1 visit) Immunizations 2 year olds (HEDIS combined rate)		80	%		60	%		60 - 70	%
Annual Dental Visit - 3 - 12 yr olds		80	%		60	%		60 - 70	%
13 - 21 yr olds		80	%		60	%		60 - 70	%
Lead screen (under age 3)		80	%		60	%		60 - 70	%

Prenatal Care and Pregnancy Outcome

The QIP for Prenatal Care and Pregnancy Outcome shall focus upon achieving improvements in compliance with prenatal care protocols and in obtaining positive pregnancy outcomes


				Compliance
Clinical Area	Target Standard			Standard
Initial visit in first trimester or within 6 wks of enrollment		85	%		75	%
Adequate frequency of prenatal care		85	%		75	%
Low birth weight babies

Amended as of July 1, 2004 IV-65

The contractor shall provide the DMAHS a full network, monthly, on computer diskette in accordance with the specifications provided in Section A.4:1 of the Appendices. The network file shall include an indicator for new additions and deletions and shall include:

1.		Any and all changes in participating primary care providers, including, for example, additions, deletions, or closed panels, must be reported monthly to DMAHS.

2.		Any and all changes in participating physician specialists, health care providers, CNPs/CNSs, ancillary providers, and other subcontractors must be reported to DMAHS on a monthly basis.

B.		DMAHS review of provider network deficiencies will be conducted on a quarterly basis or more frequently as may be required.

C.		The contractor shall provide the HBC with a full network on a monthly basis in accordance with the specifications found in Section A.4.1 of the Appendices. The electronic files shall be sent to DMAHS, and a copy to the DMAHS’ designee for distribution.

4.8.4 PROVIDER DIRECTORY REQUIREMENTS

The contractor shall prepare a provider directory which shall be presented in the following manner. Fifty (50) copies of the provider directory, and any updates, shall be provided to the HBC, and ten (10) copies shall be provided to DMAHS at least every six months or within 30 days of an update.

Primary care providers who will serve enrollees listed by

•		County, by city, by specialty

•		Provider name and degree; specialty board eligibility/certification status; office address(es) (actual street address); telephone number; fax number if available; office hours at each location; indicate if a provider serves enrollees with disabilities and how to receive additional information such as type of disability; hospital affiliations; transportation availability; special appointment instructions if any; languages spoken; disability access; and any other pertinent information that would assist the enrollee in choosing a PCP.

Contracted specialists and ancillary services providers who will serve enrollees

•

Listed by county, by city, by physician specialty, by non-physician specialty, and by adult specialist and by pediatric specialist for those specialties indicated in Section 4.8.8.C.


Amended as of *July 1, 2004*		IV-98

Subcontractors

Provide, at a minimum, a list of all other health care providers by county, by service specialty, and by name. The contractor shall demonstrate its ability to provide all of the services included under this contract.

4.8.5 CREDENTIALING/RECREDENTIALING REQUIREMENTS/ISSUES

The contractor shall develop and enforce credentialing and recredentialing criteria for all provider types which should follow the CMS’ credentialing criteria, as delineated in the NJ modified QARI/QISMC standards found in Article 4.6.1 and Section B.4.14 of the Appendices, and comply with N.J.A.C. 8:38C-1 et seq.

4.8.6 LABORATORY SERVICE PROVIDERS

The contractor shall ensure that all laboratory testing sites providing services under this contract, including those provided by primary care physicians, specialists, other health care practitioners, hospital labs, and independent laboratories have either a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number, and comply with New Jersey DHSS disease reporting requirements. Those laboratory service providers with a certificate of waiver shall provide only those tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests.

The contractor shall provide to DMAHS, on request, copies of certificates that its own laboratory or any other laboratory it conducts business with, has a CLIA certificate for the services it is performing as fulfillment of requirements in 42 C.F.R. § 493.1809.

If the contractor has its own laboratory, the contractor shall submit at the time of initial contracting a written list of all diagnostic tests performed in its own laboratory if applicable and those tests which are referred to other laboratories annually and within fifteen (15) working days of any changes.

The contractor shall inform DMAHS and provide a geographic access analysis in accordance with the specifications found in the Appendix, Section A.4.3 if it contracts with a new laboratory subcontractor 45 days prior to the effective date of the subcontractor’s contract and shall notify DMAHS of a termination of a laboratory subcontractor 90 days prior to the effective date of the subcontractor’s termination. The contractor shall provide a copy of a new subcontractor’s certificate of waiver or certificate of registration within ten (10) days of operation.


Amended as of *July 1, 2004*				IV-99

- Other:

Genetic Testing and Counseling Centers b. Hemophilia Treatment Centers

Other Specialty Centers/Providers [Institutional File]

Contractor should establish relationships with the following providers/centers on a consultant or referral basis.

1.Spina Bifida Centers/providers
2. Adult Scoliosis
3. Autism and Attention Deficits
4. Spinal Cord Injury
5. Lead Poisoning Treatment Centers
6. Child Abuse Regional Diagnostic Centers
7. County Case Management Units
8. Psychologists (for clients of DDD)
9. Physical Medicine (for inpatient rehabilitation services)
10. Maternal & Fetal Medicine
11. Medical Toxicology


Amended as of *July 1, 2004*		IV-107

Provider Network Access Standards and Ratios


Specialty	A — Miles per 2	B — Miles per 1	Min. No. Per County Capacity Limit
	Urban Non-Urban	Urban Non-urban	Except Where Noted Per Provider


Amended as of *July 1, 2004*				IV-108


PCP Children GP		6	15	2	10		2	1:		1.500
	FP	6	15	2	10		2	1:		1.500
	Peds	6	15	2	10		2	1:		1.500
Adults	GP	6	15	2	10		2	l:		1.500
	FP	6	15	2	10		2	1:		1.500
	1M	6	15	2	10		2	1:		1.500
CNPICNS		6	15	2	10		2	1:		1.000
CNM		12	25	6	15		2	1:		1.500
Dentist, Primary Care		6	15	2	10		2	1:		1.500
Allergy		15	25	10	15		2	1:		75.000
Anesthesiology		15	25	10	15		2	1:		17.250
Cardiology		15	25	10	15		2	1:		100,000
CardiovascularsurgeryDisease		15	25	10	15		2	1:		166.000
Chiropractor		15	25	10	15		1	1:		20.000
Colorectal surgery		15	25	10	15		2	1:		30.000
Dermatology		15	25	10	15		2	1:		75.000
Emergency Medicine		15	25	10	15		2	1:		19.000
Endocrinology		15	25	10	15		2	1:		143,000
Endodontia		15	25	10	15	1 (where available)		1:		30.000
Gastroenterology		15	25	10	15		2	1:		100.000
General Surgery		15	25	10	15		2	1:		30.000
Geriatric Medicine		15	25	10	15		1	1:		10.000
Hematology		15	25	10	15		2	1:		100.000
Infectious Disease		15	25	10	15		2	1:		125.000
Neonatology		15	25	10	15		2	1:		100,000
Nephrology		15	25	10	15		2	I:		125,000
Neurology		15	25	10	15		2	1:		100.000
Neurological Surgery		15	25	10	15		2	1:		166,000
Obstetrics/Gynecology		15	25	10	15		2	1:		7.100
Oncology		15	25	10	15		2	1:		100,000.
Ophthalmology		15	25	10	15		2	1:		60.00

Optometrist		15	25	10	15		2	1:		8.000
Oral Surgery		15	25	10	15		2.	1:		20,000
Orthodontia		15	25	10	15		1	1:		20.000
Orthopedic Surgery		15	25	10	15		2	l:		28.000
Otolaryngology (ENT)		15	25	10	15		2	1:		53.000
Periodontia		15	25	10	15	1 (where available)		1:		30,000
Physical Medicine		15	25	10	15	(where applicable)		1:		75,000
Plastic Surgery		15	25	10	15		2	1:		250.000
Podiatrist		15	25	10	15		2	1:		20,000
Prosthodontia		15	25	10	15	1 (where available)		I:		30.000
Psychiatrist		15	25	10	15		2	1:		30,000
Psychologist		15.	25	10	15		—	I:		30.000
Pulmonary Disease		15	25	10	15		2	1:		100,000
Radiation Oncology		15	25	10	15		2	1:		100,000
Radiology		15	25	10	15		2	1:		25,000
Rheumatology		15	25	10	15		2	1:		150,000
Audiology		12	25	6	15		2	I:		100,000
Thoracic Surgery		15	25	10	15		2	1:		150,000
Urology		15	25	10	15		2	1:		60.000
Fed Qua! Health Ctr							1		I/county if
									available
Hospital		20	35	10	15		2		2 per county
									(where applicable)
Pharmacies		10	15	5	12			1:		1,000
Laboratory		N/A	N/A	7	12
DME/Med Supplies		12	25	6	15		1	1:		50.000
Hearing Aid		12	25	6	15		1	1:		50,000
Optical Appliance		12	25	6	15		2	1:		50,000

of medicine in the following counties: Cape May, Cumberland, Gloucester, Hunterdon, Salem, Sussex.

b.		Cardiology, pediatric — In-county alternative: adult cardiovascular disease; out of county pediatric referral applies to: Cumberland. Hunterdon, Somerset, Sussex, Warren.

c.		Endocrinology, adult — In-county alternative: none, refer out of county for Cape May, Gloucester, Sussex, Warren.

d.		Endocrinology, pediatric — In-county alternative: adult endocrinologist; out of county referral for pediatric endocrinology applies to: Atlantic, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem, Somerset, Sussex, Warren.

e.		Gastroenterology, pediatric — In-county alternative: adult gastroenterologists; out of county referral for pediatric gastroenterology applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Ocean, Salem, Sussex, Warren.

f.		General Surgery, pediatric — In-county alternative: adult general surgery; out of county referral for pediatrics applies to: Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Morris, Salem, Somerset, Sussex, Warren.

g.		Geriatrics — In-county alternative: Family Practitioner or Internist; applies to: Cape May, Cumberland, Gloucester, Mercer, Morris, Salem, Somerset, Sussex, Warren.

h.		Hematology/Oncology, pediatric - In-county alternative: none; out of county pediatrics referral applies to: Burlington, Cape May, Cumberland, Gloucester, Salem, Somerset, Warren.

i.		Infectious Disease, pediatric — In-county alternative: Adult infectious disease; out of county pediatric referral applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Ocean, Salem, Somerset, Sussex, Warren.

j.		Nephrology, adult — In-county alternative: none; refer out of county for Cape May, Sussex, Warren.

k.		Nephrology, pediatric — In-county alternative: adult nephrologist; out of county pediatric referral applies to: Atlantic, Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Mercer, Monmouth, Ocean, Salem, Somerset, Sussex, Warren.


Amended as of		*July 1, 2004*		IV-1’14

1.		Neonatal/Perinatal medicine — Alternative: none, refer out of county.

m.		Neurology, pediatric — In-county alternative: adult neurology; out of county pediatric referral applies to: Burlington, Cape May, Cumberland, Gloucester, Hunterdon, Sussex, Warren.

n.		Neurological Surgery — In-county alternative: none; out of county referral applies to: Cape May, Cumberland, Gloucester, Hudson, Salem, Warren.

o.		Plastic Surgery — In-county alternative: none; out of county referral applies to: Cape May, Salem, Sussex, Warren.

		Pulmonary Disease, pediatric — In-county alternative: Adult pulmonary disease; out of county pediatric referral applies to: Burlington, Cape May, Cumberland, Gloucester, Ocean, Warren.

q.		Radiation Oncology — In-county alternative: none; out of county referral applies to: Cape May, Salem, Sussex, Warren.

r.		Rheumatology, pediatric — In-county alternative: adult rheumatology; out of county pediatric referral applies to: all counties except Bergen and Essex.

s.		Thoracic surgery — In-county alternative: none, refer out of county for Cape May, Hunterdon, Morris, Sussex, Warren.

Hospitals. For the following counties, the contractor may limit its hospital provider network to one (1) hospital, which must be a full service, acute care hospital including at least licensed medical-surgical, pediatric, obstetrical, and critical care services: Cape May, Cumberland, Gloucester, Hunterdon, Salem, Somerset, Sussex, and Warren.

4.8.9 DENTAL PROVIDER NETWORK REQUIREMENTS

A. The contractor shall establish and maintain a dental provider network, including primary and specialty care dentists, which is adequate to provide the full scope of benefits. The contractor shall include general dentists and pediatric dentists as primary care dentists (PCDs). A system whereby the PCD initiates and coordinates any consultations or referrals for specialty care deemed necessary for the treatment and care of the enrollee is preferred.

B. The dental provider network shall include sufficient providers able to meet the dental treatment requirements of patients with developmental disabilities. (See Article 4.5.2E for details.)


Amended as of		*July 1, 2004*		IV-115

The contractor shall submit to DMAHS for review and approval prior to implementation any changes required to comply with HIPAA.

The contractor shall submit at least annually or 30 days prior to any changes, lists of names, addresses, ownership/control information of participating providers and subcontractors, and individuals or entities, which shall be incorporated in this contract.

1.		The contractor shall obtain prior DMAHS review and written approval of any proposed plan for merger, reorganization or change in ownership of the contractor and approval by the appropriate State regulatory agencies.

2.		The contractor shall comply with Article 4.9.1 G. l to ensure uninterrupted and undiminished services to enrollees, to evaluate the ability of the modified entity to support the provider network, and to ensure that any such change has no adverse effects on DMAHS’ managed care program and shall comply with the Departments of Banking and Insurance, and Health and Senior Services statutes and regulations.

H.		The contractor shall demonstrate its ability to provide all of the services included under this contract through the approved network composition and accessibility.

I.		The contractor shall not oblige providers to violate their state licensure regulations.

J.		The contractor shall provide its providers and subcontractors with a schedule of fees and relevant policies and procedures at least 30 days prior to implementation.

K.		The contractor shall arrange for the distribution of informational materials to all its providers and subcontractors providing services to enrollees, outlining the nature, scope, and requirements of this contract.

L.		Subcontractor Delegation. The contractor shall monitor any functions and responsibilities it delegates to any subcontractor. The contractor shall be accountable for any and all functions and responsibilities it delegates to a subcontractor. The contractor shall obtain the prior approval of DMAHS for any such delegation and shall meet the requirements of 42 C.F.R. § 438.

4.9.2 CONTRACT SUBMISSION

The contractor shall submit to DMAHS one complete, fully executed contract for each type of provider, i.e., primary care physician, physician specialist, non-physician practitioner, hospital and other health care providers/services covered under the benefits package, subcontract and the form contract of any subcontractor’s provider contracts. The use of a signature stamp is not permitted and shall not be considered a fully executed contract. Contracts shall be submitted with all attachments, appendices, referenced


Amended as of *July* 1, *2004*		IV-118

documents, and with rate schedules, etc., upon request. A copy of the appropriate completed contract checklist fog DHS, DHSS, and DOBI shall be attached to each contract form. Regulatory approval and approval by the Department is required for each provider contract form and subcontract prior to use. Submission of all other contracts shall follow the format and procedures described below:

A.		Copies of the complete fully executed contract with every FQHC. Certification of the continued in force contracts previously submitted will be permitted.

B.		Hospital contracts shall list each specific service to be covered including but not limited to:

1. Inpatient services;
2. Anesthesia and whether professional services of anesthesiologists and nurse anesthetists are included;
3. Emergency room services

a. Triage fee — whether facility and professional fees are included;
b. Medical screening fee — whether facility and professional fees are included;
c. Specific treatment rates for:


		(1) Emergent services (2) Urgent services (3) Non-urgent services (4) Other

Other — must specify

4. Neonatology — facility and professional fees
5. Radiology

a. Diagnostic
b. Therapeutic
c. Facility fee
d. Professional services

6. Laboratory — facility and professional services
7. Outpatient/clinic services must be specific and address

a. School-based health service programs
b. Audiology therapy and therapists

8. AIDS Centers
9. Any other specialized service or center of excellence
10. Hospice services if the hospital has an approved hospice agency that is Medicare certified.
11. Home Health agency services if hospital has an approved home health agency license from the Department of Health and Senior Services that meets licensing and Medicare certification participation requirements.
12. Any other service.

FQHC contracts:


Amended as of *July 1, 2004*		IV-119

The contractor shall accept enrollment of Medicaid/NJ FamilyCare eligible persons within the defined enrollment areas in the order in which they apply or are auto-assigned to the contractor (on a random basis with equal distribution among all participating contractors) without restrictions, within contract limits. Enrollment shall be open at all times except when the contract limits have been met. A contractor shall not deny enrollment of a person with an SSI disability or New Jersey Care Disabled category who resides outside of the enrollment area. However, such enrollee with a disability shall be required to utilize the contractor’s established provider network. The contractor shall accept enrollees for enrollment throughout the duration of this contract.

D.		Enrollment timeframe. As of the effective date of enrollment, and until the enrollee is disenrolled from the contractor’s plan, the contractor shall be responsible for the provision and cost of all care and services covered by the benefits package listed in Article 4.1. Enrollees who become eligible to receive services between the 1st through the end of the month shall be eligible for Managed Care services in that month. When an enrollee is shown on the enrollment roster as covered by a contractor’s plan, the contractor shall be responsible for providing services to that person from the first day of coverage shown to the last day of the calendar month of the effective date-of disenrollment. DMAHS will pay the contractor a capitation rate during this period of time.

E.		Hospitalizations. For-any eligible person who applies for participation in the contractor’s plan, but who is hospitalized prior to the time coverage under the plan becomes effective, such coverage shall not commence until the date after such person is discharged from the hospital and DMAHS shall be liable for payment for the hospitalization, including any charges for readmission within forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s disenrollment or termination becomes effective during a hospitalization, the contractor shall be liable for hospitalization until the date such person is discharged from the hospital, including any charges for readmission within forty-eight (48) hours of discharge for the same diagnosis. The contractor shall notify DMAHS within 180 days of initial hospital admission.

F.		Unless otherwise required by statute or regulation, the contractor shall not condition any Medicaid/NJ FamilyCare eligible person’s enrollment upon the performance of any act or suggest in any way that failure to enroll may result in a loss of Medicaid/NJ FamilyCare benefits.

G.		There shall be no retroactive enrollment in Managed Care. Services for those beneficiaries during any retroactive period will remain fee-for-service, except for individuals eligible under NJ FamilyCare Plans B, C, and H who are not eligible until enrolled in an MCE. Coverage shall continue indefinitely unless this contract expires or is terminated, or the enrollee is no longer eligible or is deleted from the contractor’s list of eligible enrollees.


Amended as of *July 1, 2004*	*V -* 7

Complaints and Grievances/Appeals

1.		Procedures for resolving complaints, as approved by the DMAHS;

2.		A description of the grievance/appeal procedures to be used to resolve disputes between a contractor and an enrollee, including: the name, title, or department, address, and telephone number of the person(s) responsible for assisting enrollees in grievance/appeal resolutions; the time frames and circumstances for expedited and standard grievances; the right to appeal a grievance determination and the procedures for filing such an appeal; the time frames and circumstances for expedited and standard appeals; the right to designate a representative; a notice that, all disputes involving clinical decisions will be made by qualified clinical personnel; and that all notices of determination will include information about the basis of the decision and further appeal rights, if any;

3.		The contractor shall notify all enrollees in their primary language of their rights to file grievances and appeal grievance decisions by the contractor;

S.		An explanation that Medicaid/NJ FamilyCare Plan A enrollees, and Plans D and H enrollees with a program status code of 380, have the right to a Medicaid Fair Hearing with DMAHS and the appeal process through the DHSS for Medicaid and NJ FamilyCare enrollees, including instructions on the procedures involved in making such a request;

T.		Title, addresses, phone numbers and a brief description of the contractor’s plan for contractor management/service personnel;

U.		The interpretive, linguistic, and cultural services available through the contractor’s plan;

V.		An explanation of the terms of enrollment in the contractor’s plan, continued enrollment, automatic re-enrollment, disenrollment procedures, time frames for each procedure, default procedures, enrollee’s rights and responsibilities and causes for which an enrollee shall lose entitlement to receive services under this contract, and what should be done if this occurs;

W.		A statement strongly encouraging the enrollee to obtain a baseline physical and dental examination, and to attend scheduled orientation sessions and other educational and outreach activities;

X.		A description of the EPSDT program, and language encouraging enrollees to make regular use of preventive medical and dental services;

Y.		Provision of information to enrollees or, where applicable, an authorized person, to assist them in the selection of a PCP;

Amended as of July 1, 2004

V-15

		The contractor’s system and procedure shall be available to both Medicaid beneficiaries and NJ FamilyCare beneficiaries. All enrollees have available the complaint and grievance/appeal process under the contractor’s plan, the Department of Health and Senior Services and, for Medicaid and certain NJ FamilyCare beneficiaries (i.e., Plan A enrollees and beneficiaries with a PSC of 380 under Plan D), the Medicaid Fair Hearing process. Individuals eligible solely through NJ FamilyCare Plans B, C, D, and H (except for Plan D and H individuals with a program status code of 380),do not have the right to a Medicaid Fair Hearing.

B.		Complaints. The contractor shall have procedures for receiving, responding to, and documenting resolution of enrollee complaints that are received orally and are of a less serious or formal nature. Complaints that are resolved to the enrollee’s satisfaction within three (3) business days of receipt do not require a formal written response or notification. The contractor shall call back an enrollee within twenty-four hours of the initial contact if the contractor is unavailable for any reason or the matter cannot be readily resolved during the initial contact. Any complaint that is not resolved within three business days shall be treated as a grievance/appeal, in accordance with requirements defined in Article 5.15.3.

C.		HBC Coordination. The contractor shall coordinate its efforts with the health benefits coordinator including referring the enrollee to the HBC for assistance as needed in the management of the complaint/grievance/appeal procedures.

D.		DMAHS Intervention. DMAHS shall have the right to intercede on an enrollee’s behalf at any time during the contractor’s complaint/grievance/appeal process whenever there is an indication from the enrollee, or, where applicable, authorized person, or the HBC that a serious quality of care issue is not being addressed timely or appropriately. Additionally, the enrollee may be accompanied by a representative of the enrollee’s choice to any proceedings and grievances/appeals.

E.		Legal Rights. Nothing in this Article shall be construed as removing any legal rights of enrollees under State or federal law, including the right to file judicial actions to enforce rights.

5.15.2 NOTIFICATION TO ENROLLEES OF GRIEVANCE/APPEAL PROCEDURE

The contractor shall provide all enrollees or, where applicable, an authorized person, upon enrollment in the contractor’s plan, and annually thereafter, pursuant to this contract, with. a concise statement of the contractor’s grievance/appeal procedure and the enrollees’ rights to a hearing by the Independent Utilization Review Organization (IURO) per NJAC 8:38-8.7 as well as their right to pursue the Medicaid Fair Hearing process described in-N.J.A.C. 10:49-10.1 et seq. The information shall be provided through an annual mailing, a member handbook, or any other method approved by DMAHS. The contractor shall prepare the

Amended as of July 1, 2004

V-36

		provider performance. Practice guidelines may be included in a separate document.

9.		The contractor’s policies and procedures

10.		PCP responsibilities

11.		Other provider/subcontractors’ responsibilities

12.		Prior authorization and referral procedures

13.		Description of the mechanism by which a provider can appeal a contractor’s service decision through the DHSS’ Independent Utilization Review Organization process

14.		Protocol for encounter data element reporting/records

15.		Procedures for screening and referrals for the MH/SA services

16.		Medical records standards

17.		Payment policies

18.		Enrollee rights and responsibilities

B.		Bulletins. The contractor shall develop and disseminate bulletins as needed to incorporate any and all changes to the Provider Manual. All bulletins shall be mailed to the State at least three (3) calendar days prior to publication or mailing to the providers or as soon as feasible. The Department shall have the right to issue and/or modify the bulletins at any time. If the DHS determines that there are factual errors or misleading information, the contractor shall be required to issue corrected information in the manner determined by the DHS.

		Timeframes. Within twenty (20) calendar days after the contractor places a newly enrolled provider in an active status, the contractor shall furnish the provider with a current Provider Manual, all related bulletins and the contractor’s methodology for supplying encounter data.

		The contractor shall provide a current Provider Manual to the Department annually. All updates of the manual shall also be provided to the Department within 30 days of the revision.

E.		The Provider Manual and all policies and procedures shall be reviewed at least annually to ensure that the contractor’s current practices and contract requirements are reflected in the written policies and procedures.

Amended as of July 1, 2004

VI-2

measured by procedure codes specified in Appendix Section B.7.5 using encounter data. If the contractor has not achieved the eighty (80) percent participation rate by the end of the twelve-month period, it shall submit a corrective action plan to DMAHS within thirty (30) days of notification by DMAHS of its actual participation rate. DMAHS shall have the right to conduct a follow-up onsite review and/or impose financial damages for non-compliance.

Mandatory Sanction. Failure of the contractor to achieve the minimum screening rate shall require the following refund of capitation paid:

i.		Achievement of a 50 percent to less than 60 percent EPSDT screening, dental visit and immunization rate (the lowest measured rate of each of the components of EPSDT screening, i.e., periodic exam, immunization rate, and dental screening rate, shall be considered to be the rate for EPSDT participation and the basis for the sanction): refund of $1 per enrollee for all enrollees under age 21 not screened.

ii.		Achievement of a 40 percent to less than 50 percent EPSDT screening, dental visit, and immunization rate: refund of $2 per enrollee for all enrollees under age 21 not screened.

iii.		Achievement of a 30 percent to less than 40 percent EPSDT screening, dental visit and immunization rate: refund of $3 per enrollee for all enrollees under age 21 not screened.

iv.		Achievement of less than 30 percent: refund of $4 per enrollee for all enrollees under age 21 not screened.

Discretionary Sanction. The DMAHS shall have the right to impose a financial or administrative sanction if the contractor’s performance screening rate is between sixty (60) — seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve compliance.

2.		Failure to achieve and maintain the required screening rate shall result in the Local Health Departments being permitted to screen the contractor’s pediatric members. The cost of these screenings shall be paid by the DMAHS to the LHD, and the screening cost shall be deducted from the contractor’s capitation rate in addition to the damages imposed as a result of failure to achieve EPSDT performance standards.

3.		Mandatory sanctions may be offset when the contractor demonstrates improved compliance. The Division, in its sole discretion, may reduce the sanction amount by $1 for each twelve (12) point improvement over prior reporting period

Amended as of July 1, 2004

VII-29

performance rate. Offsets shall not reduce the financial sanction amount to below $1 per enrollee not screened.

Blood Lead Screening

The contractor shall ensure that it has achieved an eighty (80) percent blood lead screening rate of its enrollees under three years of age during a twelve (12)-month contract period. Blood lead screening is described in Article 4 and shall be measured using encounter data and the DHSS database. If the contractor has not achieved the eighty (80) percent blood lead screening rate by the end of the twelve (12)-month period, it shall submit a corrective action plan to DMAHS within thirty (30) days of notification by DMAHS of its actual blood lead level screening rate. DMAHS shall have the right to conduct a follow-up onsite review and/or impose financial damages for non-compliance.

Mandatory sanction. Failure of the contractor to achieve sixty (60) percent screening rate shall require the following refund of capitation paid:

i.		Achievement of a 50 percent to less than 60 percent lead screening rate: refund of $2 per enrollee for all enrollees under age 3 not screened.

ii.		Achievement of a 40 percent to less than 50 percent lead screening rate: refund of $3 per enrollee for all enrollees under age 3 not screened.

iii.		Achievement of a 30 percent to less than 40 percent lead screening rate: refund of $4 per enrollee for all enrollees under age 3 not screened.

iv.		Achievement of less than 30 percent lead screening rate: refund of $5 per enrollee for all enrollees under age 3 not screened.

Discretionary sanction. The DMAHS shall have the right to impose a financial or administrative sanction if the contractor’s performance screening rate is between sixty (60) - seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve compliance.

The contractor must demonstrate continuous quality improvement in achieving the performance standards for EPSDT and lead screenings as stated in Article 4. The Division shall, in its sole discretion, determine the appropriateness of contractor proposed corrective action and the imposition of any other financial or administrative sanctions in addition to those set out above.

Amended as of July 1, 2004

VII-30

7.20 CONTRACTOR CERTIFICATIONS

7.20.1 GENERAL PROVISIONS

A.		With respect to any report, invoice, record, papers, documents, books of account, or other contract-required data submitted to the Department in support of an invoice or documents submitted to meet contract requirements, including, but not limited to, proofs of insurance and bonding, Lobbying Certifications and Disclosures, Conflict of Interest Disclosure Statements and/or Conflict of Interest Avoidance Plans, pursuant to the requirements of this contract, the Contractor’s Representative or his/her designee shall certify that the report, invoice, record, papers, documents, books of account or other contract required data is current, accurate, complete and in full compliance with legal and contractual requirements to the best of that individual’s knowledge and belief.

B.		The contractor shall attest, based on best knowledge, information, and belief, as to the accuracy, completeness and truthfulness of enrollment information, encounter data, provider networks, marketing materials, provider and beneficiary notifications and educational materials and any other information/documents specified in this contract.

7.20.2 CERTIFICATION SUBMISSIONS

A.		Where in this contract there is a requirement that the contractor “certify” or submit a “certification,” such certification shall be in the form of an affidavit or declaration under penalty of perjury dated and signed by the Contractor’s Representative or his/her designee.

B.		The data must be certified by one of the following:

1.		Chief Executive Officer (CEO)

2.		Chief Financial Office (CFO)

3.		An individual who has delegated authority to sign for, and who reports directly to the contractor’s CEO or CFO.

The contractor shall submit the certification concurrently with the certified data. (See Appendix, Section A.7.1 for certification forms.)

7.20.3 ENVIRONMENTAL COMPLIANCE

The contractor shall comply with all applicable environmental laws, rules, directives, standards, orders, or requirements, including but not limited to, Section 306 of the Clean Air Act (42 U.S.C. § 1857(h)), Section 508 of the Clean Water Act (33 U.S.C. § 1368), Executive Order 11738, and the Environmental Protection Agency (EPA) regulations (40 C.F.R., Part 15) that prohibit the use of the facilities included on the EPA List of Violating Facilities.

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		shall include, but not be limited to, utilization information on enrollee encounters with PCPs, children who have not received an EPSDT examination or a blood lead screening, specialty claims, prescriptions, inpatient stays, and emergency room use.

E.		The contractor shall collect and analyze data to implement effective quality assurance, utilization review, and peer review programs in which physicians and other health care practitioners participate. The contractor shall review and assess data using statistically valid sampling techniques including, but not limited to, the following:

		Primary care practitioner audits; specialty audits; inpatient mortality audits; quality of care and provider performance assessments; quality assurance referrals; credentialing and recredentialing; verification of encounter reporting rates; quality assurance committee and subcommittee meeting agendas and minutes; enrollee complaints, grievances, and follow-up actions; providers identified for trending and sanctioning, including providers with low blood lead screening rates; special quality assurance studies or projects; prospective, concurrent, and retrospective utilization reviews of inpatient hospital stays; and denials of off-formulary drug requests.

F.		The contractor shall prepare and submit to DMAHS quarterly reports to be reported by hard copy and diskette in a format and software application system determined by DMAHS, containing summary information on the contractor’s operations for each quarter of the program (See Section A.7 of the Appendices, Tables 1 through 21. Exception - Tables 3A and 3B shall be submitted monthly by the fifteenth (15`h) of every month.). These reports shall be received by DMAHS no later than forty-five (45) calendar days after the end of the quarter. After a grace period of five (5) calendar days, for each calendar day after a due date that DMAHS has not yet received at a prescribed location a report that fulfills the requirements of any one item, assessment for damages equal to one half month’s negotiated blended capitation rate that would normally be owed by DMAHS to the contractor for one recipient shall be applied. The damages shall be applied as an offset to subsequent payments to the contractor.

		The contractor shall be responsible for continued reporting beyond the term of the contract because of lag time in submitting source documents by providers.

G.		The contractor may submit encounter reports daily but must submit encounter reports at least quarterly. However, encounter reports will be processed by DMAHS’ fiscal agent no, more frequently than monthly. All encounters shall be reported to DMAHS within seventy-five (75) days of the end of the quarter in which they are received by the contractor and within one year plus seventy-five (75) days from the date of service.


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H.		The contractor shall, annually and at the time changes are made report its staffing positions including the names of supervisory personnel (Director level and above and the QM/UR personnel), organizational chart, and any position vacancies in these major areas.

I.		DMAHS shall have the right to create additional reporting requirements at any time as required by applicable federal or State laws and regulations, as they exist or may hereafter be amended and incorporated into this contract.

J.		Reports that shall be submitted on an annual or semi-annual basis, as specified in this contract, shall be due within sixty (60) days of the close of the reporting period, unless specified otherwise.

K.		MCSA Paid Claims Reconciliation. On a quarterly basis, the contractor shall provide paid claims data, via an encounter data file or separate paid claims file, that meet the HIPAA format requirements for audit and reconciliation purposes. The contractor shall provide documentation that demonstrates a 100% reconciliation of the amounts paid to the amounts billed to the DMAHS. The paid claims data shall include at a minimum, claim type, provider type, category of service, diagnosis code (5 digits), procedure/revenue code, Internal Control Number or Patient Account Number under HIPAA, provider. ID, dates of services, that will allow the DMAHS to price claims in comparison to Medicaid fee schedules for evaluation purposes.

L.		Encounter Data Submissions. The contractor shall cooperate with the DMAHS in its review of the status of encounter data submissions to determine needed improvements for accuracy and completeness of encounter data submissions. With the contract period beginning July 2005, the contractor will be subject to additional sanctions if not in full compliance with encounter data submission standards.

7.27 FINANCIAL STATEMENTS

7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)

A.		Annual Audit. The contractor shall submit its audited annual financial statements prepared in accordance with Statutory Accounting Principles (SAP) certified by an independent public accountant no later than June 1 of each year, for the immediately preceding calendar year as well as for any company that. is a financial guarantor for the contractor in accordance with N.J.S.A. 8:38-11.6.

B.		Audit of Rate Cell Grouping Costs

		The contractor shall submit, quarterly, reports found in Appendix, Section A in accordance with the “HMO Financial Guide for Reporting Medicaid/NJ Family Care Rate Cell Grouping Costs” (Appendix, Section B7.3). These reports shall be

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8.5.3 NEWBORN INFANTS

The contractor shall be reimbursed for newborns from the date of birth through the first 60 days after the birth through the period ending at the end of the month in which the 60th day falls by a supplemental payment as part of the supplemental maternity payment. Thereafter, capitation payments will be made prospectively, i.e., only when the baby’s name and ID number are accreted to the Medicaid eligibility file and formally enrolled in the contractor’s plan.

8.5.4 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME

		Because costs for pregnancy outcomes were not included in the capitation rates, the contractor shall be paid supplemental payments for pregnancy outcomes for all eligibility categories. Payment for pregnancy outcome shall be a single, predetermined lump sum payment. This amount shall supplement the existing capitation rate paid. The Department will make a supplemental payment to contractors following pregnancy outcome. For purposes of this Article, pregnancy outcome shall mean each live birth, still birth or miscarriage occurring at- the thirteenth (13th) or greater week of gestation. This supplemental payment shall reimburse the contractor for its inpatient hospital, antepartum, and postpartum costs incurred in connection with delivery. Costs for care of the baby for the first 60 days after the birth plus through the end of the month in which the 60th day falls are included (See Section 8.5.3). Regional payment shall be made by the State to the contractor based on submission of a financial summary report of hospital and/or birthing center claims paid for final pregnancy outcomes. No other services, inpatient hospital or otherwise, rendered prior to final pregnancy outcome shall qualify or be payable for a maternity supplement.

		The report shall be accompanied by a signed certification form and an electronic file to include:

1.		Paid inpatient hospital/birthing center claims;

2.		Name of mother;

3.		Mother’s Medicaid identification number;

4.		Newborn’s name, if known;

5.		Diagnosis and five-digit ICD-9 codes, including V-codes, specified by DMAHS; and

6.		Place of service.

The contractor shall continue to submit encounter data that will document each paid claim reported on the financial summary report. The DMAHS will conduct a reconciliation of these paid claims utilizing encounter data.

8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS

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K.		Hospitalizations. For any eligible person who applies for participation in the contractor’s plan, but who is hospitalized prior to the time coverage under the plan becomes effective, such coverage shall not commence until the date after such person is discharged from the hospital and DMAHS shall be liable for payment for the hospitalization, including any charges for readmission within forty-eight (48) hours of discharge for the same diagnosis. If an enrollee’s disenrollment or termination becomes effective during a hospitalization, the contractor shall be liable for hospitalization until the date such person is discharged from the hospital, including any charges for readmission within forty-eight (48) hours of discharge for the same diagnosis. The contractor must notify DMAHS of these occurrences to facilitate payment to appropriate providers.

L.		Continuation of Benefits. The contractor shall continue benefits for all enrollees for the duration of the contract period for which capitation payments have been made, including enrollees in an inpatient facility until discharge. The contractor shall notify DMAHS of these occurrences.

M.		Drug Carve-Out Report. The DMAHS will provide the contractor with a monthly electronic file of paid drug claims data for non-dually eligible, ABD enrollees.

N.		MCSA Administrative Fee. The Contractor shall receive a monthly administrative fee, PMPM, for its MCSA enrollees, by the fifteenth (15th) day of any month during which health care services will be available to an enrollee.

O.		Reimbursement for MCSA Enrollee Paid Claims. The DMAHS shall reimburse the contractor for all claims paid on behalf of MCSA enrollees. The contractor shall submit to DMAHS a financial summary report of claims paid on behalf of MCSA enrollees on a weekly basis. The report shall be summarized by category of service corresponding to the MCSA benefits and payment dates, accompanied by an electronic file of all individual claim numbers for which the State is being billed.

P.		MCSA Claims Payment Audits. The contractor shall monitor and audit claims payments to providers to identify payment errors, including duplicate payments, overpayments, underpayments, and excessive payments. For such payment errors (excluding underpayments), the contractor shall refund DMAHS the overpaid amounts. The contractor shall report the dollar amount of claims with payment errors on a monthly basis, which is subject to verification by the State. The contractor is responsible for collecting funds due to the State from providers, either through cash payments or through offsets to payments due the providers.

8.9 CONTRACTOR ADVANCED PAYMENTS AND PIPS TO PROVIDERS

A.		The contractor shall make advance payments to its providers, capitation, FFS, or other financial reimbursement arrangement, based on a provider’s historical billing or utilization of services if the contractor’s claims processing systems

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against the next PIP made to the hospital. An example of how this methodology shall work is as follows:

EXAMPLE:


	PIP			Claims		Reconciliation			Net
	Payment			Adjudicated		Adjustment			Payment		Balance .
Aug 1		300,000	(A)
Aug 1		300,000	(B)									600,000
Aug 1-31					180,000							420,000
Sept 1		300,000	(C)				(120,000	) (A)		180,000		600,000
Sept 1-30					270,000							330,000
Oct 1		300,000	(D)				(30,000	) (B)		270,000		600,000
Oct 1-31					320,000							280,000
Nov 1		300,000	(E)				20,000	(C)		320,000		600,000

8.10 FEDERALLY QUALIFIED HEALTH CENTERS

A.		Standards for Contractor FQHC Rates. The contractor shall not reimburse FQHCs less than the level and amount of payment that the contractor would make for a similar set of services if the services were furnished by a non-FQHC. The contractor may pay the FQHCs on a fee-for-service or capitated basis. The contractor shall make payments for primary care equal to, or greater than, the. average amounts paid to other primary care providers. Non-primary care services may be included if mutually agreeable between the contractor and FQHC. For non-primary care services, payments shall be equal to, or greater than, the average amounts paid to other non-primary care providers for equivalent services.

B.		DMAHS Reimbursement to FQHCs. Under Title XIX, an FQHC shall be paid under a Prospective Payment System (PPS) by DMAHS. At the end of each calendar quarter, the contractor and the FQHC will complete certain reporting requirements specified that will enable DMAHS to determine PPS reimbursement and compare that to what was actually paid by the contractor to the FQHC. DMAHS will reimburse the FQHC the difference (between the PPS rate per encounter and the payments to the FQHC made by the contractor) if the payments by the contractor to the FQHC are less than the PPS rate. In the event of an overpayment, the FQHC shall reimburse DMAHS for payments received from the contractor that are in excess of PPS rate. FQHC providers must meet the contractor’s credentialing and program requirements.

C.		Contractor Participation in Reconciliation Process. The contractor shall participate in the reconciliation processes if there is a dispute between what the