ATTACHMENT J: CRS CONTRACT REQUIREMENTS …

1 ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 1 CYE 13 CRS CONTRACT Effective 08/01/2013 TABLE OF CONTENTS CAPITATION RATES AND CONTRACTOR SPECIFIC INFORMATION .. 4 DEFINITIONS .. 5 INTRODUCTION .. 8 1. TERM OF CONTRACT .. 9 2. ELIGIBILITY FOR SERVICES .. 10 3. EXEMPT .. 12 4. EXEMPT .. 12 5. EXEMPT .. 12 6. EXEMPT .. 12 7. RECIPIENT IDENTIFICATION CARDS .. 12 8. MAINSTREAMING OF RECIPIENTS .. 12 9. TRANSITION OF RECIPIENTS .. 12 10. SCOPE OF SERVICES .. 13 11. SPECIAL HEALTH CARE NEEDS .. 15 12. EXEMPTED .. 16 13. AHCCCS GUIDELINES, POLICIES AND MANUALS .. 16 14. MEDICAID SCHOOL BASED CLAIMING PROGRAM .. 16 15. PEDIATRIC IMMUNIZATIONS AND THE VACCINES FOR CHILDREN PROGRAM .. 16 16. STAFF REQUIREMENTS AND SUPPORT SERVICES .. 16 17. WRITTEN POLICIES, PROCEDURES AND JOB DESCRIPTIONS .. 19 18. RECIPIENT 19 19. SURVEYS .. 20 20. CULTURAL 20 21. MEDICAL RECORDS .. 20 22. ADVANCE DIRECTIVES .. 21 23. QUALITY MANAGEMENT (QM) .. 21 24. MEDICAL MANAGEMENT (MM).

2 24 25. ADMINISTRATIVE PERFORMANCE STANDARDS .. 25 26. GRIEVANCE SYSTEM .. 25 ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 2 CYE 13 CRS CONTRACT Effective 08/01/2013 27. NETWORK DEVELOPMENT .. 26 28. EXEMPT .. 27 29. NETWORK MANAGEMENT .. 27 30. EXEMPT .. 27 31. EXEMPT .. 27 32. EXEMPT .. 27 33. APPOINTMENT STANDARDS FOR CRS RECIPIENTS .. 28 34. EXEMPT .. 28 35. PROVIDER POLICY AND PROCEDURE MANUAL .. 28 36. PROVIDER REGISTRATION .. 28 37. SUBCONTRACTS AND SUBCONTRACTOR MANAGEMENT .. 29 38. CLAIMS PAYMENT/HEALTH INFORMATION SYSTEM .. 29 39. EXEMPT .. 29 40. EXEMPT .. 29 41. EXEMPT .. 29 42. PHYSICIAN INCENTIVES/PAY FOR PERFORMANCE .. 29 43. MANAGEMENT SERVICES AGREEMENT AND COST ALLOCATION PLAN. 29 44. EXEMPT .. 29 45. EXEMPT .. 29 46. PERFORMANCE BOND OR BOND SUBSTITUTE .. 29 47. AMOUNT OF PERFORMANCE BOND .. 29 48. ACCUMULATED FUND DEFICIT .. 29 49. ADVANCES, DISTRIBUTIONS, LOANS AND INVESTMENTS .. 29 50. FINANCIAL VIABILITY STANDARDS .. 29 51. EXEMPT.

3 30 52. EXEMPT .. 30 53. COMPENSATION .. 31 54. PAYMENTS TO 31 55. CAPITATION ADJUSTMENTS .. 31 56. MEMBER BILLING AND LIABILITY FOR PAYMENT .. 32 57. REINSURANCE .. 32 58. COORDINATION OF BENEFITS/THIRD PARTY LIABILITY .. 34 ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 3 CYE 13 CRS CONTRACT Effective 08/01/2013 59. COPAYMENTS .. 34 60. MEDICARE SERVICES AND COST SHARING .. 35 61. EXEMPT .. 35 62. CORPORATE COMPLIANCE .. 35 63. RECORDS RETENTION .. 35 64. DATA EXCHANGE REQUIREMENTS .. 35 65. ENCOUNTER DATA REPORTING .. 35 66. RECIPIENT/MEMBER DATA EXCHANGE .. 35 67. PERIODIC REPORT REQUIREMENTS (CRS TABLES).. 35 68. REQUESTS FOR INFORMATION .. 40 69. DISSEMINATION OF INFORMATION .. 40 70. EXEMPT .. 40 71. OPERATIONAL AND FINANCIAL REVIEWS .. 40 72. SANCTIONS .. 40 73. BUSINESS CONTINUITY AND RECOVERY PLAN .. 40 74. TECHNOLOGICAL ADVANCEMENT .. 40 75. PENDING LEGISLATIVE/OTHER ISSUES .. 40 76. EXEMPT .. 40 77. ADMINISTRATIVE COORDINATION .. 40 78. COLLABORATION.

4 40 79. CURRENT PERFORMANCE IMPROVEMENT PROJECT METHODOLOGIES 41 ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 4 CYE 13 CRS CONTRACT Effective 08/01/2013 CAPITATION RATES AND CONTRACTOR SPECIFIC INFORMATION APIPA shall provide services described in this ATTACHMENT . In consideration for these services, APIPA will be paid as described in Paragraph 53, Compensation of this ATTACHMENT . For the term of October 1, 2012 through September 30, 2013, APIPA will be paid a statewide blended capitation rate of $ for CRS eligible AHCCCS members. ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 5 CYE 13 CRS CONTRACT Effective 08/01/2013 DEFINITIONS The definitions contained in Section C, Definitions, of the CONTRACT apply with the following additions: CRS RECIPIENT An individual who has completed the CRS application process, and has met all applicable criteria to be eligible to receive CRS covered Services.

5 FAMILY OR FAMILY MEMBER A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction, or other Member representative responsible for making health care decisions on behalf of the Member. Family Members may also include siblings, grandparents, aunts and uncles. FAMILY-CENTERED Care that recognizes and respects the pivotal role of the family in the lives of Members. It supports families in their natural care-giving roles, promotes normal patterns of living, and ensures family collaboration and choice in the provision of services to the Member. FIELD CLINIC A clinic consisting of single specialty health care providers who travel to health care delivery settings closer to Members and their families than the MSICs to provide a specific set of services including evaluation, monitoring, and treatment for CRS related conditions on a periodic basis.

6 GENETICS The studies of how particular traits are passed from parents to children. Identifiable genetic information receives the same level of protection as other health care information under the HIPAA Privacy Rule. GUARDIANSHIP A person authorized under state or other law to act on behalf of the member in making health-related decisions. Examples: a parent acting on behalf of an un-emancipated minor or a parent who has petitioned for guardianship for their 18-21 year old member. INTEGRATED MEDICAL RECORD A single document in which all of the medical information listed in Chapter 900 of the AMPM is recorded to facilitate the coordination and quality of care delivered by multiple providers serving a single patient in multiple locations and at varying times. INTERDISCIPLINARY TEAM Physician and non-physician professionals, the Member and Family Members who collaborate in planning, delivering and evaluating health care services.

7 INTERDISCIPLINARY CARE A meeting of the interdisciplinary team members or coordination of care among interdisciplinary treatment team members to address the totality of the treatment and service plans for the Member based on the most current information available. ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 6 CYE 13 CRS CONTRACT Effective 08/01/2013 MEDICALLY NECESSARY SERVICES Those covered services provided by qualified service providers within the scope of their practice to prevent disease, disability and other adverse health conditions or their progression or to prolong life. MINOR An individual who is: 1. Under the age of 18 years; 2. Incompetent as determined by a court of competent jurisdiction; or 3. Incapable of giving consent for medical services due to a limitation in the individual s cognitive function as determined by a physician. MULTI-SPECIALTY The use of more than one specialty physician or dentist in the treatment of a Member.

8 MULTI-SPECIALTY, INTERDISCIPLINARY, CLINIC (MSIC) An established facility where specialists from multiple specialties meet with Members and their families for the purpose of providing interdisciplinary services to treat the Member s CRS condition. NOTICE OF APPEAL RESOLUTION The written determination by the Contractor concerning an appeal. OFFICE OF CIVIL RIGHTS (OCR) The office is part of the US Department of Health and Human Services (HHS). Its HIPAA responsibilities include oversight of the privacy REQUIREMENTS . PARENT A biological, adoptive, or custodial mother or father of a child, or an individual who has been appointed as a legal guardian or custodian of a child by a court of competent jurisdiction. PARENT ACTION COUNCIL (PAC) A local, parent-driven council consisting of members including parents of a child who is or has been a CRS Member, Adults who are or were CRS Members and the CRS Contractor.

9 PAC members may also include professionals and members of advocacy groups. The PAC is established in accordance with 36-265. PRUDENT LAYPERSON A person without medical training who exercises those qualities of attention, knowledge, intelligence and judgment, which society requires of its members for the protection of their own interest and the interests of others. SERVICE PLAN A document that is developed consistent with applicable Evidence Based Practice Guidelines, which combines the various elements of treatment plans with needed family support services and care coordination activities to provide a map of the steps to be taken for each Member in achieving treatment and quality of life goals. SPECIALTY PHYSICIAN A physician who is specially trained in a certain branch of medicine related to specific services or procedures, certain age categories of patients, certain body systems, or certain types of diseases.

10 ATTACHMENT J: CRS CONTRACT REQUIREMENTS CONTRACT /RFP No. YH09-0001 7 CYE 13 CRS CONTRACT Effective 08/01/2013 STATE FISCAL YEAR (FY) The budget year-State fiscal year: July 1 through June 30. STATEWIDE Of sufficient scope and breadth to address the health care service needs of Members throughout the State of Arizona. TELEMEDICINE The delivery of diagnostic, consultation and treatment services that occur in the physical presence of the member on a real time basis through interactive audio, video and data communications, as well as the transfer of medical data on a store and forward basis for diagnostic or treatment consultations. TRANSITION PLAN A plan developed for each Member in accordance with AHCCCS Policy, which includes developmentally-appropriate strategies to transition from a pediatric to an Adult system of health care and a plan that addresses changing work, education, recreation and social needs.