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Contract #129162 Table of Contents Page 2 of 241
Table of Contents
I. Effective Date and Duration.........................................................................................................6
II. Contract in its Entirety..................................................................................................................6
III. Status of Contractor......................................................................................................................7
IV. Service Area..................................................................................................................................8
V. (Reserved) .....................................................................................................................................8
VI. Interpretation and Administration of Contract .............................................................................8
VII. Government Status......................................................................................................................10
VIII. Contractor and Data Certification...............................................................................................11
IX. Signatures ...................................................................................................................................13
Exhibit A – Definitions...........................................................................................................................14
Exhibit B – Statement of Work ..............................................................................................................33
Exhibit B – Statement of Work – Part I - Benefits.................................................................................34
1. Benefit Package..............................................................................................................34
a. OHP Plus Benefit Package .................................................................................34
b. OHP Standard Benefit Package..........................................................................34
c. Flexible Services.................................................................................................34
d. Provision of Covered Services............................................................................34
e. Mental Health Services Which are Not Covered Services.................................36
f. Client Notices .....................................................................................................37
g. Practice Guidelines.............................................................................................37
h. Utilization Management .....................................................................................37
i. Authorization for Services..................................................................................38
2. Revision of Covered Services.........................................................................................39
3. (Reserved) .......................................................................................................................39
4. Accessibility and Continuity of Care..............................................................................39
Exhibit B –Statement of Work – Part II – Providers and Delivery System ...........................................42
1. Delivery System Configuration......................................................................................42
a. Delivery System Capacity ..................................................................................42
b. Components of the Delivery System..................................................................43
c. Integration and Coordination..............................................................................52
2. Quality Assessment/Performance Improvement (QA/PI) Requirements.......................57
3. Credentialing Process .....................................................................................................59
Exhibit B –Statement of Work – Part III – Members.............................................................................62
1. Informational Materials and Education of OHP Members.............................................62
2. OHP Member Rights ......................................................................................................63
3. Grievances System..........................................................................................................65
4. Enrollment and Disenrollment........................................................................................66
5. Identification Cards ........................................................................................................69
6. Marketing........................................................................................................................70
Exhibit B –Statement of Work – Part IV – Financial Matters................................................................71
1. Financial Risk, Management and Solvency....................................................................71
2. Dual Payment..................................................................................................................72
3. (Reserved).......................................................................................................................72
Exhibit B –Statement of Work – Part V – Operations............................................................................73
1. Recordkeeping................................................................................................................73
a. Clinical Records..................................................................................................73
b. Financial Records ...............................................................................................73
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2. Contractually Required Reports, Policies and Procedures.............................................73
3. Other Reporting Requirements.......................................................................................80
4. Research, Evaluation and Monitoring ............................................................................80
Exhibit B –Statement of Work – Part VI – Relationship of Parties .......................................................81
1. AMH Compliance Review and Quality Assessment Monitoring...................................81
2. Remedies Short of Termination......................................................................................82
Exhibit C – Consideration ......................................................................................................................84
1. Payment Types and Rates...............................................................................................84
2. Payment in Full...............................................................................................................84
3. Changes in Payment Rates..............................................................................................85
4. Timing of Capitation Payments......................................................................................85
5. Settlement of Accounts...................................................................................................86
Exhibit C – Consideration – Attachment 1 - Calculation of Capitation Payments ................................87
Exhibit C – Consideration – Attachment 2 - Capitation Rates...............................................................88
Exhibit D – Standard Terms and Conditions........................................................................................112
1. Controlling State Law/Venue.......................................................................................112
2. Compliance with Applicable Laws...............................................................................112
3. Independent Contractor ................................................................................................113
4. Representations and Warranties ...................................................................................113
5. Funds Available and Authorized..................................................................................114
6. Ownership.....................................................................................................................114
7. Indemnification.............................................................................................................114
8. Events of Default..........................................................................................................115
9. Remedies for Default....................................................................................................117
10. Termination...................................................................................................................117
11. Limitation of Liabilities................................................................................................121
12. Insurance.......................................................................................................................121
13. Access to Records and Facilities ..................................................................................121
14. Information Privacy/Security/Access...........................................................................123
15. Force Majeure...............................................................................................................123
16. Successors in Interest....................................................................................................123
17. Subcontracting..............................................................................................................124
18. No Third Party Beneficiaries........................................................................................127
19. Amendments.................................................................................................................127
20. Severability...................................................................................................................127
21. Waiver...........................................................................................................................127
22. Notices..........................................................................................................................127
23. Construction..................................................................................................................128
24. Headings and Captions.................................................................................................128
25. Merger...........................................................................................................................128
26. Tort Claims...................................................................................................................128
27. Counterparts..................................................................................................................128
28. Equal Access.................................................................................................................128
Exhibit E - Required Federal Terms and Conditions............................................................................129
1. Miscellaneous Federal Provisions ................................................................................129
2. Prevention and Detection of Fraud and Abuse.............................................................129
3. Equal Employment Opportunity...................................................................................129
4. Clean Air, Clean Water, EPA Regulations...................................................................129
5. Energy Efficiency.........................................................................................................130
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6. Truth in Lobbying.........................................................................................................130
7. Health Insurance Portability and Accountability Act (HIPAA)...................................130
8. Resource Conservation and Recovery..........................................................................131
9. Audits............................................................................................................................131
10. Debarment, Suspension and Terminated Providers......................................................131
11. Drug-Free Workplace...................................................................................................132
12. Pro-Children Act...........................................................................................................132
13. Additional Medicaid and SCHIP Requirements...........................................................132
14. Agency-based Voter Registration.................................................................................133
15. Clinical Laboratory Improvements...............................................................................133
16. Advance Directives.......................................................................................................133
17. Office of Minority, Women and Emerging Small Businesses .....................................134
18. Practitioner Incentive Plans..........................................................................................134
19. Risk HMO.....................................................................................................................134
20. Conflict of Interest Safeguards.....................................................................................134
21. Non-Discrimination......................................................................................................135
22. Federal Grant Requirements.........................................................................................136
23. Provider’s Opinion........................................................................................................136
Exhibit F – Insurance Requirements.....................................................................................................137
Exhibit G – Solvency Plan and Financial Reporting............................................................................138
Exhibit G – Attachment 1.....................................................................................................................140
Report G.2: Current OHP Members with Third Party Resources (Quarterly Report) .............140
Exhibit G – Attachment 2.....................................................................................................................142
Report G.3: Quarterly Balance Sheet .......................................................................................142
Exhibit G – Attachment 3.....................................................................................................................146
Report G.4: Contractor’s Quarterly Statement of Revenue and Expenses...............................146
Exhibit G – Attachment 4.....................................................................................................................151
Report G.4.A: Health Care Expenses by Service Type............................................................151
Exhibit G – Attachment 5.....................................................................................................................153
Report G.4.B: Prevention/Education/Outreach Activities........................................................153
Exhibit G – Attachment 6.....................................................................................................................155
Report G.5: Fiscal Year Cash Flow Analysis for Corporate Activity-Indirect Method...........155
Exhibit G – Attachment 7.....................................................................................................................160
Report G.6 – Disclosure of Compensation...............................................................................160
Exhibit H – Encounter Minimum Data Set Requirements ...................................................................161
EXHIBIT H – Attachment 2 - Report Form H.1 – Signature Authorization Form..............................168
EXHIBIT H – Attachment 3 - Report Form H.2 –Data Certification and Validation Report Form*..169
EXHIBIT H - Attachment 4 - Report Form H.3 – Encounter Claim Count Verification
Acknowledgement and Action Form............................................................................170
Exhibit I – Third Party Resources and Personal Injury Liens..............................................................171
Exhibit J – Prevention and Detection of Fraud, Waste and Abuse.......................................................174
Exhibit K –Provider Capacity Assurance Report.................................................................................177
Exhibit L – Reserved............................................................................................................................179
Exhibit M – Practitioner Incentive Plans..............................................................................................180
Exhibit M – Attachment 1 ....................................................................................................................183
Report M.1: Practitioner Incentive Plan Disclosure.................................................................183
Exhibit M – Attachment 2 ....................................................................................................................185
Report M.2: Practitioner Incentive Plan Detail ........................................................................185
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Exhibit N - Grievance System..............................................................................................................187
Exhibit N – Attachment 1 - Grievance Log..........................................................................................202
Exhibit O – Enrollment Reconciliation ................................................................................................204
Exhibit O – Attachment 1.....................................................................................................................205
Enrollment Reconciliation Certification – Form 1...................................................................205
Exhibit O – Attachment 2.....................................................................................................................206
Enrollment Reconciliation Certification – Form 2...................................................................206
Schedule 1 – Client Process Monitoring System (CPMS)...................................................................207
Schedule 2.1 – Procedure for Long Term Psychiatric Care Determinations for OHP Members
18 to 64.........................................................................................................................209
Schedule 2.2 – Procedure for Long Term Psychiatric Care Determinations for OHP Members
17 and Under.................................................................................................................215
Schedule 2.3 – Procedure for Long Term Psychiatric Care Determinations for OHP Members
Requiring Geropsychiatric Treatment ..........................................................................223
Schedule 3 – Oregon Patient/Resident Care System............................................................................229
Schedule 4 – Level of Service Intensity Determination Data...............................................................233
Schedule 5 - Signature Authorization Form.........................................................................................234
Schedule 5.1 - Attestation of Revision and Submission of Contractually Required Reporting...........235
Schedule 6 – Key Personnel.................................................................................................................236
Schedule 7 – Integrated Service Array (ISA) Progress Review Report...............................................237
Schedule 8 – OHP Services Not Covered Due to Moral or Religious Reasons Certification Form....240
Schedule 9 – Subcontracted Activities.................................................................................................241
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In compliance with the Americans with Disabilities Act, this document is available
in alternate formats such as Braille, large print, audiotape, oral presentation, and
electronic format. To request an alternate format please send an email to
DHS.Forms@state.or.us or contact the Office of Document Management at (503)
378-3523 and TTY at (503) 378-3523.
OREGON HEALTH PLAN PROVIDER SERVICES CONTRACT
MENTAL HEALTH ORGANIZATION
This Contract is between the State of Oregon, acting by and through its Department of Human
Services, hereinafter referred to as “DHS”, and
Accountable Behavioral Health Alliance
310 NW 5 th Street, Suite 206
Corvallis, Oregon 97330
hereinafter referred to as Contractor, collectively referred to as the Parties.
Work to be performed under this Contract relates principally to the DHS’
Addictions and Mental Health Division (AMH)
500 Summer Street NE, E86
Salem, Oregon 97301
Contract Administrator: Kellie Skenandore, OHP Mental Health Specialist
Phone: 503-947-5530
Fax: 503-378-8467
kellie.m.skenandore@state.or.us
I. Effective Date and Duration
This Contract shall become effective on the date this Contract has been fully executed by
every party and, when required approved by the Department of Justice or on January 1,
2010 whichever date is later. Unless extended or terminated earlier in accordance with
its terms, this Contract shall expire on December 31, 2010. Contract termination shall
not extinguish or prejudice DHS’ right to enforce this Contract with respect to any default
by Contractor that has not been cured.
Contractor shall give AMH not less than 60 days notice of its intent to not proceed with a
renewal contract prior to December 31, 2010.
II. Contract in its Entirety
This Contract consists of this document together with and includes the following exhibits
and schedules, which are attached hereto and incorporated into this Contract by this
reference:
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Exhibit A: Definitions
Exhibit B: Statement of Work
Exhibit C: Consideration
Exhibit D: Standard Terms and Conditions
Exhibit E: Required Federal Terms and Conditions
Exhibit F: Insurance Requirements
Exhibit G: Solvency Plan and Financial Reporting
Exhibit H: Encounter Minimum Data Set Requirement
Exhibit I: Third Party Resources and Personal Injury Liens
Exhibit J: Prevention/Detection Fraud, Waste and Abuse
Exhibit K: Mental Health Organization Provider Capacity Assurance Report
Exhibit L: Reserved
Exhibit M: Practitioner Incentive Plans
Exhibit N: Grievance System
Exhibit O: Enrollment Reconciliation
Schedule 1: Client Process Monitoring System (CPMS)
Schedule 2.1: Procedure for Long Term Care Determinations for OHP Members 18-64
Schedule 2.2: Procedure for Long Term Care Determinations for OHP Members 17 and
Under
Schedule 2.3: Procedure for Long Term Care Determinations for OHP Members
Requiring Geropsychiatric Treatment
Schedule 3: Oregon Patient/Resident Care System
Schedule 4: Level of Service Intensity Determination
Schedule 5: Signature Authorization Form
Schedule 5.1: Attestation of Revision and Submission of Contractually Required
Reporting
Schedule 6: Key Personnel
Schedule 7: Integrated Service Array (ISA) Progress Review Report
Schedule 8: OHP Services Not Covered Due to Moral or Religious Reasons
Schedule 9: Subcontracted Activities
There are no other Contract documents unless specifically referenced and incorporated in
this Contract.
III. Status of Contractor
A. Contractor is an Oregon Corporation, an intergovernmental entity, a political
subdivision of the State of Oregon or a non-profit corporation organized under the
laws of Oregon, which is serving as a Mental Health Organization (MHO) under
this Contract.
Contractor is not a Federally Qualified Health Maintenance Organization
registered as such with the Oregon Department of Consumer and Business
Services.
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B. Contractor shall not provide prepaid health services on a capitated basis to any
persons other than OHP Members, unless Contractor meets all statutory and
regulatory requirements as a Health Care Services Contractor under ORS Chapter
750.005(4).
C. Contractor designates:
Seth Bernstein, Ph.D. Director/Manager
310 NW 5 th Street, Suite 206
Corvallis, Oregon 97330
Phone: 541-753-8997
Fax: 541-752-4877
Email: sethbernstein@abhobho.org
as the point of contact pursuant to Exhibit D, Section 22 of this Contract.
Contractor shall notify AMH in writing of any changes to the designated contact.
IV. Service Area
Contractor's designated Service Area is within Benton, Jefferson, Lincoln, Deschutes,
Klamath (only 97731, 97733, 97737 and 97739 zip codes) and Crook Counties.
Contractor shall serve, under the terms and conditions set forth in this Contract, Oregon
Health Plan (OHP) Clients living in these counties who are enrolled with Contractor by
DHS as described in Exhibit B, Part III, Section 4, Enrollment and Disenrollment, of this
Contract.
V. (Reserved)
VI. Interpretation and Administration of Contract
A. AMH has adopted reasonable and lawful policies, procedures, rules and
interpretations to promote orderly and efficient administration of this Contract.
Contractor shall abide by all laws and Oregon Administrative Rules (OARs)
applicable to Contractor’s performance under this Contract.
B. In interpreting this Contract, its terms and conditions shall be construed as much
as possible to be complementary, giving preference to this Contract, (without
exhibits, schedules or attachments) over any exhibits, schedules or attachments.
In the event of any conflict between the terms and conditions of Exhibit C,
Attachment 2, and any other exhibit, schedule or attachment, Exhibit C,
Attachment 2, shall control. In the event of any conflict between the terms and
conditions in any other exhibits, schedules or attachments, the document earlier in
the Table of Contents shall control. In the event that DHS needs to look outside
of this Contract, including its exhibits, schedules and attachments for purposes of
interpreting its terms, DHS will consider only the following sources in the order
of precedence listed:
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1. The Grant Award Letters from the Centers for Medicare and Medicaid
Services (CMS) for operation of the Oregon Reform Demonstration
(Oregon Health Plan Medicaid and State Children’s Health Insurance
Program Demonstration Project), and the Health Insurance Flexibility and
Accountability (HIFA) demonstration, including all special terms and
conditions and waivers.
2. The Federal Medicaid Act, Title XIX of the Social Security Act, and its
implementing regulations, the HIFA demonstration, and the State
Children’s Health Insurance Program (SCHIP), established by Title XXI
of the Social Security Act, except as waived by CMS for the Oregon
Health Plan Medicaid and State Children’s Health Insurance Program
Demonstration Project, and as amended and as administered in Oregon by
DHS.
3. The Oregon Revised Statutes (ORS) concerning the OHP.
4. Oregon Administrative Rules related to the OHP concerning mental health
Services promulgated by DHS.
5. Other applicable ORS’ and OAR’s concerning the Medical Assistance
Program under prepaid capitated plans, Fee-For-Service (FFS)
arrangements and mental health Services.
6. Other applicable Oregon statutes and DHS administrative rules concerning
mental health Services.
C. If Contractor believes that any provision of this Contract or DHS’ interpretation
thereof, is in conflict with federal or state statutes or regulations, Contractor shall
notify AMH in writing immediately.
Any provision of this Contract which is in conflict with Federal Medicaid and
SCHIP statutes, regulations, or CMS policy guidance shall be amended to
conform to the provision of those laws, regulations and federal policy.
D. If Contractor disputes any interpretation, action or decision of DHS concerning
this Contract, including sanctions, recovery, or overpayment actions, Contractor
may request an administrative review as described below.
1. Administrative Review
Contractor shall send the request for administrative review to the AMH
Medicaid Policy Unit Manager with a postmark within 30 calendar days of
the effective date or announcement date, whichever is last, of DHS’
interpretation, action or decision which prompted the administrative
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review request. Contractor must specify the interpretations, actions or
decisions appealed and the reason(s) for the appeal on each interpretation,
action or decision. The appeal shall include any new information or
descriptions of actions that will support a change of the original
interpretation(s), action(s), or decision(s). Within 60 calendar days of
receiving the request for an administrative review, the AMH Medicaid
Policy Unit Manager, or designee, shall do the following: determine
which interpretations, actions or decisions will be reviewed; grant or deny
an administrative review; notify Contractor of the date, time, and location
of any applicable administrative review meeting; and issue to Contractor a
written decision resulting from the administrative review, if any.
2. Contested Case Hearings
Within 30 calendar days of receiving a denial of the request for an
administrative review or of receiving an administrative review decision,
Contractor may make a written request for a contested case hearing.
Contractor shall send the request for a contested case hearing to the AMH
Medicaid Policy Unit Manager, or designee, with a postmark not later than
30 calendar days following the date of notice of adverse decision resulting
from the administrative review process. Contested case hearings shall
follow the process described in OAR 410-120-1570, Provider Appeals –
Claims Reconsideration, through 410-120-1700, Provider Appeals-
Proposed and Final Orders, except that such hearings shall be heard by the
Hearings Officer panel or other independent hearings officer designated
by DHS.
E. Contractor shall notify its subcontractors and Participating Providers of
Contractor’s process for resolving issues related to this Contract.
VII. Government Status
Contractor certifies that it is not currently employed by the federal government to provide
the work covered by this Contract. Contractor certifies that Contractor is not an
employee of the State of Oregon.
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VIII. Contractor and Data Certification
A. Contractor Tax Identification and Insurance Information. Contractor shall
provide Contractor’s Social Security number or Contractor’s federal tax ID
number and the additional information set forth below. This information is
requested pursuant to ORS 305.385 and OAR 125-246-0333(5). Social Security
Numbers provided pursuant to this Section will be used for the administration of
state federal and local tax laws.
Please print or type the following information
If Contractor is self-insured for any of the Insurance Requirements specified in
Exhibit F of this Contract, Contractor may so indicate by: (i) writing “Self-
Insured” on the appropriate line(s); and (ii) submitting a certificate of insurance as
required in Exhibit F, Section 8.
NAME (exactly as filed with the IRS):
Address:
Telephone: ( ) Facsimile Number: ( )
Proof of Insurance:
Workers Compensation – Insurance Company
Policy
Expiration Date:
Professional Liability Insurance Company
Policy # Expiration Date:
General Liability Insurance Company
Policy # Expiration Date:
Auto Insurance Company
Policy # Expiration Date:
Business Designation:
[ ] Professional Corporation [ ] Partnership [ ] Limited Partnership
[ ] Limited Liability Company [ ] Limited Liability Partnership
[ ] Corporation [ ] Sole Proprietorship [ ] Other
The above information must be provided prior to Contract execution. Contractor
shall provide proof of Insurance upon request by DHS or DHS designee. DHS
may report the information set forth above to the Internal Revenue Service (IRS)
under the name and social security number or taxpayer identification number
provided.
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B. Certification. By signature on this Contract, the undersigned hereby certifies
under penalty of perjury that:
1. The undersigned is authorized to act on behalf of Contractor and that
Contractor is, to the best of the undersigned's knowledge, not in violation
of any Oregon Tax Laws. For purposes of this certification, "Oregon Tax
Laws" means a state tax imposed by ORS 401.792 to 401.816 (Tax for
Emergency Communications), 118 (Inheritance Tax), 314 (Income Tax),
316 (Personal Income Tax), 317 (Corporation Excise Tax), 318
(Corporation Income Tax), 320 (Amusement Device and Transient
Lodging Taxes), 321 (Timber and Forestland Tax), 323 (Cigarettes and
Tobacco Products Tax), and the elderly rental assistance program under
ORS 310.630 to 310.706; and any local taxes administered by the
Department of Revenue under ORS 305.620;
2. The number shown in Part VIII, Section A. is Contractor's correct
taxpayer identification and all other information provided in Part VIII,
Section A. is true and accurate;
3. Contractor is not subject to backup withholding because:
a. Contractor is exempt from backup withholding;
b. Contractor has not been notified by the IRS that Contractor is
subject to backup withholding as a result of a failure to report all
interest or dividends; or
c. The IRS has notified Contractor that Contractor is no longer
subject to backup withholding; and
4. Contractor is an independent contractor as defined in ORS 670.600.
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Exhibit A – Definitions
In addition to any terms that may be defined elsewhere in this Contract and with the following exceptions
and additions, the terms in this Contract have the same meaning as those terms appearing in Oregon
Administrative Rules (OARs) 309-012-0140, 309-032-0535, 309-033-0210, 410-120-0000, and 410-141-
0000. The order of preference for interpreting conflicting definitions is this Contract, (following the order of
precedence in Section VI.A), Oregon Health Plan Rules of DHS, General Rules of DHS, and Mental Health
Rules of DHS. The following terms shall have the following meanings below when capitalized:
1. “Abuse” means any death caused by other than accidental or natural means; any physical injury
caused by other than accidental means or that appears to be at variance with the explanation given of
the injury; willful infliction of physical pain or injury; and sexual harassment or exploitation,
including but not limited to, any sexual contact between an employee of a facility or community
program and an OHP Member. In residential programs, Abuse includes other intentional acts or
absence of action that interfere with the mental, emotional or physical health of the resident.
2. “Action” means in the case of Contractor, (1) the denial or limited authorization of a requested
Covered Service, including the type or level of service, (2) the reduction, suspension or termination
of a previously authorized service, (3) the denial in whole or in part, of payment for a service, (4)
failure to provide services in a timely manner, (5) the failure of Contractor to act within the
timeframes provided in 42 CFR 438.408(b), or (6) for a OHP Member who resides in a rural Service
Area where Contractor is the only MHO, the denial of a request to obtain Covered Services outside of
Contractor’s Participating Provider panel pursuant to OAR 410-141-0160 and 410-141-0220.
3. “Acute Care” means intensive, psychiatric services provided on a short-term basis to a person
experiencing significant symptoms of a mental disorder that interfere with the person's ability to
perform activities of daily living.
4. “Acute Inpatient Hospital Psychiatric Care” means Acute Care provided in a psychiatric hospital
with 24-hour medical supervision.
5. “Addictions and Mental Health Division” or “AMH” means the DHS office responsible for the
administration of the state’s policy and programs for mental health, chemical dependency,
Prevention, intervention, and treatment services.
6. “Administrative Hearing” means a DHS hearing related to an Action, including a denial, reduction,
or termination of benefits that is held when requested by the OHP Member or OHP Member
Representative. An Administrative Hearing may also be held when requested by an OHP Member or
OHP Member Representative who believes a claim for Services was not acted upon with reasonable
promptness or believes the payor took an Action erroneously.
7. “AMH Representative” means the individual within AMH designated to handle Administrative
Hearings requested by OHP Members or OHP Member Representative. The role of AMH
Representative is described in Exhibit N, Grievance System.
8. “Allied Agencies” means, local and regional governmental agencies and regional authorities that
contract with DHS to provide the delivery of services to covered individuals, (e.g., LMHAs, CMHPs,
Oregon Youth Authority (OYA), Department of Corrections, local health departments, schools,
education service districts, developmental disability service programs, area agencies on aging, SPD,
DHS Rehabilitation Services under the Community Services Program, housing authorities, local
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schools, special education, law enforcement agencies, adult criminal justice and juvenile justice,
developmental disability services, Chemical Dependency Providers, residential providers, Oregon
State Hospital, Prepaid Health Plans and federally recognized American Indian tribes).
9. “Appeal” means a request by an OHP Member or OHP Member Representative, or by a Provider
acting on behalf of the OHP Member with the OHP Member’s written consent, for Contractor to
review an Action as defined in this Exhibit.
10. “Assessment” means the determination of a person's need for Covered Services. It involves the
collection and evaluation of data pertinent to the person's mental history and current problem(s)
obtained through interview, observation, and record review. The Assessment concludes with one of
the following: (1) documentation of a DSM Diagnosis providing the clinical basis for a written
Treatment Plan; or (2) a written statement that the person is not in need of Covered Services. Other
disposition information such as to whom the person was referred is included in the Clinical Record.
11. “Atypical Providers” means an entity able to enroll as a billing provider or performing provider for
medical assistance programs related non-health care services but which does not meet the definition
for health care provider for NPI purposes.
12. “Capacity” means the ability to make Covered Services available in a given geographic area relative
to the size, location and unique needs of the OHP Membership within it. Indicators of Capacity may
be represented as ratios between the number of Participating Providers per 1,000 OHP Members for a
given geographic area (county or zip code); as ratios between the number of Participating Providers
per 1,000 OHP Members; as ratios between various types of Participating Providers (psychiatrists,
case managers) per a set number of OHP Members with specific diagnoses, unique characteristics
and/or special needs; as ratios between the number of Participating Providers per the total of OHP
Members and other patients; as a function of travel time or distance between the OHP Member’s
residence and the Participating Provider; as a function of waiting time for regular appointments,
Urgent Care, emergency care and specialty care; as a function of office waiting time; and as a
function of 24-hour care. Measurement of Capacity must consider factors such as geographic or
physical barriers (mountains or rivers) which preclude access, service Utilization patterns (services
being sought outside the immediate vicinity), language or cultural barriers, and needs of migrant or
seasonal workers.
13. “Capitation” means a payment model which is based on prospective payment for services,
irrespective of the actual amount of services provided, generally calculated on a per OHP Member
per month basis.
14. “Capitation Payment” means a monthly prepayment to Contractor for the provision of capitated
services provided on behalf of OHP Members. Capitation Payment is made on a per OHP Member,
per month basis.
15. “Case Management” means services provided to OHP Members who require assistance to ensure
access to benefits and services from Allied Agencies or other service Providers. Case Management
services includes: advocating for the OHP Member's treatment needs; providing assistance in
obtaining entitlements based on mental or emotional Disability; referring OHP Members to needed
services or supports; accessing housing or residential programs; coordinating services including
mental health treatment, educational or vocational activities; and arranging alternatives to inpatient
hospital services.
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16. “Case Rate” means a flat rate paid per OHP Member for a specific range of services. A Case Rate
may be paid for each referral made to a Provider or for each admission made to a hospital. The
Provider receiving the payment assumes the risk of providing all Covered Services for the full range
of services for each OHP Member for whom the payment was made.
17. “CCC Chairperson” means a QMHP with experience in children's mental health treatment
designated by the CMHP director in each county to coordinate LTPC screenings.
18. “Chemical Dependency Provider” means a practitioner approved by DHS to Provide publicly
funded alcohol and drug abuse Rehabilitative Services.
19. “Civil Commitment” means the legal process of involuntarily placing a person, determined by the
Circuit Court to be a mentally ill person as defined in ORS 426.005 (1) (d), in the custody of DHS.
DHS has the sole authority to assign and place a committed person to a treatment facility. DHS has
delegated this responsibility to the CMHP Director. Civil Commitment does not automatically allow
for the administration of medication without informed client consent. Additional procedures
described in administrative rule must be followed before medication can be involuntarily
administered.
20. “Claim” means 1) a bill for services, 2) a line item of service or 3) all services for one recipient
within a bill.
21. “Clean Claim” means a Claim that can be processed without obtaining additional information.
22. “Client Process Monitoring System” or “CPMS” means a the automated consumer data system
maintained by DHS.
23. “Clinical Reviewer” means the entity jointly chosen to resolve disagreements related to an OHP
Member's need for LTPC immediately following an Acute Inpatient Hospital Psychiatric Care stay.
24. “Clinical Record” means a collection of all documentation regarding a Consumer’s mental health
Treatment and related services. For the purpose of confidentiality, it is considered the medical record
defined in ORS Chapter 179.
25. “Clinical Services Coordination” means coordinating the access to, and provision of, services from
multiple agencies according to the Treatment Plan; establishing crisis service linkages; advocating for
the OHP Member's treatment needs; and providing assistance to obtaining entitlements based on
mental or emotional Disability.
26. “Community Coordinating Committee” or “CCC” means a committee composed of
representatives from the local CMHP, DHS Children, CAF, Juvenile Court, local education district,
and the AMH Child and Adolescent Mental Health Specialist.
27. “Community Coordinating Committee (CCC) Care Path Plan” means a written plan for
discharge to a least restrictive appropriate Setting with specific discharge criteria. Discharge criteria
are linked to resolution of symptoms and behaviors that justified admission to LTPC. The CCC Care
Path Plan provides an opportunity for those parties most familiar with the treatment needs of the child
to develop a care path plan.
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28. “Community Emergency Service Agencies” means, but are not limited to, hospital emergency
rooms, crisis centers, protective services of DHS, OYA, local juvenile justice, police, homeless
shelters, CMHPs, and Civil Commitment investigators.
29. “Community Mental Health Program” or “CMHP” means the organization of all services for
persons with mental or emotional disorders and developmental disabilities operated by, or
contractually affiliated with, a LMHA, operated in a specific geographic area of the state under an
intergovernmental agreement or direct contract with DHS.
30. “Community Standard” means the typical expectations for access to the health care delivery system
in the OHP Member’s community of residence. Except where the Community Standard is less than
sufficient to ensure Quality of Care, DHS requires that the health care delivery system available to
OHP Members take into consideration the Community Standard and be adequate to meet the needs of
OHP Members.
31. “Condition/Treatment Pair” means the diagnoses described in the International Classification of
Diseases Clinical Modifications, 9th edition (ICD-9 CM), the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition (DSM-IV) and treatments described in the Current Procedural
Terminology, 4 th edition (CPT-4), HCPC, and BA/ECC Codes established by DHS or the DHS AMH
Medicaid Procedure Codes and Reimbursement Rates, which, when paired by the Health Services
Commission (HSC), constitute the line items in the Prioritized List of Health Services.
Condition/Treatment Pairs are referred to in OAR 410-141-0520.
32. “Consultation” means professional advice or explanation given concerning a specific OHP Member
to others involved in the treatment process, including Family members, staff members of other
human services agencies (such as DHS, schools, OYA, juvenile justice) and care providers (such as
Nursing Homes, foster homes, or residential care facility staff).
33. “Consumer” means an OHP Member with a mental or emotional disorder who receives Covered
Services. This term is also used in reference to any person receiving services through a CMHP which
are not Covered Services.
34. “Continuity of Care” means the ability to sustain services necessary for a person's treatment.
Continuity of Care is a concern when an OHP Member is transferred from one service provider to
another.
35. “Contractor Representative” means the individual within Contractor organization responsible for
handling Grievance and Administrative Hearing issues. The role of this person is described in
Exhibit N, Grievance System.
36. “Corrective Action” or Corrective Action Plan” means a requirement for the Contractor or
subcontractor to develop and implement a time specific plan, for the correction of AMH identified
areas of non-compliance, as described in this Contract.
37. “Covered Services” means services that are included in the Capitation Payment paid to Contractor
under this Contract with respect to an OHP Member under this Contract whenever services are
Medically Appropriate for the OHP Member. Services included in the Capitation Payment are
described in the State of Oregon, Oregon Health Plan Service Categories for Per Capita Costs,
October 2002 through September 2003. The Capitation Payment is based on the number of
Condition/Treatment Pair lines of the List of Prioritized Health Services funded by the Legislature
and adopted in OAR 410-141-0520. The Covered Services described in this Contract shall be
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substituted with and/or expanded to include Flexible Services and Flexible Service Approaches
identified and agreed to by Contractor, the OHP Member and, as appropriate, the Family of the OHP
Member as being an efficacious alternative. Covered Services are limited in accordance with OAR
410-141-0500, Excluded Services and Limitations for OHP Clients.
38. “Credentialing” means the authorization process by which the Contractor ensures that professionals
and other providers who will deliver services to OHP Members are licensed to practice, or otherwise
qualified for their respective positions. Authorization is determined by comparison of practitioner
qualifications with applicable requirements for education, licensure, professional standing,
experience, service availability and accessibility, and conformance with Contractor Utilization and
quality management requirements.
39. “Culturally Competent” means the Capacity to Provide services in an effective manner that is
sensitive to the culture, race, ethnicity, language and other differences of an individual. Such services
may include, but are not limited to, use of bilingual and bicultural staff, provision of services in
culturally appropriate alternative settings, and use of bicultural Paraprofessionals as intermediaries
with professional staff.
40. “Current Procedural Terminology” or “CPT” means a listing of descriptive terms and identifying
codes for reporting medical services and procedures performed by physicians. The purpose of the
terminology is to provide a uniform language that accurately describes medical, surgical, and
diagnostic services, and thereby provides an effective means for reliable nationwide communication
among physicians, patients, and third parties.
41. “Declaration for Mental Health Treatment” means a written statement of a person's decisions
concerning his or her mental health treatment. The declaration is made when the person is able to
understand and make decisions related to such treatment. It is honored when the person is unable to
make such decisions.
42. “Department of Human Services” or “DHS” or any of its programs or offices, means the
Department of Human Services established in ORS Chapter 409, including such divisions, programs
and offices as may be established therein. Wherever the former Office of Medical Assistance
Programs or OMAP is used in this Contract or in administrative rule, it shall mean the Division of
Medical Assistance Programs (DMAP). Wherever the former Office of Mental Health and Addiction
Services or OMHAS is used in this Contract or in administrative rule, it shall mean the Addictions
and Mental Health Division (AMH). Where the former Seniors and People with Disabilities or SPD
is used in this Contract or in administrative rule, it shall mean the Seniors and People with
Disabilities Division (SPD). Wherever the former Children, Adults and Families or CAF is used in
this Contract or in administrative rule, it shall mean the Children, Adults and Families Division
(CAF). Where the former Health Division is used in this Contract or in administrative rule, it shall
mean the Public Health Division (PHD).
43. “Diagnosis” or “DSM Diagnosis” means the principal mental disorder listed in the most recently
published edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), that is the
Medically Appropriate reason for clinical care and the main focus of treatment for an OHP Member.
The Principal Diagnosis is determined through the mental health Assessment and any examinations,
tests, procedures, or Consultations suggested by the Assessment. Neither a DSM "V" code disorder,
substance use disorder or mental retardation may be considered the Principal Diagnosis, although
these conditions or disorders may co-occur with the diagnosable mental disorder.
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44. “Disability” means a physical or mental impairment that substantially limits one or more major life
activities (such as caring for oneself, performing manual tasks, walking, seeing, hearing, speaking,
breathing, learning and working). It includes a record of having such an impairment or being
regarded as having such an impairment.
45. “Disenrollment” means the act of discharging an OHP Member from a Contractor’s responsibility
under this Contract. After the effective date of Disenrollment an OHP Client is no longer required to
obtain Covered Services from the Contractor, nor be referred by the Contractor.
46. “DSM Code” means the numerical code, including modifiers, which identifies psychiatric disorders
defined in the most recent American Psychiatric Association’s Diagnostic and Statistical Manual.
47. “Early Intervention” means the Provision of Covered Services directed at preventing or
ameliorating a mental disorder or potential disorder during the earliest stages of onset or prior to
onset for individuals at high risk of a mental disorder.
48. “Emergency Psychiatric Hold” means the physical retention of a person taken into custody by a
peace officer, health care facility, OSH, hospital or nonhospital facility as ordered by a physician or a
CMHP director, pursuant to ORS Chapter 426,.
49. “Emergency Response System” means the coordinated method of triaging the mental health service
needs of OHP Members and providing Covered Services when needed. The system operates 24-
hours a day, 7-days a week and includes, but is not limited to, after hours on call staff, telephone and
in person screening, Outreach, and networking with hospital emergency rooms and police.
50. “Emergency Service” means inpatient or outpatient Covered Services furnished by a Provider that is
qualified to furnish these Services and that are needed to evaluate or stabilize an Emergency
Situation. See definition for Twenty-four (24) Hour Urgent and Emergency Services.
51. “Emergency Situation” means a mental health condition manifesting itself by acute symptoms of
sufficient severity such that a prudent layperson, with an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in (1) serious jeopardy
to the health of the OHP Member, (or, with respect to a pregnant woman, the health of the woman or
her unborn child) (2) serious impairment of bodily function, or (3) serious dysfunction of any bodily
organ or part. An “Emergency Medical Condition” is determined based on the presenting symptoms
(not the final diagnosis) as perceived by a prudent layperson (rather than a Health Care Professional)
and includes cases in which the absence of immediate medical attention would not in fact have had
the adverse results described in the previous sentence.
52. “Encounter” means an outpatient contact or Acute Inpatient Hospital Psychiatric Care admission for
Covered Services provided to an OHP Member.
53. “Enhanced Care Services” means services, which are not Covered Services, defined in OAR 309-
032-720 through 309-032-830 as provided to eligible persons who reside at facilities licensed by
Senior and Disabled Services now referred to as Seniors and People with Disabilities Division.
54. “Enrollment” means the assignment of OHP Clients to Contractors per OAR 410-141-0060, Oregon
Health Plan Managed Care Enrollment Requirements. Once the OHP Client becomes an OHP
Member, the person must receive all Covered Services from the Contractor or be referred by the
Contractor to Mental Health Practitioners.
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55. “Evaluation” means a psychiatric or psychological Assessment used to determine the need for
mental health services. The Evaluation includes the collection and analysis of pertinent
biopsychosocial information through interview, observation, and psychological and
neuropsychological testing. The Evaluation concludes with a five axes Diagnosis of a DSM
multiaxial Diagnosis, prognosis for rehabilitation, and treatment recommendations.
56. “Extended Care Management” means overseeing the Utilization of extended care resources.
57. “Extended Care Management Unit” or “ECMU” means the unit within AMH responsible for
providing the clinical Assessment, Consultation, and placement of adults age 18 to 64 with severe
and persistent mental illness who require long term structure, support, rehabilitation, and supervision
within designated Extended Care Projects; the Utilization review of those projects and the screening
of all requests for admission to LTPC.
58. “Extended Care Project” means a State-funded program designed to provide necessary services for
adults in a least restrictive environment, utilizing a range of hospital, residential, and community
resources. These programs include secure residential facilities, residential psychiatric treatment, Post
Acute Intermediate Treatment Services (PAITS) programs, Geropsychiatric Treatment Program at
OSH, DHS Seniors and People with Disabilities Program enhanced care and PASSAGES Projects,
“365” Plans, Psychiatric/Vocational Projects and enhanced foster care programs.
59. “Family” means parent or parents, legal guardian, siblings, grandparents, spouse and other primary
relations whether by blood, adoption, legal or social relationship.
60. “Fee-For-Service” or “FFS” means the payment for reimbursable services retrospectively based
upon agreed rates and the amount of service provided.
61. “Flexible Service” means a service that is an alternative or addition to a Traditional Service that is as
likely or more likely to effectively treat the mental disorder as documented in the OHP Member’s
Clinical Record. Flexible Services may include, but are not limited to: Respite Care, Partial
Hospitalization, Subacute Psychiatric Care, Family Support Services, Parent Psychosocial Skills
Development, Peer Counseling, and other non-Traditional Services identified.
62. “Flexible Service Approach” means the delivery of any Covered Service in a manner or place
different from the traditional manner or place of service delivery. A Flexible Service Approach may
include delivering Covered Services at alternative sites such as schools, residential facilities, nursing
facilities, OHP Members' homes, emergency rooms, offices of DHS, other community settings;
offering flexible clinic hours; offering Covered Services through Outreach or a home-based
approach; and using peers, Paraprofessionals and persons who are Culturally Competent to engage
difficult-to-reach OHP Members.
63. “Fully Capitated Health Plans” or “FCHPs” means PHPs that contract with DHS to Provide
physical health care services under the OHP.
64. “Geropsychiatric Treatment Service” or “OSH-GTS” means four units at OSH serving frail
elderly persons with mental disorders, head trauma, advanced dementia, and/or concurrent medical
conditions who cannot be served in community programs.
65. “Grievance” means an OHP Member's or OHP Member Representative's expression of
dissatisfaction to Contractor or to a Participating Provider about any matter other than an Action.
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66. “Grievance System” means the overall system that includes Grievances and Appeals handled at the
Contractor level and access to the State fair hearing process. (Possible subjects for Grievances
include, but are not limited to, the quality of care or services provided and aspects of interpersonal
relationships such as rudeness of a Provider or employee, or failure to respect the OHP Member's
rights.)
67. “Health Care Professional” means persons with current and appropriate licensure, certification, or
accreditation in a medical, mental health or dental profession, which include but are not limited to:
medical doctors (including psychiatrists), osteopathic physicians, psychologists, registered nurses,
nurse practitioners, licensed practical nurses, certified medical assistants, licensed physician
assistants, QMHAs, QMHPs, dentists, dental hygienists, denturists, and certified dental assistants.
68. “Health Services Commission” or “HSC” means the governing body responsible for the OHP
which determines the Condition/Treatment Pairs to be included on the Prioritized List of Health
Services and determines the ranking of each pair.
69. “Incurred But Not Reported or IBNR Expenses” means expenses for services authorized by an
agency responsible for their payment, but for which no statement has yet been received by that
agency. These are expenses for which the agency is liable and which the agency will need to expect
to pay.
70. “Indian Health Care Provider” means an Indian Health Program or an Urban Indian Organization.
71. “Indian Health Program” means an Indian Health Service facility, any federally recognized tribe or
tribal organization or any tribe 638 Federally Qualified Health Center (FQHC) enrolled with DHS as
an American Indian/Alaska Native (AI/AN) provider.
72. “Intake” means the process of gathering preliminary information about a potential Consumer to
determine whether the person is eligible for services, the urgency of the situation or need for services,
and the initial provisional Diagnosis. This information is used to schedule the first appointment, if
applicable.
73. “Integrated Services Array” or “ISA” means a range of service components that are coordinated,
comprehensive, Culturally Competent, and include intensive and individualized home and
community-based services for children and adolescents with severe mental or emotional disorders
whose needs have not been adequately addressed in traditional Settings. The ISA integrates
inpatient, psychiatric residential and Psychiatric Day Treatment and community-based care provided
in a way to ensure that children and adolescents are served in the most natural environment possible
and that the use of institutional care is minimized. The intensity, frequency, and blend of these
services are based on the mental health needs of the child.
74. “Intensive Psychiatric Rehabilitation” means the application of concentrated and exhaustive
treatment for the purpose of restoring a person to a former state of mental functioning.
75. “Involuntary Psychiatric Care” means any psychiatric service, such as forced medication, which is
provided on a basis other than by informed client (or guardian) consent. Involuntary psychiatric
services are provided only when authorized by ORS Chapter 426 and in accordance with
administrative rules. Generally, a person must be determined to lack the capacity to give informed
client consent before involuntary psychiatric services may be administered.
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76. “Licensed Medical Practitioner” or “LMP” means a person who is a physician, nurse practitioner
or physician's assistant licensed to practice in the State of Oregon whose training, experience and
competence demonstrates the ability to conduct a comprehensive mental health Assessment and
provide Medication Management. The LMHA or Contractor must document that the person meets
these minimum qualifications.
77. “Local Mental Health Authority” or “LMHA” as defined in ORS 430.630, means the county court
or board of commissioners of one or more counties who choose to operate a CMHP; or, if the county
declines to operate or contract for all or part of a CMHP, the board of directors of a public or private
corporation which contracts with DHS to operate a CMHP for that county.
78. “Long-Term Psychiatric Care” or “LTPC” means inpatient psychiatric services delivered in an
Oregon State operated Hospital after Usual and Customary care has been provided in an Acute
Inpatient Hospital Psychiatric Care Setting or The Joint Commission (TJC) Residential Psychiatric
Treatment Center for children under age 18 and the individual continues to require a hospital level of
care.
79. “Marketing” means any communication, from Contractor to an OHP Client who is not enrolled with
Contractor, that can reasonably be interpreted as intended to influence the OHP Client to enroll with
Contractor, or either to not enroll in, or to disenroll from, another MHO or Managed Care
Organization.
80. “Marketing Materials” means any medium produced by, or on behalf of, a PHP that can reasonably
be interpreted as intended for Marketing as defined in OAR 410-141-0000.
81. “Medicaid” means the federal and state funded portion of the Medical Assistance Program
established by Title XIX of the Social Security Act, as amended, and administered in Oregon by
DHS.
82. “Medicaid Policy Unit” means the organizational section within AMH responsible for integrating
mental health services into the OHP.
83. “Medical Assistance Program” means a DHS program for payment of medical and remedial care
provided to eligible Oregonians that is administered by identified programs, services, and operations
within DHS. DHS has primary responsibility for coordinating the Medical Assistance Program.
84. “Medically Appropriate” means services and supplies which are required for Prevention (including
preventing a relapse), Diagnosis or Treatment of mental disorders and which are appropriate and
consistent with the Diagnosis; consistent with treating the symptoms of a mental illness or treatment
of a mental disorder; appropriate with regard to standards of good practice and generally recognized
by the relevant scientific community as effective; not solely for the convenience of the OHP Member
or provider of the service or supply.
85. “Medication Override Procedure” means the administration of psychotropic medications to a
person in an Acute Inpatient Hospital Psychiatric Care Setting when the person has refused to accept
the administration of such medications on a voluntary basis. Administration of such medications is
considered a significant procedure. Significant procedures can only be performed after the person
has been committed and only when there is good cause. A Medication Override Procedure must meet
the requirements of OAR 309-033-0640, Involuntary Administration of Significant Procedures to a
Committed Person with good cause. These procedures are used as a way to administer treatment to
an OHP Member who is incapable of providing informed consent and is in need of Treatment.
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86. “Mental Health Information System” or “MHIS” means the information system of DHS that
includes the CPMS for community based services and the OP/RCS for inpatient and acute services.
It provides a statewide client registry and Contractor registry for tracking service Utilization and
Contractor Capacity.
87. “Mental Health Organization” or “MHO” means a PHP under contract with DHS to Provide
Covered Services under the OHP. MHOs can be FCHPs, CMHPs or private MHOs or combinations
thereof.
88. “Mental Health Practitioner” means a person with current and appropriate licensure, certification,
or accreditation in a mental health profession, which include but are not limited to: psychiatrists,
psychologists, registered psychiatric nurses, QMHAs, and QMHPs.
89. “Multi-Family Treatment Group” means the planned Treatment of mental health needs identified
in the mental health Assessment which occurs in a group Setting of at least three children (none of
whom are siblings, step-siblings, or live in the same household) and their families. Groups are of
limited duration and designed for children and families dealing with similar issues.
90. “National Provider Identifier” or “NPI” means a federally directed Provider number mandated for
use on HIPAA covered transactions; individuals, Provider Organization and Subparts of Provider
Organizations that meet the definition of health care Provider (45 CFR 160.103) and who conduct
HIPAA covered transactions electronically are eligible to apply for an NPI; Medicare covered entities
are required to apply for an NPI.
91. “Notice of Action” means a written document issued to the OHP Member when a Service, benefit,
request for service authorization, or request for claim payment is denied. The Notice of Action
includes the following elements: (a) a statement of the Action, the effective date of such Action, and
the date the Notice of Action is mailed; (b) the reasons for the Action and the specific regulations that
support the Action; (c) an explanation of the right to file a Grievance with Contractor and to request
an Administrative Hearing with DHS, and the consequences of choices made; (d) a statement
referring the OHP Member to an enclosed informational notice of Grievance process form; (e) a
statement referring the OHP Member to an enclosed informational notice of Hearing rights form; and
(f) the name and telephone number of a person to contact for additional information.
92. “Notice of Intended Remedial Action” means a written document issued to Contractor when AMH
intends to take Remedial Action. The Notice of Intended Remedial Action includes the following
elements: (a) a statement of the intended Remedial Action, the effective date of such intended
Remedial Action, and the date the Notice of Intended Remedial Action is mailed; (b) the reasons for
the intended Remedial Action; (c) an explanation of Contractor’s right to request an administrative
review as described in Part VII, Section C, Interpretation and Administration of Contract; (d) an
explanation that the intended Remedial Action will be suspended when Contractor requests an
administrative review before the effective date of the intended Remedial Action and such request also
includes a request to suspend the intended Remedial Action until a decision is reached through the
administrative review process; (e) an explanation that if the intended Remedial Action is suspended
as described above in (d) and a decision is reached in favor of DHS, the intended Remedial Action
may be imposed retroactively to effective date stated in the Notice of Intended Remedial Action; and
(f) in cases where the Remedial Action includes withholding of Capitation Payments because
Contractor has failed to Provide Covered Services and/or DHS has incurred costs in providing
Covered Services, a list of OHP Members for whom Capitation Payments will be withheld, the nature
of the Covered Services denied by Contractor, and costs incurred by DHS in providing Covered
Services in accordance with this Contract.
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93. “Nursing Home” or “Nursing Facility” means an establishment with permanent facilities for the
comprehensive care of persons who require assistance with activities of daily living and 24-hour
nursing care. Nursing services exclude surgical procedures and include complex nursing tasks that
cannot be delegated to an unlicensed person. A Nursing Facility is licensed and operated pursuant to
Oregon Revised Statute 441.020(2).
94. “Oregon Health Plan” or “OHP” means the Medicaid and State Children’s Health Insurance
Program Demonstration Project, expands Medicaid and the State Children’s Health Insurance
Program eligibility to eligible OHP Clients. The OHP relies substantially upon prioritization of
health services and managed care to achieve the public policy objectives of access, cost containment,
efficacy and cost effectiveness in the allocation of health resources.
95. “OHP Client” means an individual found eligible by a program of DHS to receive health care
services under the OHP.
96. “OHP Member” means an OHP Client who is enrolled with Contractor under this Contract.
97. “OHP Member Representative” means a person who can make OHP related decisions for OHP
Members who are not able to make such decisions themselves. An OHP Member Representative
may be, in the following order of priority, a person who is designated as the OHP Member’s health
care representative, a court-appointed guardian, a spouse, or other Family member as designated by
the OHP Member, the Individual Service Plan Team (for OHP Members with developmental
disabilities), parent or legal guardian of a minor below the age of consent, a DHS case manager or
other DHS designee. For OHP Members in the care or custody of CAF or OYA, the OHP Member
Representative is DHS or OYA. For OHP Members placed by DHS through a Voluntary Child
Placement Agreement (SCF form 499), the OHP Member shall be represented by his or her parent or
legal guardian.
98. “OHP Plus Benefit Package” means a benefit package with a comprehensive range of Services, as
described in OAR 410-120-1200, Medical Assistance Benefits, available to OHP Members who are
over the age of 65, the disabled, the TANF population, General Assistance recipients, and pregnant
women and children (under the age of 19) up to 185 percent of Federal Poverty Level (FPL).
99. “OHP Standard Benefit Package” means a benefit package that provides basic health care Services
as described in OAR 410-141-0050 and OAR 410-141-1200, Medical Assistance Benefits, for adults
who are not otherwise eligible for Medicaid (Families, Adults, Adults/Couples).
100. “Oregon Patient/Resident Care System” or “OP/RCS” means the DHS data system for persons
receiving services in the Oregon State Hospitals and selected community hospitals providing Acute
Inpatient Hospital Psychiatric services under contract with DHS.
101. “Oregon State Hospital” or “OSH” means the state-operated psychiatric hospital with campuses in
Salem and Portland, and the state-operated psychiatric hospital in Pendleton.
102. “Other Inpatient Services” means services which are equivalent to Acute Inpatient Hospital
Psychiatric Care but which are provided in a non-hospital Setting.
103. “Outpatient Hospital Services” means Covered Services received in an outpatient hospital Setting
where the OHP Member has not been admitted to the facility as an inpatient, as defined in the DHS
Hospital Services Guide.
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104. “Outreach” means services provided away from the service provider’s office, clinic or other place of
business in an effort to identify or serve OHP Members who might not otherwise obtain, keep or
benefit from usual appointments. Such services include, but are not limited to, community-based
visits with an OHP Member in an attempt to engage him or her in Medically Appropriate treatment,
and providing Medically Appropriate treatment in a Setting more natural or comfortable for the OHP
Member.
105. “Paraprofessional” means a worker who does not meet the definition of QMHA or QMHP but who
assists such associates and professionals.
106. “Parent Psychosocial Skills Development” means theoretically based interventions that focus on
developing and strengthening a parent's competencies in areas of functioning such as skills in
managing stress and reducing anger.
107. “Participating Provider” means an individual, facility, corporate entity, or other organization which
provides Covered Services under an agreement with Contractor and agrees to bill in accordance with
such agreement. For Contractors who utilize a staff model and/or Provide Covered Services directly,
a Participating Provider may also include employees of Contractor.
108. “PASSAGES Projects” means one type of Extended Care Project which consists of community-
based services for adults with severe and persistent mental illness who have been hospitalized for
over six months in an Oregon State Hospital or who have had difficulty maintaining stability in other
structured community Settings. Placements in these projects are approved by the AMH ECMU.
109. “Peer Counseling” means a mental health service or support provided by trained persons with
characteristics similar to the Consumer such as persons in recovery from a major mental illness or
persons representing a generational cohort or persons with the same cultural background.
110. “Pended Encounters” means Encounters with critical errors that will process through the DHS’
MMIS. List post “must correct”, edits because of missing or erroneous data.
111. “Performance Improvement” or “PI” means improvement in the performance of the process of
health care and service delivery, rather than eliminating only low performing outliers. PI employs a
cyclical set of activities involving continuous planning, doing, checking and action (IOM 1990).
112. “Personal Care in Adult Foster Homes” means Medicaid-covered activities of daily living and
support services provided in a licensed Family home or other home for five or fewer persons who are
unable to live by themselves without supervision according to standards and procedures defined in
OAR 309-040-0000 through 309-040-0100.
113. “Post-Stabilization” means Covered Services related to an Emergency Situation that are provided
after an OHP Member is stabilized in order to maintain the stabilized condition, or to improve or
resolve the OHP Member’s condition.
114. “Potential OHP Member” means an OHP Client who is subject to mandatory Enrollment or may
voluntarily elect to enroll in a managed care program, but is not yet enrolled with a specific PHP.
115. “Preadmission Screening and Resident Review” or “PASRR” means screening and Evaluation
services for residents of Nursing Facilities to determine their need for inpatient psychiatric
hospitalization according to federal standards and procedures defined in OAR 309-048-0050 through
309-048-0130.
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116. “Prepaid Health Plan” or “PHP” means a managed care organization that contracts with DHS on a
case managed, prepaid, capitated basis under the OHP. PHPs may be Dental Care Organizations
(DCO), FCHPs, Chemical Dependency Organizations (CDO), or MHO.
117. “Prevention” means services provided to stop, lessen or ameliorate the occurrence of mental
disorders.
118. “Primary Care Practitioner” or “PCP” means a general practice physician, Family physician,
general internist, pediatrician, or gynecologist who is responsible for providing and coordinating the
OHP Member's health care services. This person authorizes referrals to specialists and payment is
contingent upon these authorizations.
119. “Principal Diagnosis” means the reason that is chiefly responsible for the visit. See DSM, Use of
the Manual, page 3.
120. “Prioritized List of Health Services” means the listing of Condition/Treatment Pairs developed by
the HSC for the purpose of implementing the OHP. See OAR 410-141-0520, Prioritized List of
Health Services, for the listing of Condition/Treatment Pairs.
121. "Professional Liability Insurance," means coverage under the Federal Tort Claims Act (the
"FTCA") if Contractor is deemed covered under the FTCA, and to the extent the FTCA covers
Contractor's professional liability under this Contract.
122. “Provide” means to furnish directly, or authorize and pay for the furnishing of, a Covered Service to
an OHP Member.
123. “Provider” means an organization, agency or individual licensed, certified or authorized by law to
render professional health services to OHP Members.
124. “Provider Panel” means those Participating Providers affiliated with the Contractor who are
authorized to Provide services to OHP Members.
125. “Provider Taxonomy Codes” means a standard administrative code set, as defined under HIPAA in
Federal regulations at 45 CFR 162, for identifying the provider type and area of specialization for all
health care providers.
126. “Psychiatric Day Treatment” means community-based day or residential treatment services for
children in a psychiatric treatment Setting which conforms to established state-approved standards.
127. “Psychiatric Rehabilitation” means the application of treatment for the purpose of restoring a
person to a former or desired state of overall functioning. See definition of Intensive Psychiatric
Rehabilitation.
128. “Psychiatric Security Review Board” or “PSRB” means the Board authorized under ORS Chapter
161 which has jurisdiction over persons who are charged with a crime and found guilty except for
insanity.
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129. “Psychiatric Vocational Project” means one type of Extended Care Project which includes two
community-based projects jointly funded by DHS Rehabilitation Services under the Community
Services Program and AMH. These two projects, Bridges in Washington County and Laurel Hill in
Eugene, Provide Intensive Psychiatric Rehabilitation Services with a vocational emphasis. Placement
in these projects is approved by the AMH ECMU.
130. “Psychoeducational Program” means training conducted for the purpose of creating an awareness
of mental disorders and Treatment.
131. “Qualified Mental Health Associate” or “QMHA” means a person delivering services under the
direct supervision of a QMHP and meeting the following minimum qualifications as documented by
Contractor: a bachelor’s degree in a behavioral sciences field; or a combination of at least three
years’ relevant work, education, training or experience; and has the competencies necessary to
communicate effectively; understand mental health Assessment, treatment and service terminology
and to apply the concepts; and Provide psychosocial Skills Development and to implement
interventions prescribed on a Treatment Plan within their scope of practice.
132. “Qualified Mental Health Professional” or “QMHP” means a LMP or any other person meeting
the following minimum qualifications as documented by Contractor: graduate degree in psychology;
bachelor’s degree in nursing and licensed by the State of Oregon; graduate degree in social work;
graduate degree in behavioral science field; graduate degree in recreational, art, or music therapy; or
bachelor’s degree in occupational therapy and licensed by the State of Oregon; and whose education
and experience demonstrates the competencies to identify precipitating events; gather histories of
mental and physical disabilities, alcohol and drug use, past mental health services and criminal justice
contacts; assess Family, social and work relationships; conduct a mental status examination;
document a multiaxial DSM Diagnosis; write and supervise a Treatment Plan; conduct a
Comprehensive Mental Health Assessment; and Provide Individual Therapy, Family Therapy, and/or
Group Therapy within the scope of their training.
133. “Quality Assessment” or “QA” means the measurement of both the technical and interpersonal
aspects of care (process) and the outcomes of that care. As such, it is the first step in Quality
Assurance and improvement. It does not move beyond problem detection and measurement (IOM
1990).
134. “Quality Assurance” means a full cycle of activities for measuring Quality of Care and maintaining
it at acceptable levels.
135. “Quality Assessment/Performance Improvement Plan” or “QA/PI Plan” means a program that
includes the basic elements as described in 42 CRF 438.240.
136. “Quality of Care” means the degree to which services produce desired health outcomes and
satisfaction of Consumers, and are consistent with current best practices.
137. “Reasonable Accommodation” means consistent with the Americans with Disabilities Act of 1990
and Section 504 of the Rehabilitation Act of 1973, means a modification to policies, practices, or
procedures when the modification is necessary to avoid discrimination on the basis of Disability
unless the service provider can demonstrate that making the modification would fundamentally alter
the nature of the service, program or activity. Reasonable Accommodations may include, but are not
limited to, activities such as the following: (1) reading, or providing a tape of, material otherwise
provided in written format to a person with a visual impairment; (2) providing a service in a more
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accessible location for a person with a mobility and other impairment; (3) providing assistance to a
person with a Disability in completing applications and other paperwork necessary to receipt of
services; and (4) modifying a waiting area layout to accommodate a person in a wheelchair.
138. “Recoup” means to deduct or withhold (part of something due) for an equitable reason. Recoupment
occurs as a deduction on the next month's Capitation Payment and is reflected on the Remittance
Advice. Types of actions that can trigger a recoupment include mid-month OHP Member out of
Service Area moves, change of PHPs, and retroactive Disenrollment actions.
139. “Rehabilitative Services” means any Medically Appropriate remedial services for the maximum
reduction of a mental Disability and attainment by the covered individual of his/her best possible
functional level.
140. “Reinsurance” means to insure by contracting to transfer in whole or in part a risk or contingent
liability already covered under an existing contract.
141. “Remedial Action” means an action taken by AMH when, in its sole judgement, it determines that
Contractor is out of compliance with this Contract. A Remedial Action includes one or more of the
following actions: suspension of Enrollment of new OHP Members, reduction of the number of OHP
Members, or withholding of a portion of Capitation Payments. A Remedial Action continues until
such time as AMH determines that Contractor is in compliance with this Contract and AMH has
recovered all costs incurred in the provision of Covered Services required by this Contract.
142. “Residential Service” means the organization of services in a home or facility including room,
board, care and other services provided to adults assessed to be in need of such services. Residential
Services include, but are not limited to, Residential Care Facilities, Residential Treatment Facilities,
Residential Treatment Homes, Crisis Respite Services and Secure Residential Treatment Facilities.
Residential Services do not include Supported Housing programs.
143. “Residential Treatment Facility” means a facility that is operated to Provide supervision, care and
treatment on a 24-hour basis for six or more residents consistent with ORS 443.400 through ORS
443.455.
144. “Residential Treatment Home” means a home that is operated to Provide supervision, care and
treatment on a 24-hour basis for five or fewer residents consistent with ORS 443.400 through ORS
443.455.
145. “Restricted Reserve Fund” means a fund that is separate from ongoing operation accounts and is
limited for use to prevent insolvency. This fund is set up to meet unexpected cash needs and to cover
debts when an organization discontinues its role as a Contractor. This fund may not be used to meet
expected ongoing obligations such as withholds, incentive payments and the like.
146. “Secure Adolescent Inpatient Program” or “SAIP” means Services Provided in an appropriately
certified facility designated by AMH as LTPC, for adolescents, age 14 through 17, determined by the
AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC.
147. “Secure Children's Inpatient Program” or “SCIP” means Services Provided in an appropriately
certified facility designated by AMH as LTPC, for children, age 13 and under, determined by the
AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC.
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148. “Service” means the care, treatment, Service Coordination or other assistance provided to an OHP
Member.
149. “Service Area” means the geographic area in which Contractor is responsible for delivering Covered
Services under this Contract.
150. “Services Coordination” means Services provided to OHP Members who require access to and/or
receive services from one or more Allied Agencies or program components according to the
Treatment Plan. Services provided may include establishing precommitment service linkages;
advocating for treatment needs; and providing assistance in obtaining entitlements based on mental or
emotional Disability.
151. “Setting” means the locations at which Covered Services are provided. Settings include such
locations as mental health offices, an individual's home or school or other identified locations.
152. “Skills Training” means a program of rehabilitation as prescribed in the Treatment Plan which is
designed to improve social functioning in areas important to maintaining or re-establishing residency
in community, such as money management, nutrition, food preparation, community awareness, and
community mobility. Skills Training can be provided on an individual basis or in a group Setting.
153. “Special Health Care Needs” means individuals who either 1) have functional disabilities, or 2) live
with health or social conditions that place them at risk of developing functional disabilities (for
example, serious chronic illnesses, or certain environmental risk factors such as homelessness or
family problems that lead to the need for placement in foster care.
154. “Specialized Medication Adjustment” means medication adjustments that because of the
complexity or danger, require a level of expertise beyond that of the usual LMP for that setting or
client.
155. “Stabilization and Transition Services” or “STS” means services Provided in an appropriately
certified facility designated by AMH as LTPC for children and adolescents under age 17 determined
by the AMH Child and Adolescent Mental Health Specialist to be appropriate for LTPC, but who can
be served in an enhanced short term treatment Setting.
156. “Stakeholders” means persons, organizations and groups with an interest in how Covered Services
are delivered under this Contract. Stakeholders may include, but are not limited to, OHP Members,
Consumers, Families, Allied Agencies, child psychiatrists, child advocates, advocacy groups, and
other groups.
157. “State Hospital” means State-operated psychiatric hospitals including OSH in Salem and Portland,
and Eastern Oregon Psychiatric Center in Pendleton.
158. “Stop Loss Coverage” means protection against catastrophic and unexpected expenses related to
Covered Services. The method of protection may include the purchase of stop loss insurance,
Reinsurance, self insurance or any other alternative determined acceptable by AMH.
159. “Subacute Psychiatric Care” means care characterized by the commitment of treatment resources
toward the resolution or amelioration of a significant, but not serious, mental health problem over a
relatively short period of time.
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160. “Supported Housing” means provision of mental health rehabilitation services in the home or other
community Setting for the purpose of assisting a person to live independently. Such services
typically include skill development in money management, nutrition, and community living;
assistance with health issues and taking prescribed medications; and provision of supportive
counseling.
161. “Tertiary Treatment” means complementary medical, psychological, or rehabilitative procedures
designed to eliminate, relieve or minimize mental or emotional disorders.
162. “Therapeutic Group Home” means a home providing planned Treatment to a child in a small
residential Setting. Treatment includes theoretically based individual and group home Skills
Development and Medication Management, Individual Therapy and Consultations as needed, to
remediate significant impairments in the child's functioning that are the result of a principal mental or
emotional disorder diagnosed on Axis I of the DSM multi-axial Diagnosis.
163. “Third Party Resources and Personal Injury Lien” mean any payments, benefits, or other
resources available from a Third Party, including but not limited to:
a. Private health insurance or group health plan;
b. Employment-related health insurance;
c. Medical support from absent parents;
d. Workers’ compensation;
e. Medicare;
f. Automobile liability insurance; and
g. Other federal programs such as Veteran's Administration, Armed Forces Retirees and
Dependent Act (CHAMPVA), Armed Forces Active Duty and Dependents Military Medical
Benefits Act (CHAMPUS), and Medicare Parts A and B, unless excluded by statute as for
example:
(1) Services provided to OHP Members pursuant to 42 CFR 136.61 Indian Health Service
(IHS) is the payor of last resort and is not considered a Third Party Resource; or
(2) Services provided to OHP Members at a tribal facility operated under a “638”
agreement pursuant to the Memorandum of Agreement between IHS and CMS is a
payor of last resort and is not considered a Third Party Resource.
h. Claims, judgments, settlements or compromises in relation to personal injuries where the
Covered Services paid by Contractor constitute assistance, as these terms are defined in ORS
416.510.
i. Another state's Title XIX, Title XXI, or state-funded Medical Assistance Program.
j. Personal estates.
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164. “365 Project” means one type of Extended Care Program which is a community-based alternative to
Oregon State Hospital services developed on an individualized basis for persons with state
hospitalization episodes of one year or longer. These are extended care projects that Provide
intensive services and supports to enable approved adults to live in community rather than
institutional Settings. Persons must be approved for placement in these projects by the AMH ECMU.
165. “Traditional Service” means a Medically Appropriate mental health service defined in the State of
Oregon, OHP Service Categories for Per Capita Costs, October 2001 through September 2002.
Traditional Services are those services that have historically been used to treat mental disorders and
include services for which Medicaid FFS billing categories exist. For OHP Members under 21 years
of age Traditional Services include the following: interpreter services; Assessment and Evaluation;
Consultation; Clinical Services Coordination; Case Management; Medication Management;
Individual Therapy, Family Therapy and Group Therapy; Multi-Family Treatment Group; Individual
Skills Development and Group Skills Development; Intensive Treatment, Structure and Support; 24-
hour Urgent and Emergency Response; and Acute Inpatient Hospital Psychiatric Care. For OHP
Members 21 years of age and older Traditional Services include the following: interpreter services;
Assessment and Evaluation; Consultation; Case Management; Medication Management; Individual
Therapy, Family Therapy and Group Therapy; Daily Structure and Support; Individual and Group
Skills Training; 24-hour Urgent and Emergency Response; Acute Inpatient Hospital Psychiatric Care;
and Covered Services provided in a variety of residential Settings.
166. “Treatment” means a planned, Medically Appropriate, individualized program of interactive
medical, psychological, or rehabilitative procedures, experiences, and/or activities designed to
rehabilitate, relieve or minimize mental or emotional disorders identified through a mental health
Assessment.
167. “Treatment Foster Care” means a program of rehabilitation as prescribed in the Treatment Plan and
provided in the child's foster home. Skill development activities are delivered on an individualized
basis and are designed to promote skill development in areas identified in the Treatment Plan. The
service requires the use of Treatment Foster Care in coordination with other mental health
interventions to reduce symptoms associated with the child's mental or emotional disorder and to
provide a structured, therapeutic environment. The service is intended to reduce the need for future
services, increase the child's potential to remain in the community, restore the child's best possible
functional level, and to allow the child to be maintained in a least restrictive setting.
168. “Treatment Parameters” means the set of all variables that may affect the treatment of a client.
Included in this set are providers, medical treatments, psychological treatments, and social
interventions.
169. “Treatment Plan” means a written individualized comprehensive plan based on a completed mental
health Assessment documenting the OHP Member's treatment goals, measurable objectives, the array
of services planned, and the criteria for goal achievement.
170. “Twenty-four (24) Hour Urgent and Emergency Services” means Services available 24 hours per
day for persons experiencing an acute mental or emotional disturbance potentially endangering their
health or safety or that of others, (or with respect to a pregnant woman, the health of the woman or
her unborn child), but not necessarily creating a sufficient cause for Civil Commitment as set forth in
OAR 309-033-0200 through 309-033-0340.
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171. “Urban Indian Organization” means a clinic designated as an Urban Indian Health Program
(UIHP) under Title V of the Indian Health Care Improvement Act, Public Law 94-437, enrolled with
DHS as a FQHC.
172. “Urgent Care” means care which is medically necessary within 48 hours to prevent a serious
deterioration in an OHP Member's mental health.
173. "Urgent Situation” means a situation requiring attention within 48 hours to prevent a serious
deterioration in an OHP Member's mental health.
174. “Usual and Customary Charges” means a required field in Exhibit H which reflects the provider’s
charge per unit of service established in accordance with OAR 410-120-0000 or other applicable state
and federal laws, rules and regulations, not in excess of the provider’s usual and customary charge to
the general public.
175. “Usual and Customary Treatment” means the application of Treatment used to prevent the need
for LTPC. Treatments include the following: (1) medical screens and Assessments used to rule out a
medical condition or identify a medical condition that may be impacting a mental disorder; (2)
appropriate use of psychotropic medications in therapeutic dosages and adjustments to such dosages
to minimize side effects; (3) other cognitive and behavioral therapeutic interventions; and (4) review
of options for discharge to nonhospital levels of care. For members who will be admitted to the
OSH-GTS, Usual and Customary Treatment includes coordination of the stabilization of acute
medical problems.
176. “Utilization” means the amount and/or pattern of Covered Services used by an OHP Member,
measured, for example, in dollars, units of service, or staff time.
177. “Utilization Guidelines” means guidelines for the amount of Covered Services expected to be used
by an OHP Member with a specific mental disorder over time.
178. “Utilization Management” means the process used to regulate the provision of services in relation
to the overall Capacity of the organization and the needs of Consumers.
179. “Valid Claim” means an invoice received by the Contractor for payment of Covered Services
rendered to an OHP Member which can be processed without obtaining additional information from
the provider of the service or from a third party; and has been received within the time limitations
prescribed in Oregon Administrative Rule 410-141-0420; Billing and Payment under the Oregon
Health Plan and is synonymous with the federal definition of a "clean claim" as defined in 42 CFR
447.45(b).
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Exhibit B – Statement of Work
Contractor agrees to perform the Work in accordance with the terms, conditions, and
specifications provided in this Contract, including the Statement of Work.
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Exhibit B – Statement of Work – Part I - Benefits
1. Benefit Package
Contractor shall Provide OHP Plus Benefit Package and OHP Standard Benefit Package of Covered
Services to OHP Members consistent with OAR 410-141-0120, Oregon Health Plan Prepaid Health Plan
Provision of Health Care Services; OAR 410-141-0520, Prioritized List of Health Services; and OAR
410-141-0480, Oregon Health Plan Benefit Package of Covered Services. Covered Services shall be
sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the
Services are provided. Contractor shall ensure that the Services offered are in an amount, duration, and
scope that is no less than that furnished to OHP Clients under FFS. Contractor may cover, for OHP
Members, Services that are in addition to those covered under the State plan.
a. OHP Plus Benefit Package
A benefit package with a comprehensive range of Services available to OHP Members who are
over the age of 65, the disabled, the TANF population, General Assistance recipients, pregnant
women and children under the age of 19.
b. OHP Standard Benefit Package
A benefit package that provides basic health care Services for adults who are not otherwise
eligible for Medicaid (Families, Adults/Couples). This benefit package has premiums
requirements.
c. Flexible Services
When delivering a Flexible Service (as opposed to using a Flexible Service Approach) and the
Provider rendering a Flexible Service is not licensed or certified by a state board or licensing
agency, or employs personnel to Provide the Service who do not meet the definition for
Qualified Mental Health Associate (QMHA) or Qualified Mental Health Professional (QMHP)
as described in Exhibit A, Definitions, Provider must meet criteria described in Exhibit B, Part
II, Section 3, Credentialing Process, Subsection a.(1)(b).
d. Provision of Covered Services
(1) Contractor shall provide reimbursement for Covered Services obtained outside its Service
Area when such Covered Services are not available within its Service Area.
(2) Notwithstanding 410-141-0500, (1) (b), Contractor shall provide Covered Services as
Medically Appropriate to those CAF children residing inside the Contractor’s Service
Area and those children whose placement by CAF for Behavioral Rehabilitative Services
(BRS) is outside the Contractor’s Service Area.
(3) Contractor shall Provide all Covered Services to OHP Members but may require, except
in an emergency, that OHP Members obtain such Covered Services from Contractor or
Providers affiliated with Contractor. Contractor shall adjudicate Valid Claims within 45
calendar days of receipt. Contractor shall ensure that neither DHS nor the OHP Member
receiving Services are held liable for any costs or charges related to Covered Services
rendered to an OHP Member whether in an emergency or otherwise.
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(4) Contractor’s obligation to pay for Emergency Services that are received from non-
Participating Providers is limited to Covered Services that are needed immediately and
the time required to reach Contractor or a Participating Provider (or alternatives
authorized by Contractor) would have meant substantial risk to the OHP Member’s health
or safety or the health or safety of another.
(a) Covered Services following the provision of Emergency Services are considered
to be Emergency Services as long as transfer of the OHP Member to Contractor or
a Participating Provider or the designated alternative is precluded because of risk
to the OHP Member’s health or safety or that of another because transfer would
be unreasonable, given the distance involved in the transfer and the nature of the
mental health condition.
(b) Contractor is responsible for arranging for transportation and transfer of the OHP
Member to Contractor’s care when it can be done without harmful consequences.
(5) Contractor shall pay for Covered Services, subject to the protection of the prudent
layperson requirements in Exhibit B-Part I, Section 1, Subsection d(4)(a) needed to assess
an Emergency Situation. If Contractor has a reasonable basis to believe that Covered
Services claimed to be Emergency Services were not in fact Emergency Services,
Contractor may deny payment for such Services. Such Services shall not be considered
Covered Services. In such circumstances, Contractor shall, within 45 calendar days of
receipt of a claim for payment, notify:
(a) The Provider of such Services of the decision to deny payment, the basis for that
decision, and the Provider’s right to contest that decision.
(b) The OHP Member of the decision to deny payment as described in Exhibit N,
Grievance System.
(6) Contractor may not prohibit or otherwise restrict a mental Health Care Professional
(acting within the lawful scope of practice) from advising or advocating on behalf of an
OHP Member for:
(a) the OHP Member’s mental health care status, medical care or treatment options,
including any alternative treatment that may be self-administered, regardless of
whether Contractor provides benefits for the particular type of care or treatment;
(b) any information the OHP Member needs in order to decide among all the relevant
treatment options;
(c) the risks, benefits, and consequences of treatment or non-treatment;
(d) the OHP Member’s rights to participate in decisions regarding his or her mental
health care as cited in 42 CFR 438.102 (a)(1)(iv), including the right to refuse
treatment, and to express preferences about future treatment decisions.
(7) Contractor shall Provide for a second opinion from a qualified mental Health Care
Professional within the Provider Panel, or arrange for the ability of the OHP Member to
obtain one outside the Provider Panel, at no cost to the OHP Member.
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(8) As per 42 CFR 438.102, Contractor is not required to provide coverage or reimburse a
counseling or referral Service if Contractor objects to the Service on moral or religious
grounds. Contractor shall notify AMH if there are any Services not provided by the
Contractor due to moral or religious reasons or if there is no limitation on Services.
Contractor shall provide this notification at least 30 days before the start of a new
Contract or implementation of a newly adopted policy. If Contractor has not changed its
policy regarding provision of Services since the beginning of the preceding contract year,
it shall so notify AMH by submission of Schedule 8. Contractor shall provide this
information to OHP Members within 90 days of any changes to its policy. Contractor
shall also make available this same information to Potential OHP Members upon request.
e. Mental Health Services Which are Not Covered Services
Contractor shall assist its OHP Members in gaining access to certain mental health Services that
are not Covered Services and that are provided under separate contract with DHS. Services that
are not Covered Services include, but are not limited to, the following:
(1) Medical Transportation pursuant to rules (OAR 410-136-0020 et. seq.) promulgated by
DHS and published in its Medical Transportation Services Guide;
(2) Medication;
(3) Therapeutic Foster Care reimbursed under HCPC Code S5145 for OHP Members under
21 years of age;
(4) Therapeutic Group Home reimbursed for OHP Members under 21 years of age;
(5) Behavioral Rehabilitative Services that are financed through Medicaid and regulated by
DHS Services to Children and Families and OYA;
(6) Investigation of OHP Members for Civil Commitment;
(7) LTPC as defined in Exhibit B, Part II, Section 1, Subsection c (10), for OHP Members 21
years of age and older;
(8) PASRR for OHP Members seeking admission to a Nursing Home;
(9) LTPC for OHP Members age 17 and under;
(a) Secure Children's Inpatient program (SCIP)
(b) Secure Adolescent Inpatient Program (SAIP)
(c) Stabilization and Transition Services (STS)
(10) Extended care Services for OHP Members 18 years of age and older including Extended
Care Management, Enhanced Care Services provided in SPD Program licensed facilities,
“365” Projects, Psychiatric Vocational Projects, PASSAGES Projects, and other Services
developed as less restrictive alternatives to LTPC at an Oregon State Hospital;
(11) Personal Care in Adult Foster Homes for OHP Members 21 years of age and older;
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(12) Other Residential Services for OHP Members 21 years of age and older provided in
Residential Care Facilities, Residential Treatment Facilities and Residential Treatment
Homes;
(13) Services provided to persons while in the custody of a correctional facility or jail;
(14) Abuse investigations and protective Services as described in OAR 309-040-0200 through
309-040-0290, Abuse Reporting and Protective Services in Community Programs and
Community Facilities, and ORS 430.735 through ORS 430.765, Abuse Reporting for the
Mentally Ill; and
(15) Personal Care Services as described in OAR 411-034-0000 through 411-034-0090 and
OAR 309-040-0300 through 309-040-0330.
f. Client Notices
Each time a Service or benefit will be terminated, suspended or reduced, or a request for Service
authorization or request for claim payment is denied, Contractor shall issue a Notice of Action.
Contractor is not obligated to issue a Notice of Action under one or more of the conditions
described in Exhibit N, Grievance System. Contractor shall make available in all clinics,
Participating Provider offices, and other Service locations frequented by OHP Members,
information concerning Client Notices, Grievances, Appeals, and Administrative Hearings.
g. Practice Guidelines
Contractor shall adopt practice guidelines that are based on valid and reliable clinical evidence or
a consensus of mental health professionals. These practice guidelines must consider the needs of
OHP Members, be adopted in Consultation with Contractor’s Participating Providers, and be
reviewed and updated periodically as appropriate. Contractor shall disseminate the practice
guidelines to all affected Providers and, upon request, to OHP Member or OHP Member
Representative. Decisions for Utilization Management, OHP Member education, coverage of
Services, or other areas to which the guidelines apply, should be consistent with the adopted
practice guidelines.
h. Utilization Management
(1) Contractor shall have written Utilization Management policies, procedures and criteria
for Covered Services. These Utilization Management procedures shall be consistent with
appropriate Utilization control requirements of 42 CFR Part 456.
(2) Contractor shall provide compensation to subcontractors that conduct Utilization
Management activities and is not structured so as to provide incentives for the
subcontractors to deny, limit or discontinue Medically Appropriate services to any OHP
Member.
(3) Contractor may adopt Treatment Parameters or Utilization Guidelines which result in
limitations being placed on Covered Services; however, Contractor shall assure that
Medically Appropriate level of Covered Services is provided based on the needs of the
OHP Member regardless of limits specified in any such Treatment Parameters or
Utilization Guidelines. Contractor may not arbitrarily deny or reduce the amount,
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Contract #129162 Exhibit B – Part I Page 38 of 241
duration, or scope of a Covered Service solely because of the Diagnosis, type of illness,
or condition, subject to the Prioritized List of Health Services.
(4) If Contractor adopts Treatment Parameters or Utilization Guidelines, Contractor shall
provide copies of such existing Treatment Parameters and Utilization Guidelines to AMH
as of the effective date of this Contract, within 45 calendar days of change or adoption,
and within 30 calendar days of AMH request.
(5) Contractor shall disseminate Treatment Parameters or Utilization Guidelines to all
affected Providers and, upon request, to OHP Member or OHP Member Representative.
(6) If Contractor adopts Treatment Parameters or Utilization Guidelines, Contractor shall
establish an appeal process that allows for an independent clinical review of the decision
by one or more QMHPs who were not involved in the original Utilization Management
decision. Contractor may use its appeal process for resolving Utilization Management
appeals.
(a) The appeal process of Contractor shall afford those persons requesting Covered
Services an expeditious method of reviewing Utilization Management decisions.
(b) Contractor shall have written policies and procedures for its Utilization
Management appeal process, notify organizations, agencies and Health Care
Professionals requesting Covered Services of such process, and, upon request,
provide a copy of written Utilization Management appeal policies and procedures.
(c) Contractor shall maintain records of all Utilization Management appeals made
and shall document all review decisions in writing. Records of Utilization
Management appeals and decisions shall be made available, within limits of laws
or rules governing confidentiality, to the person appealing the original Utilization
Management decision.
i. Authorization for Services
(1) Contractor and subcontractor, if so delegated shall have written policies and procedures
for processing requests for initial and continuing authorization of services from an OHP
Member of Provider
These procedures shall include mechanisms to ensure consistent application of review
criteria for authorization decisions; which would include the consultation with the
requesting Provider when appropriate
(2) Decisions made by a Health Care Professional with the appropriate clinical expertise in
treating the OHP Member’s mental health condition, must be included in any
determination to deny a service authorization request or to authorize a service in an
amount, duration, or scope that is less than requested. Notification of any adverse
decision made must occur in writing and provided to the OHP Member and Provider.
Notification to the Provider need not be in writing.
(3) For standard Service authorization requests, Contractor and subcontractor, if so
delegated, shall provide notice as expeditiously as the OHP Member’s mental health
condition requires, not to exceed fourteen (14) calendar days following receipt of the
request for Service, with a possible extension of 14 additional calendar days if the OHP
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Member or Provider requests extension, or if the Contractor justifies a need for additional
information and how the extension is in the OHP Member’s interest. If Contractor
extends the time frame, Contractor shall give the OHP Member and Provider a written
notice of the reason for the decision to extend the timeframe and inform the OHP
Member of the right to file a Grievance if he or she disagrees with that decision. When a
decision is not reached regarding a Service authorization request within the timeframes
specified above, Contractor shall issue a Notice of Action to the Provider and OHP
Member, or OHP Member Representative, consistent with Exhibit N, Grievance System.
(4) If an OHP Member or Provider requests, or Contractor determines, that following the
standard timeframes could seriously jeopardize the OHP Member’s life or health or
ability to attain, maintain, or regain maximum function, Contractor shall make an
expedited Service authorization decision and provide Notice as expeditiously as the OHP
Member’s mental health condition requires and no later than 3 working days after receipt
of the request for Service. Contractor may extend the 3 working days time period by up
to 14 calendar days if the OHP Member requests an extension, or if Contractor justifies a
need for additional information and how the extension is in the OHP Member’s interest.
j. Contractor shall comply with ORS 127.703, Required Policies Regarding Mental Health
Treatment Rights Information; Declaration for Mental Health Treatment.
2. Revision of Covered Services
Consistent with state law, Covered Services may be expanded, limited or otherwise changed by the
HSC, by a vote of the people, or by the Legislative Assembly. Contractor shall Provide Covered
Services consistent with the expansion or limitation, subject to Contractor’s right to terminate this
Contract as provided for in Exhibit D, Section 10, Termination and Section 18, Amendments. DHS will
promptly notify Contractor by certified mail of changes to Covered Services.
3. (Reserved)
4. Accessibility and Continuity of Care
a. Contractor shall meet, and require Providers to meet, OHP standards for timely access to care
and Services, taking into account the urgency of need for Services. Contractor shall comply with
OAR 410-141-0220, Oregon Health Plan Prepaid Health Plan Accessibility and OAR 410-141-
0160, Oregon Health Plan Prepaid Health Plan Continuity of Care. Contractor shall ensure that
Providers do not discriminate between OHP Members and non-OHP persons as it relates to
benefits and services to which they are both entitled and shall ensure that Providers offer hours
of operation to OHP Members that are no less than those offered to non-OHP Members.
b. In addition to access and Continuity of Care standards specified in the rules cited in Subsection
a, of this section, Contractors shall establish standards for access to Covered Services and
Continuity of Care which, at a minimum, include the following:
(1) For Urgent Services and Emergency Services, Contractor shall assure that OHP Members
receive an initial face-to-face or telephone screening within fifteen minutes of contact to
determine the nature and urgency of the situation.
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(2) For Emergency Services, Contractor shall assure that OHP Members receive timely
Covered Services within time frames identified by the urgent and emergency response
screening or within 24 hours of contact, whichever is shorter.
(3) For Urgent Services, Contractor shall assure that OHP Members receive timely Covered
Services within time frames identified by the urgent and emergency response screening
or within 48 hours of request, whichever is shorter.
(4) For non-Urgent Services and non-Emergency Services, Contractor shall assure that OHP
Members wait no more than two calendar weeks to be seen for an Intake Assessment
following a request for Covered Services.
(5) For post-hospital services, Contractor shall assure that OHP Members receive a Covered
Service within one calendar week following discharge from Acute Inpatient Psychiatric
Hospital Care or that such OHP Members receive follow-up Covered Services within a
Medically Appropriate period of time.
(6) For missed appointments, Contractor shall follow-up and reschedule appointments or
Provide Outreach Services as Medically Appropriate or needed to prevent serious
deterioration of the OHP Member’s mental health condition.
(7) For routine travel time from the OHP Member residence to the Participating Provider,
Contractor shall assure that OHP Members spend no more time traveling than the
Community Standard.
(8) For OHP Members who are placed in substitute care b y DHS, Contractor shall Provide a
comprehensive mental health Assessment consistent with access and Continuity of Care
standards specified in Subsection a, of this section. Contractor shall provide this
Assessment no later than 60 days following the date of placement.
c. Contractor shall establish mechanisms to ensure that Providers comply with the timely access
requirements, monitor regularly to determine compliance, and take Corrective Action if there is a
failure to comply.
d. Contractor shall have a method of responding to telephone calls from non-English speaking OHP
Members and shall make available to these OHP Members, interpreters capable of effectively
receiving, interpreting and translating routine and clinical information.
e. Contractor shall have a method of responding to telephone calls from hearing impaired OHP
Members and shall make available to these OHP Members, TDD Service and sign language or
oral interpreters capable of effectively receiving, interpreting and translating routine and clinical
information.
f. Contractor shall make Reasonable Accommodations to administrative practices and Service
approaches for Service access and Continuity of Care for OHP Members with Disability.
g. Contractor shall allow OHP Members to request an Assessment and Evaluation without
obtaining a referral from another Provider.
h. Contractor shall Provide each OHP Member with an opportunity to select an appropriate Mental
Health Practitioner and Service site.
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i. Contractor shall ensure that each Native American or Alaska Native enrolled with Contractor
shall be allowed to choose an Indian Health Care Provider as the OHP Member’s primary mental
health care Provider if:
(1) An Indian Health Care Provider is participating as a primary mental health care Provider
within the Contractor’s network; and
(2) The Native American or Alaska Native OHP Member is otherwise eligible to receive
services from such Indian Health Care Provider; and
(3) The Indian Health Care Provider has the capacity to Provide primary mental health care
services to such OHP Members.
j. Contractor shall Provide for the identified Covered Service needs of an OHP Member during
transfer from one practitioner or hospital to another regardless of whether the practitioners or
hospitals are Participating Providers. Contractor shall develop a written plan for Continuity of
Care to avoid a worsening of the OHP Member’s mental disorder when transitioning the OHP
Member. Contractor shall document that such plan is acceptable to the OHP Member and/or
OHP Member Representative or that the OHP Member and/or OHP Member Representative has
been advised of the Grievance and Administrative Hearings processes.
k. Contractor shall not deny Covered Services to, or request Disenrollment of, an OHP Member
based on disruptive or abusive behavior resulting from symptoms of a mental disorder or from
another Disability. Contractor shall develop an appropriate Treatment Plan with the OHP
Member and the Family or advocate of the OHP Member to manage such behavior.
l. Contractor shall implement mechanisms to assess each OHP Member with Special Health Care
needs in order to identify any ongoing special conditions that require a course of mental health
treatment or care management. The Assessment mechanisms must use appropriate Mental Health
Practitioners.
(1) For OHP Members with Special Health Care Needs determined to need a course of
treatment or regular care monitoring, the Treatment Plan must be developed by the
Mental Health Practitioner with OHP Member participation and in Consultation with any
specialists caring for the OHP Member; approved by Contractor in a timely manner, if
approval is required; and developed in accordance with any applicable DHS Quality
Assessment and Performance Improvement and Utilization Review standards.
(2) Based on the Assessment, Contractor shall assist OHP Member with Special Health Care
Needs in gaining direct access and Medically Appropriate to mental health specialists for
treatment of the OHP Member’s condition and identified needs.
(3) Contractor shall implement procedures to share with OHP Member’s primary health care
provider and FCHP the results of its identification and Assessment of any OHP Member
with Special Health Care Needs so that those activities need not be duplicated. Such
coordination and sharing of information shall be conducted within Federal and State
laws, rules, and regulations governing confidentiality.
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Exhibit B –Statement of Work – Part II – Providers and Delivery System
1. Delivery System Configuration
a. Delivery System Capacity
(1) Contractor shall have written policies and procedures for selection and retention of
Providers. Contractor shall maintain and monitor a Provider Panel that is supported
with written agreements, and that has sufficient Capacity and expertise to Provide
adequate, timely and Medically Appropriate access to Covered Services to OHP
Members across the age span from child to older adult. In establishing and
maintaining the Provider Panel, Contractor shall consider the following:
(a) The anticipated Medicaid Enrollment;
(b) An appropriate range of preventive and specialty services for the population
enrolled or expected to be enrolled in the Service Area;
(c) The expected Utilization of Services, taking into consideration the
characteristics and mental health care needs of OHP Members;
(d) The number and types (in terms of training, experience, and specialization) of
Providers required to Provide Services under this Contract;
(e) The number of Providers who are not accepting new OHP Members;
(f) The geographic location of Providers and OHP Members, considering distance,
travel time, the means of transportation ordinarily used by OHP Members, and
whether the location provides physical access for OHP Members with
Disabilities;
(g) Contractor shall allow each OHP Member to choose a Provider within
Contractor’s Provider Panel to the extent possible and appropriate.
(h) Contractor shall provide OHP Members with access, as Medically Appropriate,
to psychiatrists, other licensed medical professionals, or mental health
professionals.
(i) Contractor shall demonstrate that the number of Indian Health Care Providers
that are Participating Providers sufficient to ensure timely access to Covered
Services within the scope of Covered Services specified under this Contract,
for those Native American or Alaska Natives enrolled with the Contractor who
are eligible to receive services from such providers, or demonstrate in the
Contractor’s Service Area(s) that there are no or few Indian Health Care
Providers.
(2) Contractor shall identify training needs of its Provider Panel and address such needs to
improve the ability of the Provider Panel to deliver Covered Services to OHP
Members.
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(3) If Contractor is unable to Provide necessary Covered Services which are Medically
Appropriate to a particular OHP Member within its Provider Panel, Contractor shall
adequately and timely cover these services out of network for the OHP Member, for as
long as Contractor is unable to Provide them. Out of network providers must
coordinate with Contractor with respect to payment. Contractor shall ensure that cost
to OHP Member is no greater than it would be if the Services were provided within
the Provider Panel.
(4) Contractor shall participate in AMH efforts to promote the delivery of Services in a
Culturally Competent manner to OHP Members, including those with limited English
proficiency and diverse cultural and ethnic backgrounds.
(5) Contractor shall coordinate its Service delivery system planning effort with organized
planning efforts carried out by the LMHA of its Service Area.
b. Components of the Delivery System
(1) Services Coordination
(a) Contractor shall have written policies and procedures for the provision of
Services Coordination for those OHP Members with unique needs or requiring
Services from more than one Allied Agency.
(b) Contractor shall manage all Covered Services for its OHP Members with
unique needs or requiring Services from more than one Allied Agency. Such
policies and procedures shall be specific to these agencies.
(2) Preventive and Early Intervention Services
(a) Contractor shall establish and conduct preventive mental health and
Psychoeducational Programs to decrease the incidence, prevalence, and
residual effects of mental disorders in selected areas of the OHP Member
population.
(i) Contractor shall have screening mechanisms to determine the presence
and prevalence of mental disorders in its OHP Membership.
(ii) Contractor shall develop and adopt programs with the participation of
Health Care Professionals, OHP Members, Family members and Allied
Agencies.
(iii) Contractor shall have Services that are appropriate to the age, gender,
socioeconomic status, ethnicity, clinical history, and risk characteristics
of its OHP Membership.
(iv) Contractor shall have mechanisms to inform its OHP Members, Family
members, and Health Care Professionals about its preventive and
Psychoeducational Programs.
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(v) Contractor shall have mechanisms to monitor the use of its preventive
and Psychoeducational Programs and assess their impact on the OHP
Membership.
(vi) Contractor shall take actions to improve the appropriate use of
preventive and Psychoeducational Programs.
(b) Contractor shall regularly encourage OHP Members, Health Care
Professionals, and Family members to use its preventive and
Psychoeducational Programs and Services.
(3) Rehabilitative Treatment Services
(a) Contractor shall establish and make available Services for OHP Members who
have non-urgent or non-emergency needs for Covered Services. These
Services shall include Rehabilitative Covered Services.
(b) Contractor shall establish written policies and procedures that ensure Covered
Services, which are Rehabilitative, are provided within Medically Appropriate
time frames.
(4) 24 Hour Urgent and Emergency Response System
(a) Contractor shall furnish covered mental health Emergency Services that are
needed immediately, or appear to be needed immediately by a prudent
layperson, because of a sudden mental health condition. Contractor is
responsible for coverage and payment for mental health Emergency Services
and Post-Stabilization Services which are Medically Appropriate, until the
emergency is stabilized, including those of non-participating Mental Health
Practitioners or licensed facilities. Contractor may not deny payment for
covered mental health Emergency Services or Post-Stabilization Services
obtained under either of the following circumstances:
(i) an OHP Member had an Emergency Situation, including cases in which
a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate
medical attention to result in placing the health of the individual in
serious jeopardy, serious impairment or dysfunction of any bodily part
or organ; or
(ii) when a representative of the Contractor, or its Providers, instructs the
OHP Member to seek Emergency Services.
(b) Contractor may not limit what constitutes an Emergency Situation on the basis
of lists of diagnoses or symptoms.
(c) Contractor may not refuse to cover Emergency Services based on Provider’s
failure to notify Contractor, of the OHP Member’s screening and treatment,
within 10 calendar days of the OHP Member’s presentation for Emergency
Services.
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(d) An OHP Member who presents for Emergency Services may not be held liable
for payment of subsequent Services needed to diagnose the specific condition
or stabilize the OHP Member.
(e) The attending physician, or the Provider actually treating the OHP Member, is
responsible for determining when the OHP Member is sufficiently stabilized
for transfer or discharge, and that determination is binding on Contractor.
(f) Contractor is financially responsible for Post-Stabilization Services under the
following circumstances:
(i) Post-Stabilization Services that have been pre-approved by Contractor,
or subcontractor;
(ii) Post-Stabilization Services that have not been pre-approved but
provided to maintain the OHP Member’s stabilized condition within 1
hour of a request to the Contractor, or subcontractor for pre-approval of
further Post-Stabilization Services;
(iii) Post-Stabilization Services that have not been pre-approved but were
provided to maintain, improve, or resolve the OHP Member’s stabilized
condition if Provider does not receive a response to a request for pre-
approval within 1 hour; the Contractor, or subcontractor cannot be
contacted; or an agreement cannot be reached between subcontractor
and treating Provider and Contractor is not available for Consultation.
In this situation, the treating Provider may continue Services to the
OHP Member until Contractor can be reached.
(g) Contractor’s financial responsibility ends for Post-Stabilization Services that
have not been pre-approved when:
(i) Contractor’s Participating Provider with privileges at the treating
hospital assumes responsibility for the OHP Member’s care;
(ii) Contractor’s Participating Provider assumes responsibility for OHP
Member’s care through transfer;
(iii) Subcontractor and treating Provider reach an agreement concerning the
OHP Member’s care; or
(iv) The OHP Member is discharged.
(h) Contractor shall establish, consistent with OAR 410-141-0140, Oregon Health
Plan Prepaid Health Plan Emergency and Urgent Care Medical Services, an
Urgent and Emergency Response System that operates 24 hours per day, 7
days per week.
(i) Contractor shall have, and adhere to, written policies and procedures for an
Emergency Response System that provides an immediate, initial and/or limited
duration response consisting of: a telephone or face to face screening to
determine the nature of the situation and the person’s immediate need for
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Covered Services; capacity to conduct the elements of a mental health
Assessment that are needed to determine the interventions necessary to begin
stabilizing the crisis situation; development of a written initial Services plan at
the conclusion of the mental health Assessment; provision of Covered Services
and/or Outreach needed to address the Urgent or Emergency Situation; and
linkage with the public sector crisis services, such as precommitment.
(5) Involuntary Psychiatric Care
(a) Contractor shall make a reasonable effort to Provide Covered Services on a
voluntary basis and consistent with current Declaration for Mental Health
Treatment in lieu of involuntary treatment.
(b) Contractor shall have written policies and procedures describing the
appropriate use of Emergency Psychiatric Holds and alternatives to
Involuntary Psychiatric Care when a less restrictive voluntary Service will not
meet the Medically Appropriate needs of the OHP Member and the behavior of
the OHP Member meets legal standards for the use of an Emergency
Psychiatric Hold.
(c) Contractor shall only use psychiatric inpatient facilities and non-inpatient
facilities certified by DHS under OAR 309-033-0200 through 309-033-0340,
Standards for the Approval of Facilities that Provide Care, Custody and
Treatment to Committed Persons or to Persons in Custody or on Diversion, to
Provide Emergency Psychiatric Holds.
(d) Contractor shall comply with ORS Chapter 426, OAR 309-033-0200 through
309-033-0340, and OAR 309-033-0400 through 309-033-0440 for involuntary
Civil Commitment of those OHP Members who are civilly committed under
ORS 426.130.
(e) Contractor shall administer medication to OHP Members held or civilly
committed under ORS Chapter 426, regardless of Setting, only as permitted by
applicable statute and administrative rule. Contractor shall not transfer civilly
committed OHP Members to a State Hospital for the sole purpose of obtaining
authorization to administer medication on an involuntary basis.
(6) Acute Inpatient Hospital Psychiatric Care
(a) Contractor shall maintain agreements with local and regional hospitals for the
provision of emergency and non-emergency hospitalization for OHP Members
with mental disorders that require Acute Inpatient Hospital Psychiatric Care.
Hospitals selected must comply with standards as described in Exhibit B, Part
II, Section 4, Credentialing Process, Subsection a.(2) and (3).
(b) Contractor shall cover the cost of Acute Inpatient Hospital Psychiatric Care for
OHP Members who do not meet the criteria for LTPC.
(c) Contractor may request of AMH ECMU the transfer of an OHP Member from
an Acute Inpatient Hospital Psychiatric Care Setting to a highly secure
psychiatric Setting when Contractor believes that the extremely assaultive
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Contract #129162 Exhibit B – Part II Page 47 of 241
behavior of the OHP Member warrants such a Setting. If the OHP Member
does not consent to such a transfer, Contractor may, subject to applicable law,
initiate an Emergency Psychiatric Hold and a pre-commitment investigation.
The care rendered to an OHP Member transferred to a highly secure
psychiatric Setting at Contractor’s request is a Covered Service and the cost
thereof shall be borne by Contractor unless and until the OHP Member is
determined appropriate for LTPC in accordance with the process described in
this Contract. If the OHP Member is admitted to a State Hospital, Contractor
shall pay the usual and customary rates for this level of Service until such time
as the OHP Member is discharged or determined appropriate for LTPC.
(d) Contractor shall coordinate admissions to and discharges from Acute Inpatient
Hospital Psychiatric Care for OHP Members in the care and custody of DHS
Children, Adults, and Family Services or OYA with such OHP Member’s
DHS Services to Children and Families or OYA case manager. For an OHP
Member placed by DHS Children, Adults, and Family Services through a
Voluntary Child Placement Agreement (SCF form 499), coordination shall
also occur with such OHP Member’s parent or legal guardian.
(7) Contractor shall take into consideration the Service needs of OHP Members with
Special Health Care Needs when establishing its Provider network.
(8) Integrated Service Array (ISA) for Children and Adolescents
(a) The ISA is a range of service components for children and adolescents,
through and including age 17. These services target the population with severe
mental or emotional disorders whose needs have not been adequately
addressed in traditional Settings. Contractor shall ensure that the ISA will be
recovery focused, family guided, and time limited based on Medically
Appropriate criteria. In communities that lack AMH certified Psychiatric Day
Treatment programs for children and adolescents, Contractor may develop
individualized alternatives.
(b) Contractor shall develop and implement a system for the ISA that provides
cost effective, comprehensive and individualized care to children and their
families.
(i) Contractor shall have a system that promotes collaboration, within laws
governing confidentiality, between mental health, child welfare,
juvenile justice, education, families, and other community partners in
the treatment of children with serious emotional, mental health and
behavioral challenges.
(ii) Contractor shall assure access to referral and screening at multiple
entry points.
(iii) Contractors shall Provide Services that are family-driven, strengths-
based, are culturally sensitive, and that enhance and promote quality,
community-based Service delivery.
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(c) Contractor shall have policies and procedures in place to assess all OHP
Members who are children and adolescents suspected of having significant
mental or emotional disorders.
(i) The Child and Adolescent Service Intensity Instrument (CASII) will be
used as the statewide tool to assist in the determination for ISA services
for children age 6 and older. For children 5 and younger, the statewide
tool will be the Early Childhood Service Intensity Instrument (ECSII).
(ii) Contractor will prioritize children with the most serious mental health
needs for the ISA who have a mental health Diagnosis that is on or
above the funded line of the OHP Prioritized List of Health Services.
This mental health Diagnosis must be the focus of the ISA and the
Treatment Plan. In addition to considering the level of service intensity
need indicated by the CASII or ECSII score, Contractor shall take into
consideration factors including, but not limited to:
(A) exceeding usual and customary services in an outpatient
Setting;
(B) multiple agency involvement;
(C) history of one or more out-of-home placements;
(D) significant risk of out-of-home placement;
(E) frequent or imminent admission to acute inpatient psychiatric
hospitalizations or other intensive treatment services;
(F) caregiver stress;
(G) school disruption due to mental health symptomatology;
(H) elevating or significant risk of harm to self or others; or
(I) for children birth to 5:
·· ·· history of abuse or neglect;
·· ·· conditions interfering with parenting, such as poverty,
substance abuse, mental health problems, and domestic
violence, and
·· ·· significant relationship disturbance between parent(s)
and child.
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(iii) The ISA determination process shall be clearly communicated to
Family members, guardians, and community partners, and shall
encourage ISA referrals from multiple sources, including families,
Allied Agencies, schools, juvenile justice, the faith community and
health care providers.
(iv) Contractor shall make decisions regarding ISA determinations and
referrals to Services within three (3) working days consistent with
Contractor’s policies and procedures required in Exhibit B, Part II,
Section 1, Subsection b, Paragraph (8)
(v) OHP Members meeting the determination process outlined in Exhibit
B, Part II, Section 1, Subsection b, Paragraph (8) (c) (ii) for intensive
treatment services shall have access to care coordination, shall have
available a child and family team planning process and access to the
ISA.
(vi) Contractor shall continue to Provide Services consistent with access
standards identified in Exhibit B, Part I, Section 4, Subsection a and
Subsection 2, Paragraph (1) through (4) for the time period between
level of service intensity determination review and approval and
implementation of the service plan.
(vii) Contractor shall submit written policies and procedures for CASII and
ECSII administration and ISA determination processes to AMH within
30 calendar days of the effective date of this Contract. AMH will
review the policies and procedures and notify Contractor of its
determination of the review and approval within 30 days of receipt.
(viii) Contractor shall assure that admissions to psychiatric residential
treatment services are consistent with the admission and certification
requirements of 42 CFR 456.481.
(d) Contractor shall assure that Service Coordination will be provided by a person
or persons who have a strong child and adolescent mental health background,
extensive knowledge of the children’s system of care, and experience working
with families.
(i) Community Care Coordination shall Provide guidance and Case
Management services in the planning, facilitating, and coordination of
the child’s Service Coordination plan.
(ii) A child and family team shall assist in the development of the Service
Coordination plan. The team may include the child, if appropriate,
Family members, child serving agencies involved with the child,
school, and other community supports identified by the Family.
(iii) The child and family team will support and help facilitate access to a
combination of Services, informal and formal supports, and other
community resources.
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(e) Contractor shall develop and implement a Community Care Coordination
Committee that is a community level planning and decision making body to
provide practice-level Consultation, identify needed community services and
supports, and provide a forum for problem solving to families, ISA providers,
child serving agencies, and child and family teams. The Community Care
Coordination Committee shall have representation of the local system of care
that includes Consumer and Family members, child serving providers, child
and family advocates, and other local Stakeholders representative of the local
system of care.
(f) Contractor shall develop and implement a regional or local children’s mental
health system advisory council. The advisory council will advise Contractor
and provide oversight of the local or regional mental health policies and
programs for the ISA, as well as ensure continuous QAPI.
(i) The advisory council shall have representation from child welfare,
juvenile justice, education, developmental disabilities, physical health
plan, ISA providers, and other local or regional community partners
representative of the local system of care, culturally diverse populations
of mental health Consumers and their Family members.
(ii) Representation by Consumers, Family members and child and family
advocates on this advisory council shall be a minimum of 51% of total
membership, with half of the representation consisting of OHP
Members who are adolescent Consumers and family members of OHP
Members who are child and adolescent Consumers.
(g) Contractor shall work closely with AMH to ensure continuous Enrollment for
children and adolescents determined as meeting the criteria for the ISA who
are placed in treatment facilities outside Contractor’s Service Area, as defined
in Part IV of this Contract. Contractor shall notify AMH when an OHP
Member is admitted to an out of area program, as well as when the OHP
Member is scheduled for discharge from the program. AMH will work with
DHS staff to make the system adjustments that are necessary to accomplish
continuous Enrollment with Contractor. Eligibility determinations will not be
affected and will continue to be subject to the DHS criteria for participation in
the OHP.
(h) Contractor shall develop a process to assure that funding intended and
allocated for children's mental health is used for that purpose.
(i) Performance targets for the percentage of expenditures on services to
children and adolescents shall be equal to the percentage of revenues
based on child and adolescent OHP Members.
(ii) OHP Members meeting criteria for the ISA, as described in Exhibit B,
Part II, Section 1, Subsection b, Paragraph (8) (c), shall be served by a
provider certified to Provide intensive community based treatment
services under OAR 309-032-1240 to 309-032-1305.
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Contract #129162 Exhibit B – Part II Page 51 of 241
(iii) AMH will provide Contractor with performance targets that identify
funding amounts that are to be spent with organizations certified to
Provide intensive treatment services under Oregon Administrative Rule
309-032-1100 through 309-032-1230. AMH will take into account
Contractor's formal efforts to contract with ITS providers. Funds may
be used to purchase non-traditional as well as traditional mental health
services.
(i) Contractor shall have contractual relationships or memorandums of
understanding with Providers certified to Provide intensive treatment services
that demonstrate adequate and sufficient Capacity to Provide the ISA.
(j) Contractor shall ensure that all programs involved in the ISA meet the
Credentialing Standards as outlined in Exhibit B, Part II, Section 3, of this
Contract and are licensed and certified by DHS under the Applicable Oregon
Administrative Rules for the Program.
(k) Contractor shall have policies and procedures in place to assure timely
reimbursement to Providers participating in the ISA.
(i) Whenever Contractor reimburses a non-contract provider of Psychiatric
Day Treatment Services or Psychiatric Residential Treatment Services
for services identical to those purchased by AMH through direct
contracts, the reimbursement shall be no less than the amount paid by
AMH for the same services.
(l) Contractor shall have written policies and procedures describing the admission
and discharge criteria for a child or adolescent requiring the ISA level of care.
Process shall include the active participation of the Family, Allied Agencies,
and other persons involved in the child’s care.
(m) Contractor shall be required to submit additional reports and information as
identified by AMH for the purposes of QA/PI activities of the ISA. Contractor
shall work with AMH to identify specific outcomes and performance measures
that will be tracked and reported on a quarterly basis.
(i) AMH will conduct an annual survey of Family members/caregivers of
child and adolescent OHP Members receiving Covered Services and
will provide aggregate results and raw data received from Contractor's
members to the Contractor.
(ii) Contractor shall be required to submit additional reports and
information derived from this aggregate data as identified by AMH for
the purposes of QA/PI activities of the ISA.
(iii) Contractor shall collect and analyze CASII and ECSII data for QA/PI
activities. Contractor shall submit to AMH, within 60 days of the end
of each calendar quarter, a report consistent with Schedule 4, Level of
Service Intensity Determination Data.
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Contract #129162 Exhibit B – Part II Page 52 of 241
(iv) Contractor shall collaborate and assist AMH in the collection and
reporting of data for use in an ISA Progress Review, as indicators of
outcome and performance measure. Data shall include the following
domains:
(A) School;
(B) Home, life, and Family;
(C) Client functioning; and
(D) Critical incidents.
(n) In addition to the Utilization Management requirements stated in Exhibit B,
Part I, Section 1, Subsection h, Contractor shall assure that admissions to
psychiatric residential treatment programs are consistent with the admission
and certification requirements of 42 CFR 456.481 and 441.150 through
441.156.
c. Integration and Coordination
Contractor shall ensure that in the process of coordinating care, the OHP Member's privacy is
protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164
subparts A and E, to the extent that they are applicable, and consistent with other State law or
Federal regulations governing privacy and confidentiality of mental health records.
(1) Mental Health Services Which Are Not Covered Services
Contractor shall coordinate Services for each OHP Member who requires Services
from agencies providing mental health Services that are not Covered Services. These
Services include, but are not limited to, those listed in Exhibit B, Part I, Section 1,
Subsection e, Mental Health Services Which Are Not Covered Services.
(a) Contractor shall assist OHP Members who are children and adolescents age 17
and under in gaining access to Psychiatric Long Term Care when this level of
care is Medically Appropriate.
(i) Contractor shall work closely with AMH staff to ensure continuous
Enrollment for OHP Members entering into LTPC outside of
Contractor's Service Area as defined in Part IV of this Contract.
(ii) To ensure that treatment is being provided in the least restrictive and
most appropriate Setting, Contractor shall, at minimum, consult and
communicate with LTPC programs for admission and discharge
planning, and collaborate with the LTPC program regarding ongoing
treatment decisions.
(iii) Contractor shall coordinate, consult, and communicate, within the laws
governing confidentiality, with community providers and other Allied
Agencies, schools, Family members or guardians regarding treatment
for children and adolescents in LTPC.
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(2) Local Mental Health Authority (LMHA)/Community Mental Health Program (CMHP)
Contractor shall establish working relationships with the LMHA and CMHP operating
in the Service Area for the purposes of maintaining a comprehensive and coordinated
crisis response and mental health Service delivery system for OHP Member access to
mental health Services, including Civil Commitment and protective Services/Abuse
investigations processes.
(3) Community Emergency Service Agencies
Contractor shall coordinate, consult, communicate with, and provide technical
assistance to Community Emergency Service Agencies to promote appropriate
responses to, and appropriate Services for, OHP Members experiencing a mental
health crisis.
(4) Allied Agencies
Contractor shall have a mechanism for multi-disciplinary team Service planning and
Services Coordination for OHP Members requiring Services from more than one
publicly funded agency or Service Provider. This mechanism shall help avoid Service
duplication and promote access to a range and intensity of Service options that Provide
individualized, Medically Appropriate care in the least restrictive Treatment Setting
(clinic, home, school, community based care Settings licensed by Allied Agencies).
(a) Contractor shall work with DHS local and/or regional agencies to develop
specific methods for meeting federal requirements for a mental health
Assessment for children and adolescents within 60 days of placement in
substitute care.
(5) Physical Health Care Providers
(a) Contractor shall consult and communicate with the OHP Member’s physical
health care Provider as Medically Appropriate and within laws governing
confidentiality as specified in OAR 410-141-0180, Oregon Health Plan
Prepaid Health Plan Recordkeeping.
(b) Contractor shall consult with and provide technical assistance to physical
health care Providers in the Service Area to help in the early identification of
mental disorders so that intervention and Prevention strategies can begin as
soon as possible.
(c) Develop and implement methods of coordinating with FCHPs for the
appropriate coordination of Services delivered to OHP Members.
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(6) Chemical Dependency Providers
Contractor shall coordinate with Chemical Dependency Providers as Medically
Appropriate and within laws governing confidentiality and shall provide technical
assistance for the identification and referral of OHP Members with dual diagnoses.
Contractor shall work with FCHPs and Chemical Dependency Providers certified by
DHS to develop the Capacity to Provide appropriate Services to dually diagnosed
OHP Members so the needs of such persons can be better met.
(7) Integration Activities
(a) Contractor shall develop, implement and participate in activities supportive of
a continuum of care that integrates mental health, addiction and physical health
interventions in ways that are seamless and whole to the OHP Member.
Integration activities may span a continuum ranging from communication to
coordination to co-management to co-location to the fully integrated, person-
centered health care home.
(b) Contractor shall demonstrate involvement in integration activities such as, but
not limited to:
(i) Facilitation of communication and coordination between physical and
behavioral health care providers;
(ii) Enhanced communication and coordination between Contractor and
FCHPs, DCOs, physical health providers and chemical dependency
providers;
(iii) Implemenatation of integrated Prevention, early intervention and
wellness activities;
(iv) Development of infrastructure support for sharing information,
coordinating care and monitoring results;
(v) Use of screening tools treatment standards and guidelines that support
integration;
(vi) Support of a shared culture of integration across prepaid health plans
and service delivery systems; and
(vii) Implementation of a system of care approach, incorporating models
such as the Four Quadrant Clinical Integration Model of the National
Council for Community Behavioral Healthcare.
(8) Medicare Payers and Providers
(a) Pursuant to OAR 410-141-0120, Contractor shall coordinate with Medicare
payers and Providers as Medically Appropriate to coordinate the care and
benefits of OHP Members who are eligible for both Medicaid and Medicare.
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Contract #129162 Exhibit B – Part II Page 55 of 241
(b) Pursuant to OAR 410-141 0420, Contractor shall be responsible for Medicare
deductibles, coinsurance and co-payments up to Medicare’s or Contractor’s
allowable for Covered Services its Medicare eligible OHP Members receive
from a Medicare Provider, who is either a Participating Provider, or a Non-
Participating Provider, if authorized by Contractor or Contractor’s
representatives, or for Emergency Services or Urgent Care Services.
(9) OHP Members in Extended Care Settings
Contractor shall coordinate with the AMH ECMU and extended care Service
Providers to integrate Services for OHP Members in Extended Care Programs.
ECMU shall determine, after collaborating with Contractor and the Extended Care
Program, when an OHP Member is ready for discharge from the Extended Care
Program.
(10) Long Term Psychiatric Care (LTPC)
(a) If Contractor believes an OHP Member is appropriate for LTPC, Contractor
shall request a LTPC determination from the applicable DHS program. DHS
staff will render a determination within three working days of receiving a
completed request if the OHP Member is 18 or more years of age or within
seven working days of receiving a completed request if the OHP Member is
age 17 and under.
(i) For OHP Members age 18 to age 64 with no significant nursing care
needs due to an Axis III disorder of an enduring nature, the AMH
ECMU as described in Schedule 2.1, Procedure for LTPC
Determinations for OHP Members Age 18-64;
(ii) For OHP Members age 17 and under, the AMH Child and Adolescent
Community Mental Health Specialist as described in Schedule 2.2,
Procedure for LTPC Determinations for OHP Members age 17 and
under; and
(iii) For OHP Members age 65 and over or age 18 to age 64 with significant
nursing care needs due to an Axis III disorder of an enduring nature,
the OSH-GTS, Outreach and Consultation Service (OCS) Team as
described in Schedule 2.3, Procedure for Long Term Psychiatric Care
Determinations for Persons Requiring Geropsychiatric Treatment.
(b) An OHP Member is appropriate for LTPC when the OHP Member needs either
Intensive Psychiatric Rehabilitation or other Tertiary Treatment in a State
Hospital or Extended Care Program, or Extended and Specialized Medication
Adjustment in a secure or otherwise highly supervised environment; and the
OHP Member has received all Usual and Customary Treatment, including, if
Medically Appropriate, establishment of a Medication Management Program
and use of a Medication Override Procedure.
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Contract #129162 Exhibit B – Part II Page 56 of 241
(c) DHS will cover the cost of LTPC of OHP Members determined appropriate for
such care beginning on the effective date specified below in this Exhibit B,
Part II, Section 1, Subsection c, Paragraph (10) (c) and ending on the date the
OHP Member is discharged from such setting
If an OHP Member is ultimately determined appropriate for LTPC, the
effective date of such determination shall be either:
(i) The date ECMU receives a completed Request for LTPC
Determination for Persons Age 18 to 64 form, or
(ii) No more than seven (7) working days following the date the AMH
Child and Adolescent Mental Health Specialist receives a completed
request for LTPC Determination for Persons Age 17 and under form; or
(iii) The date the OSH-GTS OCS Team receives a completed Request for
LTPC Determination for Persons Requiring OSH-GTS; or
(iv) In cases where AMH and Contractor mutually agree on a date other
than these dates, the date mutually agreed upon.
(v) In cases where the Clinical Reviewer determines a date other than a
date described above in this Exhibit B, Part II, Section 1, Subsection c,
Paragraph (10) (c) (i) through (10) (c) (iii), the date determined by the
Clinical Reviewer.
In the event there is a disagreement between Contractor and AMH about
whether an OHP Member is appropriate for LTPC, Contractor may request,
within three (3) working days of receiving notice of the LTPC determination,
review by an independent Clinical Reviewer. The determination of the
Clinical Reviewer shall be deemed the determination of AMH for purposes of
this Contract. If the Clinical Reviewer ultimately determines that the OHP
Member is appropriate for LTPC, the effective date of such determination shall
be the date specified above in this Exhibit B, Part II, Section 1, Subsection c,
Paragraph (10) (c). The cost of the clinical review shall be divided equally
between Contractor and AMH.
(d) Contractor shall:
(i) For OHP Members age 18 to 64, work with the AMH ECMU, or OCS
Team in managing admissions to and discharges from LTPC for OHP
Members who require such care at OSH or Eastern Oregon Psychiatric
Center.
(ii) For OHP Members, age 17 and under, work with the AMH Child and
Adolescent Mental Health Specialist in managing admissions and
discharges to LTPC (SCIP, SAIP, STS programs).
(iii) For the OHP Member and, the parent or guardian of the OHP Member,
work to assure timely discharge from LTPC to an appropriate
community placement.
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Contract #129162 Exhibit B – Part II Page 57 of 241
(iv) For the OSH-GTS Interdisciplinary Treatment Team assigned to the
OHP Member, work to manage discharges from Long Term
Geropsychiatric Care.
(e) Contractor shall authorize and reimburse Case Management services that are
sufficient in amount, duration or scope to reasonably be expected to achieve
the purpose for which the services are provided to OHP Members receiving
care through community-based Long Term Psychiatric Care, as authorized by
the AMH ECMU.
(f) Contractor shall assure that any involuntary treatment provided under this
Contract is provided in accordance with administrative rule and statute, and
shall coordinate with the CMHP Director in assuring that all statutory
requirements are met. Contractor shall also work with the CMHP Director in
assigning a civilly committed OHP Member to any placement and participate
in circuit court hearings related to planned placements, if applicable.
(11) Consumer Involvement and Advocacy
(a) Contractor shall involve Consumers, families, Consumer advocates, and
advocacy groups in planning, developing, implementing, operating and
evaluating Services.
(b) Contractors’ advisory bodies, such as QAPI committees, policy-making bodies
or decision-making boards, shall have representation from culturally diverse
populations of mental health Consumers and their Family members.
Representation on these advisory bodies shall be a minimum of 25% of total
membership and shall consist of representatives which include the following
constituent groups: adolescent Consumers, adult Consumers, older adult
Consumers, Family members of child and adolescent Consumers and Family
members of adult and older adult Consumers.
(c) Contractor shall inform OHP Members, at least once per year, of the OHP
Member’s abilities to participate in activities of Contractor.
2. Quality Assessment/Performance Improvement (QA/PI) Requirements
a. QA/PI Program
(1) Contractor and its subcontractors shall have an ongoing QA/PI program for the
services it furnishes to its OHP Members in accordance with 42 CFR 438.240, QA/PI.
The basic elements of the Contractor’s QA/PI program must comply with the
following requirements:
(a) Implementation of a minimum of two (2) performance improvement projects
(PIP) that are designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in clinical care and
non-clinical care areas that are expected to have favorable effect on health
outcomes and OHP Member satisfaction. Contractor shall perform a mental
health/physical health collaborative PIP with a Fully Capitated Health
Plan/Physician’s Care Organization (PCO) also serving OHP Members in
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Contractor’s Service Area. As an alternative to a collaborative PIP, Contractor
may propose another PIP to AMH which must be reviewed by and have prior
approval by AMH. The PIPs must involve:
(i) Measurement of performance using objective quality indicators.;
(ii) Implementation of system interventions to achieve improvement in
quality;
(iii) Evaluation of the effectiveness of the interventions;
(iv) Planning and initiation of activities for increasing or sustaining
improvement; and
(v) Completion in a reasonable time period as to generally allow
information on the success of performance improvement projects in the
aggregate to produce new information on Quality of Care every year.
(b) Submission of performance measurement data annually that includes:
(i) Standard measures required by DHS including those that incorporate
standards established by DHS;
(ii) Submission to DHS, data specified by DHS, that enables DHS to
measure the Contractor’s performance; or
(iii) A combination of Exhibit B, Part II, Section 2, Subsections a. and b., as
approved by DHS.
(c) Have in effect mechanisms to detect both underutilization and over utilization
of services.
(d) Have in effect mechanisms to assess the quality and appropriateness of care
furnished to OHP Members with special health care needs.
(e) Any Subcontracted QAPI activity shall state the extent of the delegation and
how these activities are monitored and integrated in the overall QA/PI
program.
(2) Contractor’s QA/PI Committee shall demonstrate evidence of stakeholder
participation in the QA/PI program including a formal and ongoing process for
gathering and considering information from Stakeholders including, but not limited to:
OHP Members, Consumers, Consumer advocates, Families, parent advocates, family
members of older adults, Allied Agencies, child psychiatrists, geropsychiatrists, child
advocates, and Health Care Professionals.
(3) Contractor shall communicate to Providers the overall QA/PI Program findings,
including recommendations and opportunities for improvement.
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b. QA/PI Work Plan
Contractor shall develop and submit for approval to the AMH a written QA/PI Work Plan
within 45 days of the effective date of this Contract. AMH shall review the QA/PI Work Plan
and shall notify Contractor of its determination of approval within 30 days of receipt.
(1) Contractor shall introduce interventions and monitor progress in the domains of access
to services; quality of services; integration and coordination of services; prevention,
education and outreach; and clinical outcomes.
c. QA/PI Program Review
Contractor shall have in effect a process for the annual evaluation of the impact and
effectiveness of its QA/PI program. The review shall include performance on standard
measures as required by the State and the results of each performance improvement project.
The review shall include the analysis and integration of Grievance information into the QA/PI
program. Contractor shall submit the evaluation 45 days after the termination of this
Contract.
d. Member of AMH QA/PI Committee
Contractor shall participate as a member of the AMH QA/PI Committee if such participation
is requested by AMH.
e. External Quality Review
In conformance with 42 CFR 438 Subpart E, Contractor, or its subcontractors and Providers
shall cooperate with DHS by providing access to records and facilities for the purpose of an
annual external, independent professional review of the quality outcomes and timeliness of,
and access to, Services provided under this Contract. If the External Quality Review
Organization (EQRO) identifies an adverse clinical situation in which follow-up is needed to
determine whether appropriate care was provided, the EQRO shall report the findings to
AMH and Contractor. Contractor shall assign a staff person(s) to follow-up with the
subcontractor or Provider, inform Contractor’s QAPI Committee of the finding, and involve
the QAPI Committee in the development of the resolution. Contractor shall report the
resolution to AMH and the EQRO. If determined by AMH, at the recommendation of the
EQRO, Contractor shall develop and comply with a Corrective Action Plan as reviewed and
approved by AMH.
3. Credentialing Process
a. Contractor shall have written policies and procedures for Credentialing and recredentialing
Providers, which includes collecting evidence of credentials and screening the credentials of
Providers, programs and facilities used to deliver Covered Services. These policies and
procedures shall be consistent with OAR 410-141-0120, Oregon Health Plan Prepaid Health
Plan Provision of Health Care Services and shall include verifying possession of valid
licenses or certificates if any are required under any federal, state, or local law, rule, or
regulation to deliver Covered Services in the State of Oregon. These policies and procedures
shall also include collecting proof of liability insurance and evidence of hospital privileges of
physicians rendering Services in an Acute Inpatient Hospital Psychiatric Care Setting.
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Contract #129162 Exhibit B – Part II Page 60 of 241
b. Contractor shall submit all changes to its current Credentialing and recredentialing policy and
procedure to AMH for review and approval, as of the effective date of this Contract. If there
are no changes to the Contractor’s current Credentialing and recredentialing policies and
procedures Contractor shall submit Schedules 5.0 and 5.1 as of the effective date of this
Contract.
(1) If Participating Providers are not required to be licensed or certified by a State of
Oregon board or licensing agency, then:
(a) Participating Providers must meet the definitions for QMHA or QMHP as
described in Exhibit A, Definitions and Provide Services under the supervision
of a LMP as defined in Exhibit A, Definitions; or
(b) For Participating Providers not meeting either the QMHP or QMHA definition,
Contractor shall document and certify that the person’s education, experience,
competence, and supervision are adequate to permit the person to perform his
or her specific assigned duties.
(2) All programs operated directly or by subcontract must be accredited by nationally
recognized organizations (e.g., Council on Accredited Rehabilitation Facilities
(CARF), TJC and/or are certified under OAR 309-012-0130 et. seq. or licensed under
ORS Chapter 443 by the State of Oregon to deliver specified Services (e.g. OAR 309-
032-0525 through 309-032-0605, Standards for Adult Mental Health Services; OAR
309-032-0950 through 309-032-1080, Standards for Community Treatment Services
for Children; OAR 309-032-1100 through 309-032-1230, Intensive Treatment
Services; and OAR 309-032-1240 through 309-032-1305, Intensive Community
Based Treatment and Support Services; and OAR 309-039-0500 through 309-039-
0580, Standards for Approval of Providers of Non-Inpatient Mental Health Treatment
Services).
(3) Facilities used to deliver services specified in OAR 309-032-0850 through 309-032-
0890, Standards for Regional Acute Care Psychiatric Services for Adults, OAR 309-
033-0700 through 309-033-0740, Standards for the Approval of Community Hospital
and Non-hospital Facilities to Provide Seclusion and Restraint to Committed Persons
in Custody or on Diversion and OAR 309-032-1100 through 309-032-1230 must be
certified or licensed by the State of Oregon and be safe and adequately equipped and
adequately staffed for Covered Services provided.
(4) Contractor shall periodically check that Participating Providers, programs and
facilities are credentialed as specified above.
c. Contractor Credentialing records shall document academic degrees, licenses, certifications,
and/or qualifications of Participating Providers, programs and facilities. If the Covered
Service is Acute Inpatient Hospital Psychiatric Care, Contractor need not maintain
Credentialing records of hospital staff but shall maintain records documenting that the facility
is appropriately licensed.
d. Contractor’s subcontractors and Participating Providers shall work within the scope of
registration or licensure and qualifications specified in Exhibit B, Part II, Subsection 3,
Credentialing Process, Items a(1) through a(c).
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e. Contractor shall provide AMH with a written plan for transferring the OHP Members and an
updated Provider Capacity Assurance Report, Exhibit K, at least ninety (90) days prior to a
Material Change, pursuant to OAR 410-141-0220, (4) and OAR 410-141-0220, or the
termination or loss of a Provider or Provider group or affected by other factors which have
significant impact on access in that Service Area and which may result in transferring a
substantial number of OHP Members to other Providers employed or subcontracted with
Contractor, notwithstanding the Contract renewal date. Contractor remains responsible for
maintaining sufficient capacity and solvency, and providing all Capitated Services through the
end of the ninety (90) days period.
f. If Contractor must terminate a Provider or Provider group due to problems that could
compromise the OHP Member’s care, less than the required notice to AMH and the OHP
Member may be provided.
g. If a Provider or Provider group terminates their Subcontract or employment with Contractor
or if Contractor is affected by circumstances beyond Contractor’s control and the Contractor
cannot reasonably provide the required ninety (90) days notice, less than the required notice to
AMH may be provided with the approval of AMH.
h. Pursuant to 42 CFR 438.10(f)(5), Contractor shall provide written notice of termination of a
Participating Provider within 15 days after receipt or issuance of the termination notice, AMH
and each OHP Members who received care, or was seen on a regular basis, by the terminated
Provider.
i. If Contractor cannot demonstrate sufficient Provider Capacity, AMH reserves the right to seek other
avenues to Provide Services to OHP Members. If AMH determines that some or all of the affected
OHP Members must be Disenrolled from Contractor, the applicable provisions of the Contract shall
apply.
j. Facilities used for Acute Inpatient Hospital Psychiatric Care shall have separate units for the
Treatment of children and adults (OHP Members ages 18 and older); or Contractor may
propose, for AMH approval, an alternative to separate units which provides for the safety and
protection of all Acute Inpatient Hospital Psychiatric Care patients.
k. Contractor's provider selection policies and procedures shall not discriminate for the
participation, reimbursement, or indemnification of any provider who is acting within the
scope of his or her license or certification under applicable State law, solely on the basis of
that license or certification. This paragraph shall not be construed to prohibit Contractor from
including Providers only to the extent necessary to meet the needs of OHP Members or from
establishing any measure designed to maintain quality and control costs consistent with
Contractor's responsibilities under this Contract. This paragraph shall not be construed to
preclude Contractor from using different reimbursement amounts for different specialties or
for different practitioners in the same specialty. If Contractor declines to include individuals
or groups of providers in its network, Contractor must give the affected provider(s) written
notice of the reason for its decision.
l. Contractor's provider selection policies and procedures must not discriminate against
particular providers that serve high-risk populations or specialize in conditions that require
costly treatment. If Contractor declines to include individuals or groups of providers in its
network, Contractor must give the affected provider(s) written notice of the reason for its
decision.
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Contract #129162 Exhibit B – Part III Page 62 of 241
Exhibit B –Statement of Work – Part III – Members
1. Informational Materials and Education of OHP Members
a. Contractor shall develop and provide informational materials and educational programs as
described in OAR 410-141-0280, Oregon Health Plan Prepaid Health Plan Information
Requirements and OAR 410-141-0300, Oregon Health Plan Prepaid Health Plan Member
Education. These materials and programs shall be in a manner and format that may be
easily understood and tailored to the backgrounds and special needs of OHP Members.
Contractor shall develop, and make available to its OHP Members, a mental health
education program that addresses Prevention and Early Intervention of mental illness.
Contractor shall offer orientation to new OHP Members within 30 days of Enrollment that
helps them understand the requirements and benefits of the plan. Contractor shall
distribute an OHP Member handbook to new OHP Members within 14 calendar days of
the OHP Member's effective date of coverage with Contractor, which includes, but is not
limited to:
(1) Information about non-English language speaking Providers;
(2) Restrictions of freedom of choice among Providers;
(3) OHP Member rights and protections;
(4) Covered Services;
(5) Authorization requirements;
(6) After hours and emergency care;
(7) Specialty care;
(8) How to access other services not covered by Contractor;
(9) How to file Grievances, Appeals and request an Administrative Hearing;
(10) How to request continuation of benefits pending the resolution of a Grievance,
Appeal, or Administrative Hearing;
(11) Advance directives;
(12) Contractor's structure and operations;
(13) Practitioner Incentive Plans; and
(14) Information regarding OHP Member’s possible responsibility for charges including
Medicare deductibles and co-insurances (if they go outside of Contractor for non-
emergent care), copayments and charges for non-covered services.
(15) Cost sharing is not required for OHP Clients enrolled with Contractor and receiving
Covered Services.
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Contract #129162 Exhibit B – Part III Page 63 of 241
Contractor shall provide written notice to OHP Members of any significant changes in
program or policies and procedures at least 30 days before the intended effective date of
the change.
b. Health education shall include: promotion and maintenance of optimal health care status
to include identification of tobacco use, referral for tobacco cessation interventions
(educations material, tobacco cessation groups, pharmacological benefits and the Oregon
Tobacco Quit Line (1-877-270-STOP)).
c. Contractor shall give particular attention to the following requirements:
(1) Provide written information in each non-English language that is prevalent
pursuant to OAR 410-141-0280 (2), in Contractor’s Service Area;
(2) Make oral interpretation Services available free of charge to each OHP Member
and Potential OHP Member, for any language. Notify OHP Members how to
access those services and whom to contact to receive those services. This applies
to all non-English languages not just those that the State identifies as prevalent;
(3) Make written information available in alternate formats, for any language, taking
into consideration the special needs of OHP Members or Potential OHP Members.
Notify OHP Members how to access those formats and whom to contact to receive
those formats; and
(4) Notify OHP Members at least once a year of their right to request and obtain
informational materials and who to contact to receive those services, for any
language, as described in this section.
d. Contractor shall provide additional information that is available upon request by the OHP
Member, including information on Contractor's structure and operations, and Practitioner
Incentive Plans.
e. Contractor shall make available to OHP Members, or Potential OHP Members, in
compliance with the requirements of the Americans with Disabilities Act of 1990,
information in such alternative formats to allow the individual to effectively receive such
information. These alternative formats may include, but are not limited to culturally
appropriate information, foreign language translations, large print and audio of Braille
translations for hearing or vision impaired OHP Members.
2. OHP Member Rights
a. Contractor shall have written policies and procedures incorporating and ensuring the rights
and responsibilities of OHP Members consistent with any applicable Federal and State
laws, rules, and regulations that pertain to OHP Member rights, and shall ensure that
Contractor’s staff and Providers take those rights into account when furnishing services to
OHP Members including, but, not limited to ORS 430.210, Rights of Service Recipients;
Status of Rights; OAR 410-141-0320, Oregon Health Plan Prepaid Health Plan Member
Rights and Responsibilities; ORS 430.735 through 430.765, Abuse Reporting for the
Mentally Ill; and OAR 410-009-0050 through 410-009-0160, Abuse Reporting and
Protective Services in Community Programs and Community Facilities.
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Contract #129162 Exhibit B – Part III Page 64 of 241
b. Contractor shall furnish to OHP Members information on the rights specified in OAR 410-
141-0320, Oregon Health Plan Prepaid Health Plan Member Rights and Responsibilities.
Contractor shall also make available this same information to Potential OHP Members.
Contractor shall give particular attention to the following rights:
(1) The right to receive Covered Services;
(2) The right to receive information on available treatment options, including a second
opinion and alternatives presented in a manner appropriate to the OHP Member's
condition and ability to understand;
(3) The right to be actively involved in the development of Treatment Plans if Covered
Services are to be provided and to have parents involved in such Treatment
Planning consistent with OAR 309-032-0950 through 309-032-1080, Standards for
Community Treatment Services for Children; OAR 309-032-1100 through 309-
032-1230, Intensive Treatment Services; and OAR 309-032-1240 through 309-
032-1305, Intensive Community Based Treatment and Support Services;
(4) The right to participate in decisions regarding his or her health care, including the
right to refuse Covered Services;
(5) The right to be informed as required in ORS 127.703, Required Policies Regarding
Mental Health Treatment Rights Information; Declaration for Mental Health
Treatment;
(6) The right to request and receive a copy of his or her own Clinical Record, (unless
access is restricted in accordance with ORS 179.505 or other applicable law) and to
request that the records be amended or corrected as specified in 45 CFR Part 164;
(7) The right to privacy and confidentiality and have Clinical Records kept confidential
consistent with applicable Federal and State laws, rules and regulations.
(8) The right to have an opportunity to select an appropriate Mental Health Practitioner
and Service site from within Contractor’s Participating Provider Panel;
(9) The right to refer oneself directly to Contractor for Covered Services without first
having to gain authorization from another Provider;
(10) The right to have access to Covered Services which at least equals access available
to other persons served by Contractor;
(11) The right to receive a Notice of Action when a Service, benefit, Request for Service
Authorization or Request for Claim Payment is denied; or prior to termination,
suspension or reduction of a benefit or Service as described in Exhibit N,
Grievance System;
(12) The right to file Grievance or Appeal or request a hearing as described in Exhibit
N, a Grievance System;
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(13) The right to request an expedited Administrative Hearing if the OHP Member feels
the mental health problem is urgent or emergent and cannot wait for the normal
hearing process;
(14) The right to request Continuation of Benefits until a decision in a hearing is
rendered. The OHP Member may be required to repay any benefits continued if the
issue is resolved in favor of Contractor;
(15) The right to receive, within 30 calendar days of Enrollment, written materials
describing at least the following topics: rights and responsibilities, benefits
available, how to access Covered Services, what to do in an Emergency Situation,
and how to file a Grievance or Appeal, or request a hearing;
(16) The right to have written materials explained in a manner which is understandable;
(17) The right to access protective Services as described in ORS 430.735 through
430.765, Abuse Reporting for Mentally Ill and OAR 410-009-0050 through 410-
009-0160, Abuse Reporting and Protective Services in Community Programs and
Community Facilities;
(18) The right to be treated with respect and with due consideration for his or her dignity
and privacy;
(19) The right to be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation; and
(20) The right to exercise his or her rights, and that the exercise of those rights does not
adversely affect the way Contractor and its Providers treat the OHP Member.
c. Contractor shall post OHP Member rights in a visible location in all clinics, Participating
Provider offices, and other Service locations.
3. Grievances System
a. Contractor shall have written procedures approved in writing by DHS for accepting,
processing and responding to all Grievances and Appeals from OHP Members, consistent
with the requirements of Exhibit N and OAR 410-141-0260 through 410-141-0266,
including Grievances and Appeals related to requests for accommodation in
communication or provision of Services for OHP Members with a Disability or limited
English proficiency. AMH reviews the Contractor’s procedures for compliance with the
requirements of Exhibit N and OAR 410-141-0260 through 410-141-0266, as well as any
applicable federal requirements, including 42 CFR 438.
b. Each time a Covered Service or benefit is denied, terminated, suspended or reduced, or
when Contractor authorizes a course of Treatment or Covered Service, but subsequently
acts to terminate, discontinue or reduce the course of Treatment or a Covered Service,
Contractor shall issue a Notice of Action to the affected OHP Member at least 10 Business
Days before the date of the Action, unless there is documentation that the OHP Member
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Contract #129162 Exhibit B – Part III Page 66 of 241
had previously agreed to the change as a part of the course of Treatment. Contractor shall
comply with Exhibit N and the notice requirements in OAR 410-141-0263, Notice of
Action by a PHP, including information about continuation of benefits.
c. In the event an OHP Member or an OHP Member Representative requests an
Administrative Hearing from AMH, Contractor shall comply with the requirements of
Exhibit N and OAR 410-141-0264, Administrative Hearings.
d. Contractor shall maintain a log of all OHP Member Grievances and Appeals. The log shall
identify the OHP Member, the date of the Grievance, the resolution and the date of
resolution. Contractor shall retain Grievance and Appeal logs for 7 (seven) years. This
provision shall survive expiration or termination of this Contract.
e. Contractor shall provide a quarterly report summarizing OHP Member Grievances, using
the report format in Exhibit N, Attachment 1.
f. Contractor and its subcontractors shall cooperate with the DHS’ Client Advisory Services
Unit and the AMH Representatives in all of DHS’ activities related to OHP Member
Grievances, Appeals, and Administrative Hearings.
g. Contractor shall inform OHP Members about the Contractor’s Grievance and Appeal
procedures and timeframes, the availability of assistance in the filing process, the toll-free
numbers that an OHP Member can use to file a Grievance or Appeal by phone, how to
request continuation of benefits (and OHP Member responsibility to pay for the cost of
services furnished while an Appeal or Administrative Hearing is pending if the final
decision is adverse to the OHP Member), and how to access a Administrative Hearing at
the time of the OHP Member’s Enrollment.
4. Enrollment and Disenrollment
a. Enrollment
(1) Enrollment is the process by which DHS signs on with a particular contractor those
individuals who have been determined to be eligible for Services under the OHP.
The provisions of this section apply if Enrollment is mandatory or voluntary and if
the services are delivered by the OHP Member’s PCP or another Provider.
Enrollment is voluntary, except in the case of mandatory Enrollment programs,
pursuant to OAR 410-141-0060. DHS will sign on such individuals with contractor
selected by the individual. If an eligible individual does not select a contractor,
DHS may, pursuant to OAR 410-141-0060, Oregon Health Plan Managed Care
Enrollment Requirements, elect to assign the person to a contractor selected by
DHS. Contractor shall have an open Enrollment period at all times, during which
Contractor shall accept, without restriction, all eligible OHP Clients in the order in
which they apply and are signed on with Contractor by DHS, unless Contractor is
also a FCHP and DHS and Contractor have jointly closed Enrollment because
Contractor maximum Enrollment limit has been reached or for any other reason
mutually agreed to by DHS and Contractor under the FCHP Contract.
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Contractor shall not discriminate, and shall not use any policy or practice that has
the effect of discrimination, against any individual eligible to enroll on the basis of
mental health status or need for Covered Services, on the basis of other Disabilities,
or on the basis of race, color, or national origin.
(2) An individual becomes an OHP Member for purposes of this Contract as of the
date of Enrollment with Contractor, and as of that date, Contractor shall Provide all
Covered Services to such individual as required by the terms of this Contract. For
persons who are enrolled on the same day as they are admitted to the hospital or,
for children and adolescents admitted to psychiatric residential treatment services
(PRTS), Contractor shall be responsible for said Services. If the person is enrolled
after the first day of hospital stay or PRTS, the person shall be Disenrolled, and the
date of Enrollment shall be the next available Enrollment date following discharge
from hospital Services or PRTS.
(3) Enrollment of eligible OHP Clients with Contractor shall occur on a weekly and
monthly basis as described in OAR 410-141-0060, Oregon Health Plan Managed
Care Enrollment Requirements.
(4) DHS will make available to the Contractor Enrollment data files via an electronic
mailbox. Enrollment data files on the electronic mailbox shall remain available
until Contractor retrieves them, except where they remain for more than 6 (six)
weeks. Any Enrollment data files remaining in the electronic mailbox for 6 (six)
weeks or more may be removed at DHS’ sole discretion. For the weekly
Enrollment process, an Enrollment data file, which may contain new, current
members with changes, and/or disenrolled OHP Members shall appear in the
electronic mailbox Friday morning of each week. For the monthly Enrollment
process, Enrollment data files, which may contain new, closed, members with
changes and/or ongoing OHP Members for the next month shall appear on the
electronic mailbox three business days following the date of monthly Enrollment
cutoff. An Enrollment listing shall be made available to Contractor by the 5th of
the month in which the Enrollments are applicable.
(5) Contractor shall provide enrollment reconciliation as described in Exhibit O, of this
Contract.
b. Disenrollment
(1) An individual is no longer an OHP Member eligible for Covered Services under
this Contract as of the effective date of the OHP Member’s Disenrollment from
Contractor, and as of that date, Contractor is no longer required to Provide Services
to such individual under this Contract.
(2) An OHP Member may be disenrolled from Contractor as follows:
(a) If requested orally or in writing by the OHP Member or OHP Member
Representative, as specified in OAR 410-141-0000 and 410-141-0080 (1)
(b) for the following reasons:
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(i) With cause:
(A) at any time;
(B) if the Contractor does not, because of moral or religious
objections, cover the Service the OHP Member seeks;
(C) if the OHP Member needs related Services to be performed
at the same time and not all related Services are available
within the Provider network and the OHP Member’s primary
care Provider or another Participating Provider receiving the
Services separately would subject the OHP Member to
unnecessary risk;
(D) for other reasons, including, but not limited to, poor Quality
of Care, lack of access to services covered under this
Contract, or lack of access to Participating Providers
experienced in dealing with the OHP Member's needs; or
(E) if the OHP Member moves out of the Contractor’s Service
Area.
(ii) Without cause:
(A) after six months of Enrollment;
(B) whenever the OHP Member's eligibility is re-determined by
DHS;
(C) if continued Enrollment would be detrimental to the OHP
Member's health;
(D) the OHP Member is a Native American, Alaskan Native; or
(E) for Continuity of Care.
(b) If requested by Contractor because the OHP Member:
(i) is unruly or abusive to others;
(ii) threatens or commits an act of physical violence;
(iii) committed fraudulent or illegal acts such as permitting the use of
OHP Member identification card by another person;
(iv) is suspected of altering a prescription;
(v) is suspected of thefts or other criminal acts committed in any
Provider's or Contractor's premises;
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Contract #129162 Exhibit B – Part III Page 69 of 241
(vi) otherwise misused the Medical Assistance Program;
(vii) is under the jurisdiction of the PSRB; or
(viii) for other reasons specified in OAR 410-141-0080.
(c) If requested by the PSRB for an OHP Member under its jurisdiction.
AMH approval is required for all Disenrollment requests of OHP Members,
Contractor, or PSRB for OHP Members under PSRB jurisdiction.
(3) The effective date of Disenrollment shall be the first of the month following AMH
approval for Disenrollment. If Contractor receives a request for Disenrollment
from an OHP Member, Contractor shall forward the request to AMH within 10
business days. If AMH fails to make a Disenrollment determination by the first
day of the second month following the month in which the OHP Member files a
request for Disenrollment, the Disenrollment is considered approved. For OHP
Members under PSRB jurisdiction who are approved for Disenrollment at the
request of Contractor or PSRB, the effective date of Disenrollment may be made
retroactive to the date the OHP Member was enrolled with Contractor or placed
under PSRB jurisdiction, whichever is more recent.
(4) If DHS disenrolls an OHP Member retroactively, any Capitation Payments received
by Contractor for that OHP Member after the effective date of Disenrollment shall
be handled as described in Exhibit C, Section 5, Settlement of Accounts.
(5) Contractor shall not request Disenrollment of an OHP Member for reasons related
to:
(a) An adverse change in the OHP Member's health status;
(b) Utilization of medical services;
(c) Diminished mental capacity;
(d) Uncooperative or disruptive behavior resulting from the OHP Member's
special needs (except when the continued Enrollment seriously impairs
Contractor's ability to furnish Services to either the OHP Member or other
OHP Members);
(e) A Disability or any condition that is a direct result of the OHP Member’s
Disability; or
(f) Other reasons specified in OAR 410-141-0080.
5. Identification Cards
DHS hereby waives the requirement that Contractor issue identification cards to OHP Members as
specified in OAR 410-141-0300, Oregon Health Plan Prepaid Health Plan Member Education.
Contractor may issue identification cards to OHP Members. Such identification cards shall be for
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Contract #129162 Exhibit B – Part III Page 70 of 241
Contractor’s convenience only and shall confer no rights to Covered Services or other benefits
under this Contract. To be entitled to such Covered Services or benefits, the holder of the card
must, in fact, be an OHP Member and be eligible for Covered Services under this Contract. Each
identification card shall indicate that the holder of the card is not entitled to benefits under this
Contract unless currently and lawfully enrolled as an OHP Member. If Contractor serves non-
OHP Members, identification cards of non-OHP Members and OHP Members shall be as similar
as possible and shall not distinguish the OHP Member as different in any way.
6. Marketing
Contractor must have in place a mechanism for OHP Members and Potential OHP Members to
receive information to help them understand the requirements and benefits available under this
Contract. Contractor shall have information available for Potential OHP Members to assist them
in making an informed decision about Enrollment with Contractor. Contractor shall ensure that
staff activities and written materials are accurate and available in both oral and written format and
do not intentionally mislead confuse, or defraud OHP Members or Potential OHP Members about
options available through Contractor. Statements that will be considered inaccurate, false, or
misleading include, but are not limited to, any assertion or statement (whether written or oral) that
the OHP Member must enroll with Contractor in order to obtain benefits or in order not to lose
benefits; or that the Contractor is endorsed by CMS, the federal or state government, or similar
entity. Pursuant to OAR 410-141-0270, Contractor shall cooperate with AMH in developing
written materials to be included in OHP application packets.
a. Contractor, and subcontractors, shall not initiate contact nor market independently to
Potential OHP Members in an attempt to influence an individual’s Enrollment with
Contractor, without the express written consent of AMH.
b. Pursuant to OAR 410-141-0270(1), and as defined in OAR 410-141-0000 Contractor and
subcontractors may not conduct, directly or indirectly, door-to-door, telephonic, mail or
other cold call marketing practices to entice Potential OHP Members to enroll with
Contractor, or to not enroll with another Contractor.
c. Contractor, and subcontractors, shall not seek to influence an individual’s Enrollment with
the Contractor in conjunction with the sale of any other insurance.
d. Contractor and subcontractors may engage in activities intended to Provide Outreach to
Contractor’s enrolled OHP Members for the purpose of enhancing mental health
promotion or education within Contractor’s Service Area.
e. Contractor shall submit to AMH, for review and approval, all written marketing materials
to OHP Members or Potential OHP Members that reference benefits and/or coverage.
Marketing material shall be made available to all OHP Members, or Potential OHP
Members, within Contractor’s Service Area. Marketing materials expressly for the
purpose of mental health promotion, education or Outreach do not require prior approval.
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Contract # 129162 Exhibit B – Part IV Page 71 of 241
Exhibit B –Statement of Work – Part IV – Financial Matters
1. Financial Risk, Management and Solvency
Contractor shall assume the risk for providing Covered Services to its OHP Members.
Contractor shall provide assurances to AMH that Contractor’s provision(s) against the
risk of insolvency are adequate to ensure that OHP Members will not be liable for
Contractor’s debts if Contractor becomes insolvent. Contractor shall maintain risk
protection against catastrophic or unexpected OHP Member expenses related to Covered
Services, and shall maintain protections against insolvency, as specified in Exhibit G,
Solvency Plan and Financial Reporting. If Contractor expects to change any elements of
the Solvency Plan or solvency protection arrangements, Contractor shall provide written
advance notice to AMH at least sixty (60) calendar days before the proposed effective
date of change. Such changes are subject to written approval from AMH.
a. Failure to maintain adequate financial Solvency, as determined by DHS, shall be
grounds for termination of this Contract by DHS.
b. In the event that insolvency occurs, Contractor remains financially responsible for
providing Covered Services for OHP Members through the end of the period for
which Contractor has been paid, including inpatient admissions up until date of
discharge, except for persons approved for Long Term Psychiatric Care as defined
in Exhibit B, Part II, Section 1, Subsection c, Paragraph (10) of this Contract.
c. OHP Member shall not be held liable for payments and Contractor shall not bill,
charge, seek compensation, remuneration, or reimbursement from any OHP
Member for:
1. any debt or payment of claims due to Contractor’s insolvency;
2. Covered Services provided to the OHP Member for which DHS did not
pay Contractor;
3. Covered Services provided to the OHP Member by a Provider under a
contractual, referral, or other arrangement for which Provider did not
receive payment from Contractor; or
4. Payment for Covered Services provided under a contract, referral, or other
arrangement, other than co-payments, if applicable.
d. Contractor shall not seek recourse against DHS for Covered Services provided
during the period for which Capitation Payments were made by DHS to
Contractor even in the event Contractor becomes insolvent.
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Contract # 129162 Exhibit B – Part IV Page 72 of 241
2. Dual Payment
Except as specifically permitted by this Contract, Contractor shall not be compensated for
work performed under this Contract from any other department of the State of Oregon,
nor from any other source including the federal government. Contractor shall
immediately report any funds received by Contractor through activities arising under this
Contract.
Certain federal laws governing reimbursement of Federally Qualified Health Centers,
Rural Health Centers and Indian Health Care Providers may require AMH to provide
supplemental payments to those entities, even though those entities have subcontracted
with Contractor to provide Covered Services and including Indian Health Care Providers
that do not have a subcontract with the Contractor. These supplemental payments are
outside the scope of this Contract and do not violate the prohibition on dual payments
contained herein. Contractor is required to maintain encounter data records and such
additional subcontract information documenting Contractor’s reimbursement to Federally
Qualified Health Clinics, Rural Health Centers and Indian Health Care Providers, and to
provide such information to AMH upon request. Contractor is required to provide
information documenting Contractor’s reimbursement to non-participating Indian Health
Care Providers to AMH upon request.
3. (Reserved)
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Contract #129162 Exhibit B – Part V Page 73 of 241
Exhibit B –Statement of Work – Part V – Operations
1. Recordkeeping
a. Clinical Records
Contractor shall maintain recordkeeping consistent with OAR 410-141-0180, Oregon Health
Plan Prepaid Health Plan Recordkeeping. Clinical Records shall document the degree of
agreement or disagreement of the OHP Member, or the legal guardian of the OHP Member, with
the Covered Service and Treatment Plans recommended and explained by the Mental Health
Practitioner. If the Clinical Record does not include a signed and dated consent of the OHP
Member or the legal guardian of the OHP Member to the recommended Covered Service or
Treatment Plan, the Clinical Record shall document the reason such signature is missing.
Clinical Records shall also include the signatures, signature dates, and academic degrees of all
persons providing Covered Services and, if applicable, the signatures, signature dates, and
academic degrees of all persons providing clinical, medical or direct supervision of the case.
Clinical records shall be retained for seven (7) years after the date of services for which claims
are made. If an audit, litigation, research and evaluation, or other action involving the records is
started before the end of the seven (7) year period, the clinical records must be retained until all
issues arising out of the action are resolved.
b. Financial Records
Contractor shall maintain complete and legible financial records pertinent to Covered Services
delivered and Capitation Payments received. Such records shall be maintained in accordance
with accounting principles approved by the American Institute of Certified Public Accountants,
Generally Accepted Accounting Principles (GAAP), and/or other applicable accounting
guidelines such as those outlined in OMB circulars A-87 and A-122.
Financial records, supporting documents, statistical records and all other records pertinent to this
Contract shall be retained for a period of five (5) years after final payment is made under this
Contract or until all pending matters are resolved, whichever period is longer. Contractor shall
maintain an appropriate record system for Services to enrolled members and retain records in
accordance with 45 CFR Part 74, unless otherwise specified in applicable Oregon Revised
Statutes or Oregon Administrative Rules.
2. Contractually Required Reports, Policies and Procedures
Contractor shall submit timely, accurate and complete reports as follows:
The reports listed with an asterisk (*) need only to be submitted by Contractor for initial review and
approval by AMH. For subsequent AMH reviews of these same policies, procedures and reports,
Contractor shall submit Schedule 5, signing the affirmation that these documents have been approved
during a previous contract year and that no revisions have occurred since the initial submission and
AMH approval. Contractor shall review at least annually all internal policies and procedures, required
to be submitted, reviewed and approved by AMH.
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Contract #129162 Exhibit B – Part V Page 74 of 241
a. Reports Initially Due on Effective Date of this Contract
(1) List of Subcontracted Activities and the Entities Performing the Subcontracted
Activities.
(a) See Exhibit D, Section 17, Subsection g and Schedule 9.
(b) Submission is due on the effective date of this Contract.
(2) Practitioner Incentive Plan
(a) See Exhibit M.
(b) Submission is due on:
(i) The effective date of this Contract,
(ii) Within 30 calendar days of AMH request, and
(iii) As of the effective date of an amendment extending the Service Area.
(3) *Grievance Systems, including Member Appeal Form and Notice of Denial Letter
(a) See Exhibit B, Part III, Section 3.
(b) Submission due by the effective date of this Contract or through affirmation and
submission of Schedule 5 and 5.1.
(4) *Third Party Resources and Personal Injury Lien Policy and Procedures
(a) See Exhibit I
(b) Submission due by the effective date of this Contract or through affirmation and
submission of Schedule 5 and 5.1.
(5) *Utilization Management Policies and Procedures
(a) See Exhibit B, Part I, Section 1, Subsection h, Paragraph (3)
(b) Submission due on
(i) The effective date of this Contract or through affirmation and submission
of Schedule 5 and 5.1.,
(ii) Within 45 calendar days of change or adoption, and
(iii) Within 30 calendar days of AMH request.
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Contract #129162 Exhibit B – Part V Page 75 of 241
(6) *OHP Member Information Materials, including Member Handbook and Annual
Notification to OHP Members Regarding Ability to Participate in Activities of
Contractor
(a) See Exhibit B, Part III, Section 1 and Exhibit B, Part II, Section 1, Subsection c,
Paragraph (11).
(b) Submission due on:
(i) The effective date of this Contract or through affirmation and submission
of Schedule 5 and 5.1., and
(ii) Upon changes – within 30 days before the intended change requiring
revision.
(7) Mental Health Organization Provider Capacity Assurance Report
(a) Contractor shall submit to AMH, the Mental Health Provider Capacity Report, as
described in Exhibit K.
(b) Submission due at the time it enters into a contract with DHS,
(8) Affirmation of Services not provided due to Moral or Religious Reasons
(a) See Schedule 8
(b) Submission due upon effective date of this contract.
(9) Credentialing and Recredentialing Policy and Procedure
(a) See Exhibit B, Part II, Section 3.b.
(b) Due upon effective date of this Cotnract or through affirmation and submission of
Schedule 5.0 and Schedule 5.1.
(10) Subcontracted Activities
(a) See Schedule 9
(b) Due upon effective date of this Contract.
b. Reports Due within 30 Days of Effective Date of this Contract
(1) Proof of Excess Loss Protection/Stop Loss
(a) See Exhibit G.
(b) Submission due within 30 days of effective date of this Contract
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Contract #129162 Exhibit B – Part V Page 76 of 241
(2) Key Personnel
Contractor shall submit to AMH, upon the effective date of this Contract, and
immediately following any changes, the names telephone numbers, email address and fax
number for the following key personnel: Chief Executive Officer (CEO)/Chief Financial
Officer (CFO), Contractor, Director/Manager, Operations Manager (if applicable),
Medical Director, Contract Liaison, QA/PI Liaison, Administrative Assistant (or
applicable title), Children’s Coordinator, Adult Coordinator, Grievance, Appeals and
Hearing Liaison, and Long Term Psychiatric Care Liaison, and Other.
(a) See Schedule 6
(b) Submission due on effective date of this Contract.
(c) Immediately upon changes
(3) *Policy and Procedure: CASII and ECSII Administration
(a) See Exhibit B, Part II, Section 1, Subsection b (8) (c) (vii).
(b) Submission due within 30 days of effective date of this Contract or by affirmation
and submission of Schedule 5 and 5.1.
(4) *Policy and Procedure for Level of Service Intensity Determination
(a) See Exhibit B, Part II, Section 1, Subsection b (8) (c) (vi).
(b) Submission due on effective date of this Contract or through affirmation and
submission of Schedule 5 and 5.1.
(5) *Policy and Procedure for Prevention and Detection of Fraud, Waste and Abuse
(a) See Exhibit J
(b) Submission due within 30 days of effective date of this Contract or by affirmation
and submission of Schedule 5 and 5.1.
c. Reports Due within 45 Days of the Effective Date of this Contract
(1) QA/PI Work Plan
(a) See Exhibit B, Part II, Section 2, Subsection b.
(b) Submission due within 45 days of the effective date of this Contract.
(c) AMH shall review the Work Plan within 30 days of receipt.
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Contract #129162 Exhibit B – Part V Page 77 of 241
d. Fiscal Year End Reporting
(1) Annual Audited Financial Report
(a) See Exhibit G.
(b) Submission due within 180 calendar days from the end of the Contractor fiscal
year.
(2) G.5: Fiscal Year Cash Flow Analysis
(a) See Exhibit G.
(b) Submission due within 90 calendar days following the end of the Contractor’s
fiscal year.
(3) G.4: Statement of Revenue and Expenses (Annual Fiscal Year)
(a) See Exhibit G
(b) Submissions due 60 calendar days following the end of the Contract year.
e. Reports due within 60 calendar days following the end of each calendar quarter
(1) Evidence of Restricted Reserve
(a) See Exhibit G.
(b) Submission due within 60 calendar days following the end of each calendar
quarter: 06-01, 09-01, 12-01, 03-01.
(2) G.2 Third Party Resource Collections
(a) See Exhibit G
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
(3) G.3 Quarterly Balance Sheet
(a) See Exhibit G
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
(4) G.4 Contractors Quarterly Statement of Revenue and Expenses
(a) See Exhibit G
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
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Contract #129162 Exhibit B – Part V Page 78 of 241
(5) G.4A Health Care Expenses By Service Type
(a) See Exhibit G
(b) 60 calendar days following the end of each calendar quarter06-01, 09-01, 12-01,
03-01
(6) G.4B Prevention/Education/Outreach (PEO)
(a) See Exhibit G
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
(7) Grievance Log
(a) See Exhibit B, Part III, Section 3 and Exhibit N, Attachment 1.
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
(8) Level of Service Intensity Determination
(a) See Schedule 4
(b) 60 calendar days following the end of each calendar quarter 06-01, 09-01, 12-01,
03-01
(9) Integrated Service Array (ISA) Progress Report
(a) See Schedule 7
(b) Collect data at least once every 90 days
(c) Submit 60 calendar days following the end of each calendar quarter.
f. Due After Termination of this Contract
(1) QA/PI Work Plan Report
(a) See Exhibit B, Part II. Section 2, Subsection b, Paragraph (iii)
(b) Submission due 45 days after termination of this Contract for the current contract
cycle.
g. Encounter Data
(1) See Exhibit H and forms H.1, H.2 and H.3
(2) Submission due within 180 calendar days of the date of Services, and
Corrections due within 63 calendar days of DMAP notice of a pended Encounter
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Contract #129162 Exhibit B – Part V Page 79 of 241
h. Report Form H.1, Signature Authorization Form
(1) See Exhibit H.1
(2) Submission due within 30 days of effective date of this Contract
(3) Immediately upon changes thereafter
i. Report Form H.2 –Data Certification and Validation Report Form
(1) Form must be submitted concurrently with each Encounter Data submission
j. Report Form H.3 - Claim Count Verification Acknowledgement and Action Form
(1) Form must be completed as an acknowledgement and action Form and return I to
Contractor’s designated Encounter Data Liaison within ten (10) Business Days of receipt
of the Out of Balance Data Validation.
k. Client Process Monitoring System
(1) See Schedule 1
(2) Submission due within 30 calendar days of initiation of Services and within 30 calendar
days of termination of Services.
l. Oregon Patient/Resident Care System
(1) See Schedule 3
(2) Submission due within 12 hours of admission to Acute Care Inpatient Hospital
Psychiatric Care
m. Enrollment Reconciliation
(1) See Exhibit O
(2) Submission due with 10 (ten) days of receipt of monthly ongoing 834 file.
n. Disclosure of Compensation
(1) See Exhibit G, Attachment 7, Report G.6
(2) Submission due on March 31 of each contract year.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit B – Part V Page 80 of 241
3. Other Reporting Requirements
a. Abuse Reporting and Protective Services
For adult OHP Members, Contractor and Participating Providers shall comply with all protective
Services, investigation and reporting requirements described in OAR 410-009-0050 through 410-
009-0160, Abuse Reporting and Protective Services in Community Programs and Community
Facilities and ORS 430.735 through 430.765, Abuse Reporting for Mentally Ill.
b. Failure to Comply with Data Submission Requirements
Contractor’s failure to submit data in accordance with this Contract shall be considered in
noncompliance with the terms of this Contract and shall be grounds for withholding Capitation
Payments as specified in Exhibit B, Part VI, Section 2, Remedies Short of Termination.
c. Other Systems
Contractor shall maintain a health information system that collects, analyzes, integrates, and
reports data on OHP Member and Provider characteristics as specified by DHS. Contractor shall
make collected data available to the State or CMS upon request. The system will have
automated capacity adequate to track changes to and errors in the Enrollment listing, including
capability to track Disenrollments for other than loss of OHP eligibility; track Utilization
Management activities; Grievances and Appeals; coordinate benefits with other payers; collect
funds from other payers; and track claims received, adjudicated and paid.
d. (Reserved)
4. Research, Evaluation and Monitoring
a. In addition to submission of data described in Exhibit B, Part V, Section 3, Data Systems,
Contractor shall cooperate with AMH in collection of information through Consumer surveys,
on-site reviews, medical chart reviews, financial reporting and financial record reviews,
interviews with staff, and other information for the purposes of monitoring compliance with this
Contract, verification of Services actually provided, and for developing and monitoring
performance objectives. Contractor shall assist AMH with development and distribution of
survey instruments for use in evaluating integration of Covered Services in the OHP. Contractor
and its subcontractors shall provide access to records and facilities as described in OAR 410-
141-0180, Oregon Health Plan Prepaid Health Plan Recordkeeping, Exhibit B, Part V, Section 1,
Recordkeeping and Exhibit B, Part VI, Section 24, AMH Compliance Review and Quality
Assessment Performance Improvement Monitoring.
b. Contractor shall assist AMH in developing detailed procedures for tracking and evaluating
potential adverse selection created by the urban and/or rural environment, as applicable.
Contractor shall work with AMH to assure that such procedures include collection and
evaluation of information that will enable AMH to compare the intensity of Covered Services
rendered to OHP Members of different Mental Health Organization models.
c. Contractor, or its subcontractors and Providers shall cooperate with DHS for an annual external,
independent professional review of the quality outcomes and timeliness of and access to services
provided in this Contract as indicated in Exhibit B, Part II, Section 2.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit B - -Part VI Page 81 of 241
Exhibit B –Statement of Work – Part VI – Relationship of Parties
1. AMH Compliance Review and Quality Assessment Monitoring
a. AMH will conduct Contract compliance and QAPI monitoring related to this
Contract. Contractor and its subcontractors shall cooperate in such monitoring
and Contractor shall notify its subcontractors and Participating Providers of such
monitoring, related instructions and request for information.
b. AMH will provide Contractor thirty (30) calendar days written notice of any
Contract compliance and QAPI monitoring activity which requires any action or
cooperation of Contractor as specified in D., below, unless one of the following
conditions exist or is suspected to exist:
(1) Operations of Contractor or its subcontractors or Participating Providers
threaten the health or safety of any OHP Member; or
(2) Contractor or its subcontractors or Participating Providers may act to alter
records or make then unavailable for inspection.
c. Notice of monitoring shall include the date the monitoring shall occur, names of
individuals conducting the monitoring, and instructions and requests for
information.
d. Monitoring procedures may include, but are not limited to, the following:
(1) Entry and inspection of any facility used in the delivery of Covered
Services;
(2) A request for submission to AMH of copies of documents, or access to
such documents during a site visit, as needed to verify compliance with
this Contract or state and federal laws, rules and regulations;
(3) The completion by Contractor of self-assessment checklist or pre-site visit
questionnaires recording the degree of compliance or noncompliance with
specific Contract or rule requirements; and
(4) Conduct of interviews with, and administration of questionnaires to
Contractor staff, Participating Providers, Health Care Professionals, Allied
Agencies, and Consumers knowledgeable of Service operations.
e. Contractor shall cooperate with AMH in the development of a Corrective Action
Plan to bring Contractor performance in compliance with this Contract or state
and federal laws, rules and regulations.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit B - -Part VI Page 82 of 241
f. AMH will make available to Contractor a written report of its findings and
conclusions within sixty (60) calendar days of the completion of the monitoring.
2. Remedies Short of Termination
a. Whenever AMH, in its sole judgment, determines that Contractor is out of
compliance with this Contract, AMH may, at its discretion, take Remedial Action
as outlined in policies adopted by AMH. The policies shall be provided to
Contractor as adopted by AMH. AMH shall issue a Notice of Intended Remedial
Action which provides, in non-Emergency Situations, at least thirty (30) calendar
days’ notice prior to the effective date of the Remedial Action, and in Emergency
Situations, at least seven (7) calendar days’ notice prior to the effective date of
Remedial Action. Contractor may request an administrative review concerning
the Notice of Intended Remedial Action and may also request suspension of the
Remedial Action until a decision is reached through the administrative review
process. To receive a suspension of the intended Remedial Action, Contractor
must request an administrative review before the effective date of the intended
Remedial Action and include a request to suspend the intended Remedial Action.
If the intended Remedial Action is suspended and a decision is reached in favor of
AMH, AMH may impose the Remedial Action retroactively to the effective date
stated in the Notice of Intended Remedial Action.
b. Remedial Action provides for a range of options of varying severity depending on
the seriousness and nature of the Contract violation. Options include suspension
or freezing of Enrollment, financial withholds, or other sanctions designed to
remedy Contract violations. Conditions that may result in Remedial Action
include, but are not limited to:
(1) Failure to substantially Provide Medically Appropriate Services that are
required to be provided to OHP Members under this Contract;
(2) Contractor acts to discriminate among OHP Members on the basis of their
mental health status or need for mental health Services;
(3) Misrepresentation or falsification of information that Contractor provides
to an OHP Member or OHP Member Representative, Potential OHP
Member, Provider, CMS or DHS;
(4) Failure to comply with the requirements for physician incentive plans;
(5) Failure to provide a Provider Panel sufficient to ensure adequate Capacity
to Provide Medically Appropriate Covered Services in accordance with
access requirements specified in this Contract;
(6) Failure to maintain an internal QA/PI program;
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit B - -Part VI Page 83 of 241
(7) Failure to comply with the operational and financial reporting
requirements specified in this Contract;
(8) Failure to comply with fraud, waste and abuse requirements;
(9) Failure to make timely claims payments to Providers or provide timely
approval of authorizations;
(10) Failure to comply with Encounter Data submission requirements specified
in this Contract;
(11) Distribution directly, or indirectly through any agent or independent
contractor, marketing materials that have not been approved by AMH or
that contain false or materially misleading information; or
(12) Violation of any of the other applicable requirements of sections 1903(m)
or 1932 of the Social Security Act and any implementing regulations.
c. AMH will provide CMS written notice whenever it imposes or lifts Remedial
Action no later than 30 days after the date the Remedial Action is taken or
removed. Notification to CMS will include the type of Remedial Action and the
reason for the decision to impose or lift a Remedial Action. Payment for the new
OHP Member will be denied when, and for so long as, payment to those OHP
Members is denied by CMS.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C Page 84 of 241
Exhibit C – Consideration
1. Payment Types and Rates
a. In consideration of all work to be performed by Contractor under this Contract, DHS will pay
Contractor a monthly Capitation Payment for each OHP Member, for the period beginning on
the date of Enrollment and ending on the date of Disenrollment. Contractor shall be paid a
Capitation Payment only for those OHP Members who are enrolled with Contractor according to
DHS records. Where the date of an OHP Member’s Enrollment or Disenrollment is during mid-
month, the Capitation Payment for that OHP Member shall be prorated. DHS may withhold
payment for new OHP Members when, and for so long as, DHS determines that Contractor
meets the circumstances cited in 42 CFR 434.67. Contractor shall be responsible for all federal
and state taxes applicable to compensation or payments paid to Contractor under this Contract
and, unless Contractor is subject to backup withholding, DHS will not withhold from such
compensation or payments any amounts to cover Contractor’s federal or state tax obligations.
Contractor is not eligible for any social security, unemployment insurance or workers’
compensation benefits from compensation or payments paid to Contractor under this Contract,
except as a self-employed individual.
(1) For each month during the designated period, for the tables contained in Attachment 2, to
this Exhibit C, DHS will pay Contractor the Capitation amount listed for each OHP
Member falling within the designated rate category/county who is enrolled with
Contractor for the full month. For any month when one or more OHP Members are
enrolled for only part of the month, the Capitation amount for each OHP Member shall be
prorated based upon the number of days such OHP Member is enrolled during the month.
(a) DHS has developed actuarially set Adjusted Per Capita Costs necessary to cover
the reasonable costs of the services to be provided under this Contract. A full
description of the methodology used to calculate per capita costs and Capitation
Payments may be found in the documents described in Attachment 2, to this
Exhibit C.
(b) DHS will provide, upon Contractor request, and when available, documents
produced by the actuarial firm which document and describe the Capitation rate
development process.
(2) In addition to the base Capitation Payment rate paid to Contractor, DHS shall pay a
hospital reimbursement adjustment and graduate medical education adjustment to the
Capitation Payment rate to Contractor in accordance with the Capitation Payments
calculation reflected in the rate schedule in Attachment 2. Contractor shall distribute
such hospital reimbursement adjustment and graduate medical education payment
amounts to eligible hospitals located in Oregon that receive Medicare reimbursement
based upon diagnostic related groups, in accordance with requirements established by
DHS.
2. Payment in Full
The consideration listed in Attachment 2 to this Exhibit C is the total consideration payable to
Contractor for all work performed under this Contract.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C Page 85 of 241
3. Changes in Payment Rates
The Capitation Payment may be changed by amendment to this Contract pursuant to Exhibit D, Section
10, Termination and Section 18, Amendments, of this Contract, except that changes in Covered Services
in response to revisions in the Prioritized List of Health Services by the HSC that would have an
actuarial impact, as determined by DHS, on Contractor’s projected costs greater than 1% or in response
to action by the Oregon Legislative Assembly shall be made as follows:
a. DHS will notify Contractor within thirty (30) calendar days of any action by the HSC under ORS
414.720 or the Legislative Assembly that will necessitate a change in the Capitation Payment.
b. In the event of any action as described in Exhibit C, Section 3, Changes in Payment Rates,
Subsection a, DHS will prepare and provide to Contractor an amendment to this Contract. The
new Capitation Payment under such amendment shall take effect no earlier than thirty (30)
calendar days from the date the amendment is mailed or delivered to Contractor and, no earlier
than sixty (60) calendar days following final legislative action.
c. Contractor shall sign any such amendment within forty-five (45) calendar days of receipt of the
amendment, or such later date as DHS may specify. If Contractor fails to sign the amendment
within such time period, DHS may, at its sole discretion, terminate this Contract, effective on the
proposed effective date of the amendment or such later date as DHS may specify.
d. No amendment to this Contract shall be effective and binding until it has been signed by all
parties and all necessary State of Oregon approvals have been obtained.
4. Timing of Capitation Payments
a. The date on which DHS will process Capitation Payments will depend on whether the
Enrollment occurred on a weekly or monthly basis. For OHP Members enrolled with Contractor
during a weekly Enrollment cycle, Capitation Payments will be mailed to Contractor by the first
working day following the date of Enrollment. For OHP Members enrolled with Contractor
during a monthly Enrollment cycle, Capitation Payments will be made available to Contractor by
the 10th day of the month to which such payments are applicable. Both sets of payments will
appear on the monthly remittance advice.
b. DHS will also send Contractor an Enrollment listing by the 5th day of each month. If Contractor
believes that there are any errors in the remittance advice, Enrollment data files, or Enrollment
listing, Contractor shall notify DHS. Except for newborns and notwithstanding any errors in the
remittance advice, Enrollment data files, or Enrollment listing, retroactive Capitation Payments
shall not be made to Contractor for OHP Members not appearing on Contractor’s Enrollment
data files or listing.
c. All FFS claims must be billed by Contractor, its subcontractor, or its Participating Providers
directly in accordance with OAR 410-141-0420, Billing and Payment Under the Oregon Health
Plan. Billing Providers must be enrolled with DHS in order to receive payment. Contractor shall
not submit any FFS claims for any Covered Services provided to OHP Members.
d. Contractor shall meet the requirements of FFS timely payment:
(1) Pay 90% of all Clean Claims from Providers, who are in individual or group practice or
who practice in shared health facilities, within 90 days of the date of receipt, and
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C Page 86 of 241
(2) Abide by the specifications of the following:
(a) The date receipt is the date the agency receives the claim, as indicated by its date
stamp on the claim.
(b) The date of payment is the date of the check or other form of payment.
(3) Exception: The Contractor and its Providers may, by mutual agreement, establish an
alternative payment schedule. Any alternative schedule must be stipulated in this
Contract.
e. Contractor shall pay Indian Health Care Providers for services, covered and delivered under this
contract, for their OHP Members who are Native Americans or Alaska Natives enrolled with the
Contractor and eligible on the date of Service. Reimbursement shall occur as follows:
(1) Participating Providers that are Indian Health Care Providers must be paid at a rate equal
to the rate negotiated between the Contractor and the Participating Provider involved
which for a Federally Qualified Health Center (FQHC) may not be less than the level and
amount of payment which the Contractor would make for the Services, if the Services
were furnished by a Participating Provider which is not an FQHC.
(2) Non-Participating Providers that are Indian Health Care Providers that are not FQHCs,
must be paid at a rate that is not less than the level and amount of payment which the
Contractor would make for the Services if Services were furnished by a Participating
Provider which is not an Indian Health Care Provider.
(3) Non-Participating Providers that are Indian Health Care Providers, but that are not
FQHCs must be paid at a rate equal to the amount of payment that the Contractor would
pay an FQHC that is a Participating Provider with respect to the Contractor, but is not an
Indian Health Care Provider for such services.
f. Contractor shall make prompt payment to Indian Health Care Providers that are Participating
Providers.
5. Settlement of Accounts
a. If an OHP Member is disenrolled, DHS may Recoup or Contractor shall refund to DHS,
Capitation Payments received for the OHP Member for any period after the Disenrollment date.
b. DHS will have no obligation to make any payments to Contractor for any period(s) during which
Contractor substantially fails to carry out the terms of this Contract. Any payments received by
Contractor from DHS for such periods, and any other payments received by Contractor from
DHS to which Contractor is not entitled under the terms of this Contract, will be considered an
overpayment and will be recovered from Contractor.
c. Any Capitation Payments received by Contractor that are considered an overpayment may be
offset by any future payments to which Contractor would be entitled under DHS rules for any
Covered Services provided by Contractor.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 1 Page 87 of 241
Exhibit C – Consideration – Attachment 1 - Calculation of Capitation Payments
Calculation of Capitation Payments
DHS has developed actuarially set Adjusted Per Capita Costs (Capitation Rates) to reimburse
plans for providing the Covered Services. A full description of the methodology used to calculate
per capita costs may be found in the PricewaterhouseCoopers (PwC) document Oregon Health
Plan Medicaid Demonstration Analysis of Calendar Years 2010-2011 Average Costs , dated
September 15, 2008 and as amended December 12, 2008, which is by this reference incorporated
herein. A full description of the methodology used to calculate Capitation Rates for the Plus
Benefit Package and Standard Benefit Package may be found in the DHS document Oregon
Health Plan Medicaid Demonstration Capitation Rate Development, January 2010-December
2010 , dated October 15, 2009, which is by this reference incorporated herein.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 88 of 241
Exhibit C – Consideration – Attachment 2 - Capitation Rates
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Temporary Assistance to Needy Families (Adults Only)
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $3.56 $0.89 $4.45 1.058 0.991 $4.66
Alternative to IP $0.12 $0.00 $0.12 1.058 1.000 $0.13
Ancillary Services $0.06 $0.00 $0.06 1.058 1.000 $0.07
Assess & Eval $1.59 $0.00 $1.59 1.058 1.000 $1.68
Case Management $1.88 $0.00 $1.88 1.058 1.000 $1.99
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 1.058 1.000 $0.02
Med Management $0.21 $0.00 $0.21 1.058 1.000 $0.22
OP Therapy $4.70 $0.00 $4.70 1.058 1.000 $4.97
Other OP $0.11 $0.00 $0.11 1.058 1.000 $0.11
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $2.20 $0.00 $2.20 1.058 1.000 $2.33
Phys OP $11.16 $0.00 $11.16 1.058 1.000 $11.81
Support Day Program $0.32 $0.00 $0.32 1.058 1.000 $0.34
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 3.28%
Total Services $26.23 $0.89 $27.12 $28.62
Adjusted Base $27.68
Adjusted HRA $0.94
Admin $2.76
Total Services with Admin $31.38
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 89 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Poverty Level Medical Adults
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.00 $0.25 $1.25 1.002 0.991 $1.25
Alternative to IP $0.05 $0.00 $0.05 1.002 1.000 $0.05
Ancillary Services $0.00 $0.00 $0.00 1.002 1.000 $0.00
Assess & Eval $0.80 $0.00 $0.80 1.002 1.000 $0.80
Case Management $0.60 $0.00 $0.60 1.002 1.000 $0.60
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 1.002 1.000 $0.00
Med Management $0.03 $0.00 $0.03 1.002 1.000 $0.03
OP Therapy $1.47 $0.00 $1.47 1.002 1.000 $1.47
Other OP $0.05 $0.00 $0.05 1.002 1.000 $0.05
PEO $0.30 $0.00 $0.30 1.000 1.000 $0.30
Phys IP $0.52 $0.00 $0.52 1.002 1.000 $0.52
Phys OP $4.25 $0.00 $4.25 1.002 1.000 $4.26
Support Day Program $0.14 $0.00 $0.14 1.002 1.000 $0.14
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 2.65%
Total Services $9.22 $0.25 $9.47 $9.47
Adjusted Base $9.22
Adjusted HRA $0.25
Admin $0.91
Total Services with Admin $10.39
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 90 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: PLM, TANF, and CHIP Children < 1
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.01 $0.00 $0.02 1.000 0.991 $0.02
Alternative to IP $0.04 $0.00 $0.04 1.000 1.000 $0.04
Ancillary Services $0.00 $0.00 $0.00 N/A N/A $0.00
Assess & Eval $0.01 $0.00 $0.01 1.000 1.000 $0.01
Case Management $0.06 $0.00 $0.06 1.000 1.000 $0.06
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 N/A N/A $0.00
Med Management $0.00 $0.00 $0.00 N/A N/A $0.00
OP Therapy $0.01 $0.00 $0.01 1.000 1.000 $0.01
Other OP $0.00 $0.00 $0.00 N/A N/A $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.01 $0.00 $0.01 1.000 1.000 $0.01
Phys OP $0.19 $0.00 $0.19 1.000 1.000 $0.19
Support Day Program $0.00 $0.00 $0.00 1.000 1.000 $0.00
Intensive Treatment Services ($0.01) $0.00 ($0.01) 1.000 1.000 ($0.01)
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.53%
Total Services $0.60 $0.00 $0.60 $0.60
Adjusted Base $0.60
Adjusted HRA $0.00
Admin $0.06
Total Services with Admin $0.66
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 91 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: PLM, TANF, and CHIP Children 1 - 5
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.07 $0.02 $0.09 0.994 0.991 $0.09
Alternative to IP $0.00 $0.00 $0.00 0.994 1.000 $0.00
Ancillary Services $0.00 $0.00 $0.00 0.994 1.000 $0.00
Assess & Eval $0.32 $0.00 $0.32 0.994 1.000 $0.32
Case Management $0.22 $0.00 $0.22 0.994 1.000 $0.22
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 0.994 1.000 $0.01
Med Management $0.00 $0.00 $0.00 0.994 1.000 $0.00
OP Therapy $0.44 $0.00 $0.44 0.994 1.000 $0.44
Other OP $0.00 $0.00 $0.00 0.994 1.000 $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.17 $0.00 $0.17 0.994 1.000 $0.17
Phys OP $2.18 $0.00 $2.18 0.994 1.000 $2.17
Support Day Program $0.19 $0.00 $0.19 0.994 1.000 $0.19
Intensive Treatment Services $0.95 $0.00 $0.95 8.568 1.000 $8.16
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.38%
Total Services $4.87 $0.02 $4.89 $12.08
Adjusted Base $12.03
Adjusted HRA $0.05
Admin $1.17
Total Services with Admin $13.24
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 92 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: PLM, TANF, and CHIP Children 6 - 18
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.51 $0.38 $1.89 1.147 0.991 $2.14
Alternative to IP $0.22 $0.00 $0.22 1.147 1.000 $0.25
Ancillary Services $0.01 $0.00 $0.01 1.147 1.000 $0.01
Assess & Eval $1.20 $0.00 $1.20 1.147 1.000 $1.38
Case Management $1.35 $0.00 $1.35 1.147 1.000 $1.55
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 1.147 1.000 $0.02
Med Management $0.04 $0.00 $0.04 1.147 1.000 $0.04
OP Therapy $2.45 $0.00 $2.45 1.147 1.000 $2.81
Other OP $0.12 $0.00 $0.12 1.147 1.000 $0.14
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.37 $0.00 $1.37 1.147 1.000 $1.57
Phys OP $8.56 $0.00 $8.56 1.147 1.000 $9.82
Support Day Program $0.61 $0.00 $0.61 1.147 1.000 $0.70
Intensive Treatment Services $9.52 $0.00 $9.52 1.224 1.000 $11.66
CONS Assessments $0.03 $0.00 $0.03 1.000 1.000 $0.03
HRA % 1.36%
Total Services $27.30 $0.38 $27.68 $32.41
Adjusted Base $31.97
Adjusted HRA $0.44
Admin $3.13
Total Services with Admin $35.54
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 93 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Aid to the Blind/Aid to the Disabled with Medicare
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $2.82 $0.00 $2.82 0.900 0.991 $2.52
Alternative to IP $2.62 $0.00 $2.62 0.900 1.000 $2.36
Ancillary Services $0.05 $0.00 $0.05 0.900 1.000 $0.04
Assess & Eval $1.15 $0.00 $1.15 0.900 1.000 $1.03
Case Management $19.87 $0.00 $19.87 0.900 1.000 $17.88
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.77 $0.00 $0.77 0.900 1.000 $0.69
Med Management $3.14 $0.00 $3.14 0.900 1.000 $2.83
OP Therapy $6.58 $0.00 $6.58 0.900 1.000 $5.93
Other OP $0.05 $0.00 $0.05 0.900 1.000 $0.04
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $6.98 $0.00 $6.98 0.900 1.000 $6.28
Phys OP $11.89 $0.00 $11.89 0.900 1.000 $10.70
Support Day Program $17.49 $0.00 $17.49 0.900 1.000 $15.74
Intensive Treatment Services $0.00 $0.00 $0.00 1.000 1.000 $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.00%
Total Services $73.69 $0.00 $73.69 $66.33
Adjusted Base $66.33
Adjusted HRA $0.00
Admin $6.40
Total Services with Admin $72.73
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 94 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Aid to the Blind/Aid to the Disabled without Medicare
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $23.22 $5.80 $29.01 0.900 0.991 $25.87
Alternative to IP $2.85 $0.00 $2.85 0.900 1.000 $2.57
Ancillary Services $0.21 $0.00 $0.21 0.900 1.000 $0.19
Assess & Eval $2.23 $0.00 $2.23 0.900 1.000 $2.01
Case Management $16.80 $0.00 $16.80 0.900 1.000 $15.12
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.61 $0.00 $0.61 0.900 1.000 $0.55
Med Management $2.85 $0.00 $2.85 0.900 1.000 $2.57
OP Therapy $8.53 $0.00 $8.53 0.900 1.000 $7.67
Other OP $0.27 $0.00 $0.27 0.900 1.000 $0.24
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $11.02 $0.00 $11.02 0.900 1.000 $9.92
Phys OP $21.06 $0.00 $21.06 0.900 1.000 $18.95
Support Day Program $14.08 $0.00 $14.08 0.900 1.000 $12.67
Intensive Treatment Services $18.72 $0.00 $18.72 0.837 1.000 $15.66
CONS Assessments $0.06 $0.00 $0.06 1.000 1.000 $0.06
HRA % 4.51%
Total Services $122.80 $5.80 $128.60 $114.35
Adjusted Base $109.20
Adjusted HRA $5.16
Admin $11.03
Total Services with Admin $125.39
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 95 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Old Age Assistance with Medicare
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.35 $0.00 $0.35 1.000 0.991 $0.35
Alternative to IP $0.12 $0.00 $0.12 1.000 1.000 $0.12
Ancillary Services $0.06 $0.00 $0.06 1.000 1.000 $0.06
Assess & Eval $0.31 $0.00 $0.31 1.000 1.000 $0.31
Case Management $1.72 $0.00 $1.72 1.000 1.000 $1.72
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.04 $0.00 $0.04 1.000 1.000 $0.04
Med Management $0.21 $0.00 $0.21 1.000 1.000 $0.21
OP Therapy $0.73 $0.00 $0.73 1.000 1.000 $0.73
Other OP $0.03 $0.00 $0.03 1.000 1.000 $0.03
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.92 $0.00 $0.92 1.000 1.000 $0.92
Phys OP $1.66 $0.00 $1.66 1.000 1.000 $1.66
Support Day Program $2.22 $0.00 $2.22 1.000 1.000 $2.22
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.00%
Total Services $8.66 $0.00 $8.66 $8.66
Adjusted Base $8.66
Adjusted HRA $0.00
Admin $0.84
Total Services with Admin $9.49
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 96 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: Old Age Assistance without Medicare
Base
Capitation
Rate
Hospital
Reimburs
ement
Adjustmen
t
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $6.76 $1.69 $8.45 1.000 0.991 $8.37
Alternative to IP $0.00 $0.00 $0.00 N/A N/A $0.00
Ancillary Services $0.77 $0.00 $0.77 1.000 1.000 $0.77
Assess & Eval $0.83 $0.00 $0.83 1.000 1.000 $0.83
Case Management $3.48 $0.00 $3.48 1.000 1.000 $3.48
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 N/A N/A $0.00
Med Management $0.37 $0.00 $0.37 1.000 1.000 $0.37
OP Therapy $0.49 $0.00 $0.49 1.000 1.000 $0.49
Other OP $0.00 $0.00 $0.00 N/A N/A $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.62 $0.00 $1.62 1.000 1.000 $1.62
Phys OP $8.81 $0.00 $8.81 1.000 1.000 $8.81
Support Day Program $2.45 $0.00 $2.45 1.000 1.000 $2.45
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 6.12%
Total Services $25.87 $1.69 $27.56 $27.48
Adjusted Base $25.80
Adjusted HRA $1.68
Admin $2.65
Total Services with Admin $30.13
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 97 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: SCF Children
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $5.24 $1.31 $6.55 0.997 0.991 $6.47
Alternative to IP $2.78 $0.00 $2.78 0.997 1.000 $2.77
Ancillary Services $0.02 $0.00 $0.02 0.997 1.000 $0.01
Assess & Eval $4.33 $0.00 $4.33 0.997 1.000 $4.31
Case Management $10.08 $0.00 $10.08 0.997 1.000 $10.04
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.11 $0.00 $0.11 0.997 1.000 $0.11
Med Management $0.13 $0.00 $0.13 0.997 1.000 $0.13
OP Therapy $13.32 $0.00 $13.32 0.997 1.000 $13.28
Other OP $0.31 $0.00 $0.31 0.997 1.000 $0.31
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $8.33 $0.00 $8.33 0.997 1.000 $8.30
Phys OP $44.67 $0.00 $44.67 0.997 1.000 $44.53
Support Day Program $4.40 $0.00 $4.40 0.997 1.000 $4.38
Intensive Treatment Services $106.39 $0.00 $106.39 1.139 1.000 $121.14
CONS Assessments $0.26 $0.00 $0.26 1.000 1.000 $0.26
HRA % 0.65%
Total Services $200.64 $1.31 $201.95 $216.33
Adjusted Base $214.93
Adjusted HRA $1.40
Admin $20.87
Total Services with Admin $237.21
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 98 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: OHP Families
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.86 $0.47 $2.33 0.975 0.991 $2.25
Alternative to IP $0.01 $0.00 $0.01 0.975 1.000 $0.01
Ancillary Services $0.05 $0.00 $0.05 0.975 1.000 $0.05
Assess & Eval $0.57 $0.00 $0.57 0.975 1.000 $0.55
Case Management $0.69 $0.00 $0.69 0.975 1.000 $0.67
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 0.975 1.000 $0.00
Med Management $0.13 $0.00 $0.13 0.975 1.000 $0.13
OP Therapy $2.54 $0.00 $2.54 0.975 1.000 $2.48
Other OP $0.04 $0.00 $0.04 0.975 1.000 $0.04
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.24 $0.00 $1.24 0.975 1.000 $1.21
Phys OP $6.54 $0.00 $6.54 0.975 1.000 $6.38
Support Day Program $0.12 $0.00 $0.12 0.975 1.000 $0.11
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 3.19%
Total Services $14.11 $0.47 $14.57 $14.19
Adjusted Base $13.74
Adjusted HRA $0.45
Admin $1.37
Total Services with Admin $15.56
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 99 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Linn/Benton/Marion/Polk/Yamhill
Rate Group: OHP Adults & Couples
Base
Capitation
Rate
Hospital
Reimburse
ment
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $7.18 $1.79 $8.98 0.900 0.991 $8.00
Alternative to IP $0.62 $0.00 $0.62 0.900 1.000 $0.56
Ancillary Services $0.04 $0.00 $0.04 0.900 1.000 $0.04
Assess & Eval $1.24 $0.00 $1.24 0.900 1.000 $1.12
Case Management $4.09 $0.00 $4.09 0.900 1.000 $3.68
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.12 $0.00 $0.12 0.900 1.000 $0.11
Med Management $0.42 $0.00 $0.42 0.900 1.000 $0.37
OP Therapy $4.98 $0.00 $4.98 0.900 1.000 $4.49
Other OP $0.09 $0.00 $0.09 0.900 1.000 $0.08
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $3.85 $0.00 $3.85 0.900 1.000 $3.47
Phys OP $13.09 $0.00 $13.09 0.900 1.000 $11.78
Support Day Program $2.40 $0.00 $2.40 0.900 1.000 $2.16
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 4.46%
Total Services $38.43 $1.79 $40.22 $36.16
Adjusted Base $34.54
Adjusted HRA $1.61
Admin $3.49
Total Services with Admin $39.64
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 100 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Temporary Assistance to Needy Families (Adults Only)
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $3.56 $0.89 $4.45 1.058 0.987 $4.65
Alternative to IP $0.12 $0.00 $0.12 1.058 1.000 $0.13
Ancillary Services $0.06 $0.00 $0.06 1.058 1.000 $0.07
Assess & Eval $1.59 $0.00 $1.59 1.058 1.000 $1.68
Case Management $1.88 $0.00 $1.88 1.058 1.000 $1.99
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 1.058 1.000 $0.02
Med Management $0.21 $0.00 $0.21 1.058 1.000 $0.22
OP Therapy $4.70 $0.00 $4.70 1.058 1.000 $4.97
Other OP $0.11 $0.00 $0.11 1.058 1.000 $0.11
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $2.20 $0.00 $2.20 1.058 1.000 $2.33
Phys OP $11.16 $0.00 $11.16 1.058 1.000 $11.81
Support Day Program $0.32 $0.00 $0.32 1.058 1.000 $0.34
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 3.28%
Total Services $26.23 $0.89 $27.12 $28.60
Adjusted Base $27.66
Adjusted HRA $0.94
Admin $2.76
Total Services with Admin $31.36
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 101 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Poverty Level Medical Adults
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.00 $0.25 $1.25 1.002 0.987 $1.24
Alternative to IP $0.05 $0.00 $0.05 1.002 1.000 $0.05
Ancillary Services $0.00 $0.00 $0.00 1.002 1.000 $0.00
Assess & Eval $0.80 $0.00 $0.80 1.002 1.000 $0.80
Case Management $0.60 $0.00 $0.60 1.002 1.000 $0.60
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 1.002 1.000 $0.00
Med Management $0.03 $0.00 $0.03 1.002 1.000 $0.03
OP Therapy $1.47 $0.00 $1.47 1.002 1.000 $1.47
Other OP $0.05 $0.00 $0.05 1.002 1.000 $0.05
PEO $0.30 $0.00 $0.30 1.000 1.000 $0.30
Phys IP $0.52 $0.00 $0.52 1.002 1.000 $0.52
Phys OP $4.25 $0.00 $4.25 1.002 1.000 $4.26
Support Day Program $0.14 $0.00 $0.14 1.002 1.000 $0.14
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 2.65%
Total Services $9.22 $0.25 $9.47 $9.47
Adjusted Base $9.22
Adjusted HRA $0.25
Admin $0.91
Total Services with Admin $10.38
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 102 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: PLM, TANF, and CHIP Children < 1
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.01 $0.00 $0.02 1.000 0.987 $0.02
Alternative to IP $0.04 $0.00 $0.04 1.000 1.000 $0.04
Ancillary Services $0.00 $0.00 $0.00 N/A N/A $0.00
Assess & Eval $0.01 $0.00 $0.01 1.000 1.000 $0.01
Case Management $0.06 $0.00 $0.06 1.000 1.000 $0.06
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 N/A N/A $0.00
Med Management $0.00 $0.00 $0.00 N/A N/A $0.00
OP Therapy $0.01 $0.00 $0.01 1.000 1.000 $0.01
Other OP $0.00 $0.00 $0.00 N/A N/A $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.01 $0.00 $0.01 1.000 1.000 $0.01
Phys OP $0.19 $0.00 $0.19 1.000 1.000 $0.19
Support Day Program $0.00 $0.00 $0.00 1.000 1.000 $0.00
Intensive Treatment Services ($0.01) $0.00 ($0.01) 1.000 1.000 ($0.01)
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.53%
Total Services $0.60 $0.00 $0.60 $0.60
Adjusted Base $0.60
Adjusted HRA $0.00
Admin $0.06
Total Services with Admin $0.66
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 103 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: PLM, TANF, and CHIP Children 1 - 5
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.07 $0.02 $0.09 0.994 0.987 $0.09
Alternative to IP $0.00 $0.00 $0.00 0.994 1.000 $0.00
Ancillary Services $0.00 $0.00 $0.00 0.994 1.000 $0.00
Assess & Eval $0.32 $0.00 $0.32 0.994 1.000 $0.32
Case Management $0.22 $0.00 $0.22 0.994 1.000 $0.22
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 0.994 1.000 $0.01
Med Management $0.00 $0.00 $0.00 0.994 1.000 $0.00
OP Therapy $0.44 $0.00 $0.44 0.994 1.000 $0.44
Other OP $0.00 $0.00 $0.00 0.994 1.000 $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.17 $0.00 $0.17 0.994 1.000 $0.17
Phys OP $2.18 $0.00 $2.18 0.994 1.000 $2.17
Support Day Program $0.19 $0.00 $0.19 0.994 1.000 $0.19
Intensive Treatment Services $0.95 $0.00 $0.95 0.069 1.000 $0.07
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.38%
Total Services $4.87 $0.02 $4.89 $3.98
Adjusted Base $3.96
Adjusted HRA $0.01
Admin $0.38
Total Services with Admin $4.36
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 104 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: PLM, TANF, and CHIP Children 6 - 18
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.51 $0.38 $1.89 1.147 0.987 $2.13
Alternative to IP $0.22 $0.00 $0.22 1.147 1.000 $0.25
Ancillary Services $0.01 $0.00 $0.01 1.147 1.000 $0.01
Assess & Eval $1.20 $0.00 $1.20 1.147 1.000 $1.38
Case Management $1.35 $0.00 $1.35 1.147 1.000 $1.55
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.01 $0.00 $0.01 1.147 1.000 $0.02
Med Management $0.04 $0.00 $0.04 1.147 1.000 $0.04
OP Therapy $2.45 $0.00 $2.45 1.147 1.000 $2.81
Other OP $0.12 $0.00 $0.12 1.147 1.000 $0.14
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.37 $0.00 $1.37 1.147 1.000 $1.57
Phys OP $8.56 $0.00 $8.56 1.147 1.000 $9.82
Support Day Program $0.61 $0.00 $0.61 1.147 1.000 $0.70
Intensive Treatment Services $9.52 $0.00 $9.52 1.272 1.000 $12.11
CONS Assessments $0.03 $0.00 $0.03 1.000 1.000 $0.03
HRA % 1.36%
Total Services $27.30 $0.38 $27.68 $32.86
Adjusted Base $32.41
Adjusted HRA $0.45
Admin $3.17
Total Services with Admin $36.03
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 105 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Aid to the Blind/Aid to the Disabled with Medicare
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $2.82 $0.00 $2.82 0.900 0.987 $2.51
Alternative to IP $2.62 $0.00 $2.62 0.900 1.000 $2.36
Ancillary Services $0.05 $0.00 $0.05 0.900 1.000 $0.04
Assess & Eval $1.15 $0.00 $1.15 0.900 1.000 $1.03
Case Management $19.87 $0.00 $19.87 0.900 1.000 $17.88
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.77 $0.00 $0.77 0.900 1.000 $0.69
Med Management $3.14 $0.00 $3.14 0.900 1.000 $2.83
OP Therapy $6.58 $0.00 $6.58 0.900 1.000 $5.93
Other OP $0.05 $0.00 $0.05 0.900 1.000 $0.04
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $6.98 $0.00 $6.98 0.900 1.000 $6.28
Phys OP $11.89 $0.00 $11.89 0.900 1.000 $10.70
Support Day Program $17.49 $0.00 $17.49 0.900 1.000 $15.74
Intensive Treatment Services $0.00 $0.00 $0.00 1.000 1.000 $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.00%
Total Services $73.69 $0.00 $73.69 $66.32
Adjusted Base $66.32
Adjusted HRA $0.00
Admin $6.40
Total Services with Admin $72.72
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 106 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Aid to the Blind/Aid to the Disabled without Medicare
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $23.22 $5.80 $29.01 0.900 0.987 $25.77
Alternative to IP $2.85 $0.00 $2.85 0.900 1.000 $2.57
Ancillary Services $0.21 $0.00 $0.21 0.900 1.000 $0.19
Assess & Eval $2.23 $0.00 $2.23 0.900 1.000 $2.01
Case Management $16.80 $0.00 $16.80 0.900 1.000 $15.12
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.61 $0.00 $0.61 0.900 1.000 $0.55
Med Management $2.85 $0.00 $2.85 0.900 1.000 $2.57
OP Therapy $8.53 $0.00 $8.53 0.900 1.000 $7.67
Other OP $0.27 $0.00 $0.27 0.900 1.000 $0.24
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $11.02 $0.00 $11.02 0.900 1.000 $9.92
Phys OP $21.06 $0.00 $21.06 0.900 1.000 $18.95
Support Day Program $14.08 $0.00 $14.08 0.900 1.000 $12.67
Intensive Treatment Services $18.72 $0.00 $18.72 1.002 1.000 $18.76
CONS Assessments $0.06 $0.00 $0.06 1.000 1.000 $0.06
HRA % 4.51%
Total Services $122.80 $5.80 $128.60 $117.34
Adjusted Base $112.05
Adjusted HRA $5.29
Admin $11.32
Total Services with Admin $128.66
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 107 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Old Age Assistance with Medicare
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $0.35 $0.00 $0.35 1.000 0.987 $0.35
Alternative to IP $0.12 $0.00 $0.12 1.000 1.000 $0.12
Ancillary Services $0.06 $0.00 $0.06 1.000 1.000 $0.06
Assess & Eval $0.31 $0.00 $0.31 1.000 1.000 $0.31
Case Management $1.72 $0.00 $1.72 1.000 1.000 $1.72
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.04 $0.00 $0.04 1.000 1.000 $0.04
Med Management $0.21 $0.00 $0.21 1.000 1.000 $0.21
OP Therapy $0.73 $0.00 $0.73 1.000 1.000 $0.73
Other OP $0.03 $0.00 $0.03 1.000 1.000 $0.03
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $0.92 $0.00 $0.92 1.000 1.000 $0.92
Phys OP $1.66 $0.00 $1.66 1.000 1.000 $1.66
Support Day Program $2.22 $0.00 $2.22 1.000 1.000 $2.22
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 0.00%
Total Services $8.66 $0.00 $8.66 $8.66
Adjusted Base $8.66
Adjusted HRA $0.00
Admin $0.84
Total Services with Admin $9.49
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 108 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: Old Age Assistance without Medicare
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $6.76 $1.69 $8.45 1.000 0.987 $8.34
Alternative to IP $0.00 $0.00 $0.00 N/A N/A $0.00
Ancillary Services $0.77 $0.00 $0.77 1.000 1.000 $0.77
Assess & Eval $0.83 $0.00 $0.83 1.000 1.000 $0.83
Case Management $3.48 $0.00 $3.48 1.000 1.000 $3.48
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 N/A N/A $0.00
Med Management $0.37 $0.00 $0.37 1.000 1.000 $0.37
OP Therapy $0.49 $0.00 $0.49 1.000 1.000 $0.49
Other OP $0.00 $0.00 $0.00 N/A N/A $0.00
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.62 $0.00 $1.62 1.000 1.000 $1.62
Phys OP $8.81 $0.00 $8.81 1.000 1.000 $8.81
Support Day Program $2.45 $0.00 $2.45 1.000 1.000 $2.45
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 6.12%
Total Services $25.87 $1.69 $27.56 $27.45
Adjusted Base $25.77
Adjusted HRA $1.68
Admin $2.65
Total Services with Admin $30.10
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 109 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: SCF Children
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $5.24 $1.31 $6.55 1.058 0.987 $6.84
Alternative to IP $2.78 $0.00 $2.78 1.058 1.000 $2.94
Ancillary Services $0.02 $0.00 $0.02 1.058 1.000 $0.02
Assess & Eval $4.33 $0.00 $4.33 1.058 1.000 $4.58
Case Management $10.08 $0.00 $10.08 1.058 1.000 $10.66
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.11 $0.00 $0.11 1.058 1.000 $0.11
Med Management $0.13 $0.00 $0.13 1.058 1.000 $0.14
OP Therapy $13.32 $0.00 $13.32 1.058 1.000 $14.09
Other OP $0.31 $0.00 $0.31 1.058 1.000 $0.33
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $8.33 $0.00 $8.33 1.058 1.000 $8.81
Phys OP $44.67 $0.00 $44.67 1.058 1.000 $47.26
Support Day Program $4.40 $0.00 $4.40 1.058 1.000 $4.65
Intensive Treatment Services $106.39 $0.00 $106.39 1.043 1.000 $110.93
CONS Assessments $0.26 $0.00 $0.26 1.000 1.000 $0.26
HRA % 0.65%
Total Services $200.64 $1.31 $201.95 $211.90
Adjusted Base $210.53
Adjusted HRA $1.37
Admin $20.45
Total Services with Admin $232.35
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 110 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: OHP Families
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $1.86 $0.47 $2.33 0.975 0.987 $2.24
Alternative to IP $0.01 $0.00 $0.01 0.975 1.000 $0.01
Ancillary Services $0.05 $0.00 $0.05 0.975 1.000 $0.05
Assess & Eval $0.57 $0.00 $0.57 0.975 1.000 $0.55
Case Management $0.69 $0.00 $0.69 0.975 1.000 $0.67
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.00 $0.00 $0.00 0.975 1.000 $0.00
Med Management $0.13 $0.00 $0.13 0.975 1.000 $0.13
OP Therapy $2.54 $0.00 $2.54 0.975 1.000 $2.48
Other OP $0.04 $0.00 $0.04 0.975 1.000 $0.04
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $1.24 $0.00 $1.24 0.975 1.000 $1.21
Phys OP $6.54 $0.00 $6.54 0.975 1.000 $6.38
Support Day Program $0.12 $0.00 $0.12 0.975 1.000 $0.11
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 3.19%
Total Services $14.11 $0.47 $14.57 $14.18
Adjusted Base $13.73
Adjusted HRA $0.45
Admin $1.37
Total Services with Admin $15.55
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit C – Attachment 2 Page 111 of 241
Oregon Health Plan Medicaid Demonstration
Capitation Rates for January 2010 through December 2010
Plan: Accountable Behavioral Health Alliance
Region: Other
Rate Group: OHP Adults & Couples
Base
Capitation
Rate
Hospital
Reimbursem
ent
Adjustment
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Geographic
Factor
Adjusted
Capitation
Rate
Mental Health
Acute Inpatient $7.18 $1.79 $8.98 0.900 0.987 $7.97
Alternative to IP $0.62 $0.00 $0.62 0.900 1.000 $0.56
Ancillary Services $0.04 $0.00 $0.04 0.900 1.000 $0.04
Assess & Eval $1.24 $0.00 $1.24 0.900 1.000 $1.12
Case Management $4.09 $0.00 $4.09 0.900 1.000 $3.68
Consultation $0.00 $0.00 $0.00 N/A N/A $0.00
Family Support $0.12 $0.00 $0.12 0.900 1.000 $0.11
Med Management $0.42 $0.00 $0.42 0.900 1.000 $0.37
OP Therapy $4.98 $0.00 $4.98 0.900 1.000 $4.49
Other OP $0.09 $0.00 $0.09 0.900 1.000 $0.08
PEO $0.29 $0.00 $0.29 1.000 1.000 $0.29
Phys IP $3.85 $0.00 $3.85 0.900 1.000 $3.47
Phys OP $13.09 $0.00 $13.09 0.900 1.000 $11.78
Support Day Program $2.40 $0.00 $2.40 0.900 1.000 $2.16
Intensive Treatment Services $0.00 $0.00 $0.00 N/A N/A $0.00
CONS Assessments $0.00 $0.00 $0.00 N/A N/A $0.00
HRA % 4.46%
Total Services $38.43 $1.79 $40.22 $36.12
Adjusted Base $34.51
Adjusted HRA $1.61
Admin $3.49
Total Services with Admin $39.61
Admin % 8.80%
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 112 of 241
Exhibit D – Standard Terms and Conditions
1. Controlling State Law/Venue
This Contract shall be governed and construed in accordance with the laws of the State of
Oregon, without regard to principles of conflicts of laws. Any action or suit involving this
Contract shall be filed and tried in Marion County, Oregon. Provided, however, if the action or
suit might be brought in a federal forum, then it shall be brought and conducted solely and
exclusively with the United States District Court for the District of Oregon. Nothing herein
shall be constituted as a waiver of the State’s sovereign or governmental immunity, whether
derived from the Eleventh Amendment to the United States Constitution or otherwise, or of any
defenses to claims or jurisdictions based thereon. Contractor, by signature below if its
authorized representative, hereby consents to the in personam jurisdiction of said court.
2. Compliance with Applicable Laws
a. Contractor shall comply and cause all subcontractors to comply with all state and local
laws, rules and regulations, applicable to this Contract or to the performance of Work as
they may be adopted or amended from time to time, including but not limited to the
following: (i) ORS Chapter 659A.142; (ii) all other applicable requirements of state
civil rights and rehabilitation statutes, rules and regulations;; (iii) DHS rules pertaining
to the provisions of prepaid capitated health care and services, OAR Chapter 410,
Division 141; (iv) all other DHS Rules in OAR Chapter 410; and (v) all DHS Rules in
OAR Chapter 309. These laws, rules and regulations, are incorporated by reference
herein to the extent that they are applicable to this Contract and required by law to be so
incorporated. DHS' performance under this Contract is conditioned upon Contractor's
compliance with the provisions of ORS 279B.220, 279B.225, 279B.230, 279B.235 and
279B.270, which are incorporated by reference herein. Contractor shall, to the
maximum extent economically feasible in the performance of this Contract, use
recycled paper (as defined in ORS 279A.010(1)(gg)), recycled PETE products (as
defined in ORS 279A.010(1)(hh)), and other recycled products (as "recycled product" is
defined in ORS 279A.010(1)(ii)).
b. In compliance with the Americans with Disabilities Act of 1990, any written material
that is generated and provided by Contractor under this Contract to DHS clients,
including eligible OHP Clients, shall, at the request of such DHS clients, be reproduced
in alternate formats of communication, to include Braille, large print, audiotape, oral
presentation, and electronic format. DHS shall not reimburse Contractor for costs
incurred in complying with this provision. Contractor shall cause all subcontractors
under this Contract to comply with the requirements of this provision.
c. Contractor shall comply with the federal laws, rules and executive orders, as set forth or
incorporated, or both, in this Contract and all other federal laws, rules and executive
orders, applicable to Contractor's performance under this Contract as they may be
adopted or amended from time to time.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 113 of 241
3. Independent Contractor
a. Contractor is not an officer, employee, or agent of the State of Oregon as those terms
are used in ORS 30.265 or otherwise.
b. If Contractor is currently performing work for the State of Oregon or the federal
government, Contractor by signature to this Contract, represents and warrants that
Contractor's Work to be performed under this Contract creates no potential or actual
conflict of interest as defined by ORS Chapter 244 and that no statutes, rules or
regulations of the State of Oregon or federal agency for which Contractor currently
performs work would prohibit Contractor's Work under this Contract. If compensation
under this Contract is to be charged against federal funds, Contractor certifies that it is
not currently employed by the federal government.
c. Contractor is responsible for all federal and state taxes applicable to compensation paid
to Contractor under this Contract and, unless Contractor is subject to backup
withholding, DHS will not withhold from such compensation any amounts to cover
Contractor's federal or state tax obligations. Contractor is not eligible for any social
security, unemployment insurance or workers' compensation benefits from
compensation paid to Contractor under this Contract, except as a self-employed
individual.
d. Contractor shall perform all Work as an independent contractor. DHS reserves the right
(i) to determine and modify the delivery schedule for the Work and (ii) to evaluate the
quality of the Work Product, however, DHS may not and will not control the means or
manner of Contractor's performance. Contractor is responsible for determining the
appropriate means and manner of performing the Work.
4. Representations and Warranties
a. Contractor's Representations and Warranties Contractor represents and warrants to
DHS that:
(1) Contractor has the power and authority to enter into and perform this Contract,
(2) this Contract, when executed and delivered, shall be a valid and binding
obligation of Contractor enforceable in accordance with its terms,
(3) Contractor has the skill and knowledge possessed by well-informed members of
its industry, trade or profession and Contractor will apply that skill and
knowledge with care and diligence to perform the Work in a professional
manner and in accordance with standards prevalent in Contractor's industry,
trade or profession,
(4) Contractor shall, at all times during the term of this Contract, be qualified,
professionally competent, and duly licensed to perform the Work, and
(5) Contractor prepared its application related to this Contract, if any, independently
from all other applicants, and without collusion, fraud, or other dishonesty.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 114 of 241
b. Warranties Cumulative. The warranties set forth in this section are in addition to, and
not in lieu of, any other warranties provided.
5. Funds Available and Authorized
a. AMH certifies at the time this Contract is signed that sufficient funds are available and
authorized for expenditure to finance costs of this Contract within AMH’s current
appropriation or limitation. However, AMH’s performance during the term of this
Contract may be contingent on continued appropriations, limitations, allotments, or
other expenditure authority. Similarly, the continuation of this Contract, or any
extension, after the end of the biennium in which this Contract is signed, is contingent
upon AMH receiving appropriations, limitations, allotments or other expenditure
authority to make payments as required under this Contract. AMH may terminate this
Contract pursuant to Exhibit D, Section 10, if AMH fails to receive funding,
appropriations, limitations, allotments, or other expenditure authority as contemplated
by AMH’s budget or spending plan and AMH determines, in its assessment and ranking
of the policy objectives explicit or implicit in AMH’s budget or spending plan, that it is
necessary to terminate this Contract.
b. All billings and payments processed through the Medicaid Management Information
System (MMIS) shall be processed in accordance with the provisions of Oregon
Administrative Rules (OAR) 407-120-0100 through 407-120-0200, OAR 407-120-0300
through OAR 407-120-0380 and any other DHS Oregon Administrative Rules that are
program specific to the billings and payments and, if applicable, to billing and payment
of OHP services.
6. Ownership
Contractor shall notify AMH of any changes in the ownership of Contractor and provide AMH
with full and complete information of each person or corporation with an ownership or control
interest (which equals or exceeds 5 percent) in the managed care plan, or any subcontractor in
which Contractor has an ownership interest that equals or exceeds 5 percent.
7. Indemnification
CONTRACTOR SHALL DEFEND , SAVE , HOLD HARMLESS AND INDEMNIFY THE
STATE OF OREGON , DHS AND THEIR OFFICERS , AGENTS , EMPLOYEES , FROM
AND AGAINST ALL CLAIMS SUITS , ACTIONS , DAMAGES , LIABILITIES , COSTS AND
EXPENSES OF WHATSOEVER NATURE RESULTING FROM , ARISING OUT OF , OR
RELATING TO THE ACTIVITIES OR OMISSIONS OF CONTRACTOR OR ITS OFFICERS ,
EMPLOYEES , AGENTS OR SUBCONTRACTORS UNDER THIS SECTION . IF
CONTRACTOR IS A COUNTY (AS THE WORD “COUNTY ” IS USED IN ARTICLE XI,
SECTION 10 OF THE OREGON CONSTITUTION ) OR A PUBLIC BODY (AS “PUBLIC
BODY ” IS DEFINED IN ORS 30.260(4)), CONTRACTOR ’S LIABILITY UNDER THIS
CONTRACT IS SUBJECT TO THE LIMITATIONS OF THE OREGON TORT CLAIMS
ACT AND OF ARTICLE XI, SECTION 10 OF THE OREGON CONSTITUTION .
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 115 of 241
TO THE EXTENT PERMITTED BY ARTICLE XI, SECTION 7 OF THE OREGON
CONSTITUTION AND BY THE OREGON TORT CLAIMS ACT , DHS SHALL
INDEMNIFY , WITHIN THE LIMITS OF THE OREGON TORT CLAIMS ACT ,
CONTRACTOR AGAINST LIABILITY FOR DAMAGE TO LIFE AND PROPERTY
ARISING FROM DHS ACTIVITIES UNDER THIS CONTRACT , PROVIDED DHS SHALL
NOT BE REQUIRED TO INDEMNIFY CONTRACTOR FOR ANY SUCH LIABILITY
ARISING OUT OF THE WRONGFUL ACTS OF CONTRACTOR OR THE EMPLOYEES ,
AGENTS , OR SUBCONTRACTORS OF CONTRACTOR .
THE OBLIGATIONS OF THIS SECTION 7 ARE SUBJECT TO THE LIMITATIONS IN
SECTION 11 OF THIS EXHIBIT .
8. Events of Default
a. Default by Contractor. Contractor shall be in default under this Contract if:
(1) Contractor institutes or has instituted against it insolvency, receivership or
bankruptcy proceedings, makes an assignment for the benefit of creditors, or
ceases doing business on a regular basis;
(2) Contractor no longer holds a license or certificate that is required for Contractor
to perform the Work and Contractor has not obtained such license or certificate
within ten (10) Business Days after delivery of AMH’s notice or such longer
period as AMH may specify in such notice;
(3) Contractor commits any material breach or default of any covenant, warranty,
obligation or certification under this Contract, fails to perform the Work in
conformance with the specifications and warranties provided herein, or so fails
to pursue the Work as to endanger Contractor’s performance under this Contract
in accordance with its terms, and such breach, default or failure is not cured
within ten (10) Business Days after delivery of AMH’s notice or such longer
period as AMH may specify in such notice;
(4) Contractor knowingly has a director, officer, partner or person with beneficial
ownership of more than 5% of Contractor’s equity or has an employment,
consulting or other subcontractor agreement for the provision of items and
services that are significant and material to Contractor’s obligations under this
Contract, concerning whom:
(a) Any license or certificate required by law or regulation to be held by
Contractor or subcontractor to Provide services required by this Contract
is for any reason denied, revoked or not renewed;
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 116 of 241
(b) Is suspended, debarred or otherwise excluded from participating in
procurement activities under Federal Acquisition Regulation or from
participating in non-procurement activities under regulations issued
pursuant to Executive Order No. 12549 or under guidelines
implementing such order;
(c) Is suspended or terminated from the Oregon Medical Assistance
Program or excluded from participation in the Medicare program; is
convicted of a felony or misdemeanor related to a crime or violation of
Title XVIII, XIX, or XX of the Social Security Act or related laws (or
entered a plea of nolo contendere).
(5) If AMH determines that health or welfare of OHP Members is in jeopardy if this
Contract continues; or
(6) If AMH Determines:
(a) That amendment of this Contract is required due to change(s) in federal
or State law or regulations, or due to changes in Covered Services or
Capitation Payments under ORS 414.735; and
(b) That failure to amend this Contract to execute those changes in the time
and manner proposed in the amendment may place AMH at risk of non-
compliance with federal or State statute or regulations or changes
required by the Legislative Assembly or the Legislative Emergency
Board; or
(c) That Contractor failed to execute the amendment to this Contract within
the time allowed.
b. Default by AMH
AMH shall be in default under this Contract if:
(1) AMH fails to pay Contractor any amount pursuant to the terms of this Contract,
and AMH fails to cure such failure within fifteen (15) days after delivery of
Contractor’s notice or such longer period as Contractor may specify in such
notice; or
(2) AMH commits any other material breach or default of any covenant, warranty,
or obligation under this Contract, fails to perform its commitments hereunder
within the time specified or any extension thereof, and AMH fails to cure such
failure within ten (10) Business Days after delivery of Contractor’s notice or
such longer period as Contractor may specify in such notice.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit D Page 117 of 241
9. Remedies for Default
a. AMH’s Remedies
In the event Contractor is in default under Exhibit D, Section 8, AMH may, at its
option, pursue any or all of the remedies available to it under this Contract and at law or
in equity, including, but not limited to:
(1) Termination of this Contract under Exhibit D, Section 10, Subsection a. (1);
(2) Withholding payments under Exhibit C, for Work that has not met AMH’s
approval or the service levels set forth in this Contract;
(3) Initiation of an action or proceeding for damages, specific performance,
declaratory or injunctive relief; and
(4) Exercise of its right of setoff.
These remedies are cumulative to the extent the remedies are not inconsistent, and
AMH may pursue any remedy or remedies singly, collectively, successively or in any
order whatsoever. If it is determined for any reason that Contractor was not in default
under Exhibit D, Section 8, the rights and obligations of the parties shall be the same as
if this Contract was terminated pursuant to Exhibit D, Section 10 Subsection a. (1).
b. Contractor’s Remedies
In the event AMH terminates this Contract for convenience under Exhibit D, Section
10, or in the event AMH is in default under Exhibit D, Section 8 and whether or not
Contractor elects to exercise its right to terminate this Contract under Exhibit D, Section
10, Contractor’s sole monetary remedy shall be a claim for any unpaid Capitation
Payments as identified in Exhibit C less previous amounts paid and any claims which
AMH has against Contractor. If previous amounts paid to Contractor exceed the amount
due to Contractor under this Exhibit D, Section 9, Contractor shall pay any excess to
AMH upon written demand.
10. Termination
a. This Contract may be terminated under any of the following conditions:
(1) This Contract may be terminated by mutual consent of both parties or by either
party upon thirty (30) calendar days written notice. If termination is initiated by
Contractor, DHS has a right to full disclosure of Contractor’s records required
by this Contract. Contractor shall promptly provide such disclosure to DHS
upon demand. If termination is initiated by DHS under Exhibit C, Section 3,
Changes in Payment Rates, the thirty (30) calendar days notice period does not
apply and the termination is effective upon written notice to Contractor.
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(2) DHS may also terminate this Contract effective upon delivery of written notice
to Contractor, or at such later date as may be established by DHS, as set forth
elsewhere in this Contract, under any of the following conditions:
(a) If DHS funding from federal, state or other sources is not obtained, or is
withdrawn, reduced or limited, or if DHS expenditures are greater than
anticipated, such that funds are insufficient to allow for the purchase of
Services as required by this Contract.
(b) If federal or state regulations or guidelines or CMS waiver terms are
modified, changed or interpreted in such a way that the Services are no
longer allowable or appropriate for purchase under this Contract or are
no longer eligible for the funding proposed for payments under this
Contract.
(c) If any license, registration or certificate required by law or regulation to
be held by Contractor or Contractor’s subcontractors or Participating
Providers to Provide Covered Services is for any reason denied, revoked
or not renewed.
(d) If AMH determines that the health or welfare of OHP Members is in
jeopardy should this Contract continue.
(e) If Contractor fails to Provide Services called for by this Contract, fails to
perform any other provisions of this Contract within the time specified or
any extension thereof, or fails to pursue the work of this Contract in
accordance with its terms; and such failure continues for ten (10)
calendar days, or such longer period as AMH may authorize, after
Contractor’s receipt of written notice thereof.
(f) If Contractor fails to perform or otherwise comply with any provision
contained in Exhibit B, Statement of Work.
(g) If Contractor is a Fully Capitated Health Plan and no longer provides
Services under this Contract in all of the counties listed in Part IV
Service Area, pursuant to its FCHP Service agreement with DHS.
(h) If Contractor is a county government (or a group of counties acting
through a lead county under ORS Chapter 190 or an intergovernmental
entity created by a group of counties under ORS Chapter 190) and no
longer operates or contracts for CMHPs (or in the case of a group of
counties acting through a lead county under ORS Chapter 190 or an
intergovernmental entity created by a group of counties under ORS
Chapter 190, one or more of the said counties no longer operates or
contracts for CMHPs) pursuant to ORS 430.620 under an
Intergovernmental Agreement with DHS.
b. Before terminating an MCO or PCCM Contract under 42 CFR 438.708, DHS must
provide the entity a pre-termination hearing. DHS must:
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(1) Give the MCO or PCCM written notice of its intent to terminate, the reason for
termination, and the time and place of the hearing;
(2) Give the entity (after the hearing) written notice of the decision affirming or
reversing the proposed termination of this Contract, and for an affirming
decision, the effective date of termination; and
(3) For an affirming decision, give OHP Members of the MCO or PCCM notice of
the termination and information, consistent with 438.10, on their options for
receiving OHP services following the effective date of termination.
c. Notwithstanding Paragraphs (1) and (2) of this subsection, if DHS initiates termination
of this Contract, Contractor may request a Contract pre-termination hearing within ten
(10) days of the Notice of Termination as follows:
(1) A Contract pre-termination hearing allows an opportunity for the Administrator
of DHS, or designee, to reconsider the decision to terminate this Contract. The
request for a Contract pre-termination hearing may include the provision of new
information that may result in DHS changing its decision.
(2) A written request for Contract pre-termination hearing must be received by the
Administrator of AMH within ten (10) days of the date of the issuance of DHS
notice of termination. If a written request for Contract pre-termination hearing
is not received within this ten (10) day period or if Contractor withdraws a
hearing request, any right to such hearing shall be considered waived.
(3) Contractor must submit any documentation it intends to ask the Administrator of
AMH to review at the Contract pre-termination hearing. In the Administrator’s
discretion, the Contract pre-termination hearing can occur based solely on
document review. If the Administrator decides that a meeting will assist the
decision, the Administrator will notify Contractor requesting the Contract pre-
termination hearing of the date, time and place of the meeting. The meeting will
be conducted in the following manner:
(a) It will be conducted by the Administrator of AMH, or designee;
(b) No minutes or transcript of the meeting is required;
(c) Contractor will be given an opportunity to present information.
(d) DHS staff will not be available for cross-examination, although staff
may assist the Administrator of AMH in providing information relevant
to the hearing.
(e) The Administrator of AMH may request Contractor to submit
documentation of new information that has been presented orally. In
such an instance, a specific date for receiving such information will be
established.
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(f) The record of the hearing will include the information in DHS’s file, and
relevant information timely submitted to the Administrator of AMH by
Contractor.
(g) The Administrator or designee shall issue a Contract pre-termination
hearing decision within thirty (30) days of the close of record.
(4) If Contractor timely requests a Contract pre-termination hearing, the
Administrator of AMH shall:
(a) Notify individuals enrolled with Contractor of the hearing request, and
(b) Permit such OHP Members to disenroll immediately with Contractor
without cause.
(5) Where Contractor and DHS mutually agree to termination under Subsection a,
Paragraph (1), above, or Contractor seeks to terminate this Contract, Contractor
will be deemed to have waived a request for pre-termination hearing.
d. Any termination of this Contract shall be without prejudice to any obligations or
liabilities of either party already accrued prior to such termination, except that
Contractor shall be solely responsible for its obligations or liabilities after the
termination date when the obligations or liabilities result from Contractor’s failure to
provide for termination of, or right to terminate, its commitments concurrently with and
consistent with the termination of this Contract.
e. In the event of termination of this Contract, DHS will give OHP Members notice of the
termination and information on options for receiving Covered Services following the
date of termination.
(1) Contractor shall ensure the orderly and reasonable transfer of OHP Member care
in progress, whether or not those OHP Members are hospitalized. If Contractor
chooses to Provide Services to a former OHP Member who is no longer an OHP
Member or who is enrolled with another contractor at the time Contractor
renders the Service, DHS shall have no responsibility to pay for such Services.
(2) Upon termination, DHS shall conduct a final accounting of Capitation Payments
received for OHP Members enrolled during the month in which termination is
effective and shall be accomplished as follows:
(a) Mid-month Termination: For termination of this Contract that occurs
during mid-month, the Capitation Payments for that month shall be
apportioned on a daily basis. Contractor shall be entitled to Capitation
Payments for the period of time prior to the date of termination, and
DHS shall be entitled to a refund for the balance of the month.
(b) Responsibility for Claims: Contractor is responsible for any and all
claims from subcontractors or other Providers, including Emergency
Service Providers, for Covered Services provided prior to termination
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date. Contractor shall promptly notify DHS of any outstanding claims
for which DHS may owe, or be liable for, a Fee-For-Service payment,
which are known to Contractor at the time of termination or when such
new claims incurred prior to termination are received. Contractor shall
supply DHS, with all information necessary for reimbursement of such
claims.
(3) The rights and obligations of the parties arising under the following: Exhibit B,
Part V, Section 1, Recordkeeping, Subsection c, Government Access to Records;
Exhibit D, Section 1, Controlling State Law/Venue; Exhibit D, Section 10,
Terminations, Subsection c and Subsection d; Exhibit F, Insurance
Requirements, shall survive the termination or expiration of this Contract.
AMH intends to amend this Contract pursuant to Exhibit D, Section 18, to
reflect implementation of its new Medical Management Information System
(MMIS).
11. Limitation of Liabilities
NEITHER PARTY SHALL BE LIABLE TO THE OTHER FOR ANY INCIDENTAL OR
CONSEQUENTIAL DAMAGES ARISING OUT OF OR RELATED TO THIS CONTRACT .
NEITHER PARTY SHALL BE LIABLE FOR ANY DAMAGES OF ANY SORT ARISING
SOLELY FROM THE TERMINATION OF THIS CONTRACT OF ANY PART HEREOF IN
ACCORDANCE WITH ITS TERMS .
12. Insurance
Contractor shall maintain insurance as set forth in Exhibit F, which is attached hereto.
13. Access to Records and Facilities
a. Access
Contractor shall provide, and shall require its subcontractors to provide, the timely and
unrestricted right of access to its facilities and to its books, documents, papers, plans,
writings, financial and Clinical Records and all accompanying billing records that are
directly pertinent to this Contract in order to make audits, examinations, excerpts,
transcripts and copies of such documents to:
(1) AMH;
(2) DHS;
(3) The U. S. Centers for Medicare and Medicaid Services;
(4) The Comptroller General of the United States;
(5) The Oregon Secretary of State;
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(6) The Oregon Department of Justice Medicaid Fraud Control Unit; and
(7) All their duly authorized representatives.
Records shall be made available for the purposes of research, data collections,
evaluations, monitoring, and auditing activities, examination, excerpts and
transcriptions. Contractor shall, upon request and without charge, provide a suitable
work area and copying capabilities to facilitate such a review or audit. This right also
includes timely and reasonable access to Contractor’s personnel and subcontractors for
the purpose of interview and discussion related to such documents. The rights of access
in this subsection are not limited to the required retention period, but shall last as long
as the records are retained.
b. Confidentiality
Except as required by Subsection a., above, Contractor and its agents, employees and
subcontractors shall maintain all OHP Member information and records, whether hard
copy or computerized, as confidential, consistent with OAR 410-141-0180, Oregon
Health Plan Prepaid Health Plan Record Keeping, and Exhibit B, Part V, Section 1,
Record Keeping of this Contract.
(1) For the protection of OHP Members and consistent with the requirements of 42
CFR Part 431, Subpart F and ORS 411.320, Contractor shall not disclose or use
the contents of any records, files, papers or communications for purposes other
than those directly connected with the administration of this Contract, except
with the written consent or authorization of the OHP Member, his or her
attorney, or, the OHP Member Representative, or except as permitted by ORS
179.505 or by 2007 Senate Bill 163 (Chapter 798, 2007 Laws) and the DHS
rules thereunder.
(2) If Contractor or its subcontractor is a public body within the meaning of the
Oregon Public Records Law, the Contractor or subcontractor shall ensure that
the confidentiality of OHP Members is maintained in accordance with ORS
192.502(2) (personal privacy exemption), ORS 192.502(8) (confidential under
federal law), and ORS 192.502(9) (confidential under State law) or other
relevant exemptions.
(3) To the extent that information about OHP Members includes confidential
protected health information or records about alcohol and drug abuse treatment,
mental health treatment, HIV/AIDS, and/or genetics, Contractor, its agents,
employees and subcontractors shall comply with the specific confidentiality
requirements applicable to such information or records under federal and State
law.
(4) Contractor, its agents, employees and subcontractors shall ensure that
confidential records are secure from unauthorized disclosure. Electronic storage
and transmission of confidential OHP Member information and records shall
assure accuracy, backup for retention, and safeguards against tampering,
backdating, or alteration.
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c. Contractor understands and agrees that information prepared, owned, used or retained
by DHS is subject to the Public Records Law, ORS 192.410 et. seq.
14. Information Privacy/Security/Access
If the Work performed under this Contract requires Contractor or, when allowed, its
subcontractor(s), to have access to or use of any DHS computer system or other DHS
Information Asset for which DHS imposes security requirements, and DHS grants Contractor
access to such DHS Information Assets or Network and Information Systems, Contractor shall
comply and require any subcontractor(s) to which such access has been granted to comply with
OAR 407-014-0300 through OAR 407-014-0320, as such rules may be revised from time to
time. For purposes of this section, “Information Asset” and “Network and Information
System” have the meaning set forth in OAR 407-014-0305, as such rule may be revised from
time to time.
15. Force Majeure
Neither Contractor nor DHS shall be held responsible for delay or default caused by fire, riot,
war, major disaster, epidemic, or acts of God which is beyond either Contractor’s or DHS’s
reasonable control. Contractor or DHS shall, however, make all reasonable efforts to remove
or eliminate such a cause of delay or default and shall, upon cessation of the cause, diligently
pursue performance obligations under this Contract.
If the rendering of Services or benefits under this Contract is delayed or made impractical due
to a labor dispute involving Contractor, care may be deferred until after resolution of the labor
dispute except when care or Service is needed for an emergency or urgent need or when there is
a potential for a serious adverse mental health or medical consequence if Treatment or
Diagnosis is delayed more than thirty (30) calendar days.
If a labor dispute disrupts normal execution of Contractor duties under this Contract, Contractor
shall notify OHP Members in writing of the situation and direct OHP Members to bring serious
health care needs to Contractor’s attention.
16. Successors in Interest
a. Contractor shall not assign or transfer any of its interest in this Contract without the
prior written consent of AMH. Subject to the immediately preceding sentence, the
provisions of this Contract shall be binding upon and shall inure to the benefit of the
parties hereto, and their respective successors and permitted assigns, if any. In addition
to any other assignment or transfer of interest, for purposes of this Contract, all of the
following fundamental changes shall be considered an assignment of an interest in this
Contract subject to AMH prior written consent.
(1) A consolidation or merger of Contractor, or of a corporation or other entity or
person controlling or controlled by Contractor, with or into a corporation or
entity or person, or any other reorganization or transaction or series of related
transactions involving the transfer of more than 50% of the equity interest in
Contractor or more than 50% of the equity interest in a corporation or other
entity or person controlling or controlled by Contractor, or
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(2) The sale, conveyance or disposition of all or substantially all of the assets of
Contractor, or of a corporation or other entity or person controlling or controlled
by Contractor, in a transaction or series of related transactions.
b. Contractor shall notify AMH at least forty-five (45) calendar days prior to any
assignment or transfer of an interest in this Contract and shall reimburse DHS for all
legal fees reasonably incurred by DHS in reviewing the proposed assignment or transfer
and in negotiating and drafting appropriate documents.
17. Subcontracting
Contractor must oversee and is accountable for any functions and responsibilities that it
subcontract to any subcontractor as specified in 42 CFR 438.230. Subject to the provisions of
this section, Contractor may subcontract work to be specified by Contractor to be performed
under this Contract. No subcontract shall terminate or limit Contractor’s legal responsibility to
DHS for the timely and effective performance of its duties and responsibilities under this
Contract. The requirements of this section do not prevent the Contractor from including
additional terms and conditions in its subcontracts to meet the legal obligations or system
requirements of the Contractor.
a. Contractor shall evaluate the prospective subcontractor’s ability to perform the activities
to be subcontracted, prior to subcontracting.
b. Contractor shall have a written agreement that specifies the subcontracted activities and
reporting responsibilities of the subcontractor.
c. The following requirements of this Contract may not be subcontracted:
(1) QA/PI programs for the services it furnishes to OHP Members; and
(2) Adjudication of Final Appeals in a Member Grievance and Appeal Process. If
AMH approves the subcontracting of Grievance System activities, Contractor
shall require subcontractors to have written policies and procedures for
accepting, processing and responding to all complaints and appeals from family
members and OHP Members consistent with 410-141- 0260 through 410-141-
0266
d. Contractor’s agreement with the subcontractor shall provide for the revocation of the
subcontract or imposition of other sanctions if the subcontractor’s performance is
inadequate to meet the requirements of this Contract.
e. Contractor shall monitor subcontractors performance for contractual compliance on an
ongoing basis. Upon identification of areas of deficiency the Contractor shall require of
the subcontractor, a Contractor approved Corrective Action Plan, as defined in Exhibit
A of this Contract. The Corrective Action Plan shall provide the following information:
(1) Reason(s) for the Corrective Action Plan;
(2) Effective date of the Corrective Action Plan;
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(3) Required resolution of the area(s) of concern; and
(4) Intended remedies short of termination should the subcontractor not come into
compliance within the required timeframe.
Upon notification of the subcontractor, Contractor shall also provide notification to AMH
outlining information as stated in this section.
f. All subcontracts shall meet the requirements described below and shall incorporate
portions of this Contract, as applicable, based on the scope of work to be subcontracted.
All subcontracts shall meet the following requirements:
(1) Be in writing and incorporate each applicable requirement of this Contract,
including the following: Exhibit B, Part V, Section 1, Recordkeeping; Exhibit
D, Section 7, Indemnification; Section 10, Termination, Section 18,
Amendments and Section 25, Tort Claims; Exhibit E, Required Federal Terms
and Conditions; Exhibit F, Insurance Requirements; and every other provision in
this Contract that sets requirements for any of the activities being subcontracted.
(2) If Contractor is contracting with Federally Qualified Health Clinics (FQHCs)
and Rural Health Clinics (RHC’s) Contractor shall provide payment that is not
less than the level and amount of payment which the Contractor would make for
the same service(s) furnished by a Provider, which is not an FQHC or RHC
consistent with the requirements for 42 USC 1396b (m) (2)(A)(ix) and BBA
4712(b)(2).
(3) Clearly identify work to be performed by the subcontractor and what portion of
that work, if any, the subcontractor may further subcontract.
(4) Ensure that the requirements of 42 CFR Part 438 that are appropriate to the
Services or activities required under the subcontract are fulfilled.
(5) Contain a provision that the subcontractor and referral Providers shall not bill,
charge, seek compensation, remuneration or reimbursement from, or have
recourse against DHS or any OHP Member for Covered Services provided
during the period for which Capitation Payments were made by DHS to
Contractor with respect to said OHP Member, even if Contractor becomes
insolvent. Subcontractors and referral Providers may not bill OHP Members
any amount greater than would be owed by the OHP Member if the Contractor
provided the services directly (i.e., no balance billing by Providers).
(6) Contain a provision that the subcontractor shall continue to Provide Covered
Services during periods of Contractor insolvency or cessation of operations
through the period for which Capitation Payments were made to Contractor.
(7) Contain a provision requiring the subcontractor to follow OAR 410-141-0420,
Billing and Payment Under the Oregon Health Plan, when submitting Fee-For-
Service claims for Oregon Health Plan Services provided to OHP Members that
are not Covered Services.
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(8) Contain a provision that describes billing and payment processes for all
subcontracted services and activities.
(9) In cases where the subcontractor has assumed any risk covered under this
Contract, contain a provision that the subcontractor must protect itself against
loss by either self-insuring or providing proof of Reinsurance and by
maintaining a Restricted Reserve Fund as described in Exhibit G, Solvency Plan
and Financial Reporting.
(10) If Contractor chooses to subcontract the Grievance and Appeal Process,
Contractor shall require the subcontractor to have written policies and
procedures for accepting, processing and responding to all Grievances from
Family Members, Allied Agencies, and OHP Members consistent with Exhibit
N, Grievance System.
(11) Contain a provision that data used for analysis of delivery system Capacity,
Consumer satisfaction, financial solvency, and Encounter, client process
monitoring, and Acute Inpatient Hospital Psychiatric Care admission data
submission must be provided to Contractor to meet reporting requirements
described in Exhibit K, Provider Capacity Assurance Report; Exhibit N,
Attachment 1 Grievance Log; Exhibit G, Solvency Plan and Financial
Reporting; Exhibit H, Encounter Minimum Data Set Requirements; Schedule 1,
Client Process Monitoring System; and Schedule 3, Oregon Patient/Resident
Care System.
(12) Contain a provision that requires the subcontractor to have a planned, systematic
and ongoing process for monitoring, evaluating and improving the quality and
appropriateness of Covered Services provided to OHP Members.
(13) Contain a provision that requires the subcontractor to participate in Quality
Assessment and Quality Improvement activities of Contractor, or those of AMH
if requested to do so.
(14) Contain a provision that requires the subcontractor to provide access to records
and facilities as described in OAR 410-141-0180, Oregon Health Plan Prepaid
Health Plan Recordkeeping, Exhibit B, Part V, Section 1, Recordkeeping and
Exhibit B, Part VI, Section 1, AMH Compliance Review and Quality Assurance
Monitoring and to cooperate with AMH in medical and financial record reviews,
and Contract compliance and QA monitoring.
(15) Contain a provision that requires the subcontractor to cooperate with all
processes and procedures of Abuse reporting, investigations, and protective
Services as described in ORS 430.735 through 430.765, Abuse Reporting for
Mentally Ill and OAR 410-009-0050 through 410-009-0160, Abuse Reporting
and Protective Services in Community Programs and Community Facilities.
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(16) If Contractor chooses to subcontract Utilization Management activities,
Contractor shall assure that compensation to Providers is not structured so as to
provide incentives to deny, limit or discontinue Medically Appropriate services
to OHP members.
g. On the effective date of this Contract, Contractor shall submit Schedule 9 to AMH in
writing specifying the activities subcontracted and the entities performing such
subcontracted activities. Contractor shall notify AMH by resubmitting Schedule 9 of
changes in subcontracted activities within thirty (30) calendar days of such change(s).
18. No Third Party Beneficiaries
DHS and Contractor are the only parties to this Contract and are the only parties entitled to
enforce its terms. Nothing in this Contract gives, is intended to give, or shall be construed to
give or provide any benefit or right, whether directly, indirectly or otherwise, to third persons
unless such third persons are individually identified by name herein and expressly described as
intended beneficiaries of the terms of this Contract.
19. Amendments
The terms of this Contract shall not be waived, altered, modified, supplemented, or amended, in
any manner whatsoever, without a duly executed amendment. Any amendments to this
Contract shall be effective only when reduced to writing, signed by both parties, and when
signed by the Oregon Department of Justice as approved for legal sufficiency.
20. Severability
If any term or provision of this Contract is declared by a court of competent jurisdiction to be
illegal or in conflict with any law, the validity of the remaining terms or provisions shall not be
affected, and the rights and obligations of the parties shall be construed and enforced as if the
Contract did not contain the particular term or provision held to be invalid.
21. Waiver
The failure of either party to enforce any provision of this Contract shall not constitute a waiver
of that or any other provision.
22. Notices
Any notice under this Contract shall be deemed received the earlier of either the date of actual
delivery or two (2) working days after mailing certified and postage prepaid through the U.S.
Postal Service addressed as follows:
If to Contractor: To the address listed in Part III, “Status of Contractor”, of this Contract
If to an OHP Member: To the latest address provided for the OHP Member on an address list,
Enrollment or change of address form actually received by Contractor.
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If to DHS: AMH Medicaid Policy Unit Manager, 500 Summer St. NE, E-86, Salem, Oregon
97301-1118.
23. Construction
This Contract is the product of extensive negotiations between DHS and Contractor. The
provisions of this Contract are to be interpreted and their legal effects determined as a whole.
A court interpreting this Contract shall give a reasonable, lawful and effective meaning to the
Contract to the extent possible.
24. Headings and Captions
The headings used in this Contract are for reference and convenience only, and in no way
define, limit, or describe the scope or intent of any provisions or sections of this Contract.
25. Merger
This Contract constitutes the entire agreement between the parties. No waiver, consent,
modification or change of terms of this Contract shall bind either party unless in writing and
signed by both parties. Such waiver, consent, modification, or change, if made, shall be
effective only in the specific instance and for the specific purpose given. There are no
understandings, agreements, or representations, oral or written, not specified herein regarding
this Contract. Contractor, by signature of its authorized representative, hereby acknowledges
that he or she had read this Contract, understands it and agrees to be bound by its terms and
conditions.
26. Tort Claims
Contractor and its subcontractors, employees, and agents are performing the work under this
Contract as independent Contractors and not as officers, employees, or agents of the State as
those terms are used in ORS 30.265. It is understood, however, that if Contractor subcontracts
with an Oregon public entity, officer or employee, that entity, officer or employee will be an
independent Contractor but may be subject to the Oregon Tort Claims Act, ORS 30.260 to
30.300.
27. Counterparts
This Contract and any subsequent amendments may be executed in several counterparts, all of
which when taken together shall constitute one agreement binding on all parties,
notwithstanding that all parties are not signatories to the same counterpart. Each copy of this
Contract and any amendments so executed shall constitute an original.
28. Equal Access
Contractor shall provide equal access to Covered Services for both male and female members
under 18 years of age, including access to appropriate facilities, services and treatment, to
achieve the policy in ORS 417.270.
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Exhibit E - Required Federal Terms and Conditions
Contractor shall comply and, as indicated, cause all subcontractors to comply with the following federal
requirements to the extent that they are applicable to this Contract, to Contractor, or to the Work, or to any
combination of the foregoing. For purposes of this Contract, all references to federal and state laws are
references to federal and state laws as they may be amended from time to time.
1. Miscellaneous Federal Provisions
Contractor shall comply and cause all subcontractors to comply with all federal laws, regulations,
executive orders applicable to this Contract or to the delivery of Work. Without limiting the
generality of the foregoing, Contractor expressly agrees to comply and cause all subcontractors to
comply with the following laws, regulations and executive orders to the extent they are applicable to
this Contract: (a) Title VI and VII of the Civil Rights Act of 1964, (b), 45 CFR Part 84 which
implements , Title V, Sections 503 and 504 of the Rehabilitation Act of 1973, (c) the Americans with
Disabilities Act of 1990, (d) Executive Order 11246, (e) the Health Insurance Portability and
Accountability Act of 1996, (f) the Age Discrimination in Employment Act of 1967, as amended, and
the Age Discrimination Act of 1975, (g) the Vietnam Era Veterans' Readjustment Assistance Act of
1974, (h) all regulations and administrative rules established pursuant to the foregoing laws, (i) all
other applicable requirements of federal civil rights and rehabilitation statutes, rules and regulations,
(j) all federal law governing operation of CMHPs, including without limitation, all federal laws
requiring reporting of Client Abuse. These laws, regulations and executive orders are incorporated by
reference herein to the extent that they are applicable to this Contract and required by law to be so
incorporated. No federal funds may be used to provide Work in violation of 42 USC 14402.
2. Prevention and Detection of Fraud and Abuse
Contractor shall have in place internal controls, policies or procedures capable of preventing and
detecting fraud and abuse activities as they relate to the OHP as outlined in Exhibit J, Prevention and
Detection of Fraud, Waste and Abuse policies and procedures shall be reviewed annually. Contactor
shall submit to DHS for review and approval written fraud, waste and abuse policies and procedures.
Due within 30 days of the effective date of this Contract.
3. Equal Employment Opportunity
If this Contract, including amendments, is for more than $10,000, then Contractor shall comply and
cause all subcontractors to comply with Executive Order 11246, entitled "Equal Employment
Opportunity," as amended by Executive Order 11375, and as supplemented in Department of Labor
regulations (41 CFR Part 60).
4. Clean Air, Clean Water, EPA Regulations
If this Contract, including amendments, exceeds $100,000 then Contractor shall comply and cause all
subcontractors to comply with all applicable standards, orders, or requirements issued under Section
306 of the Clean Air Act (42 U.S.C. 7606), the Federal Water Pollution Control Act as amended
(commonly known as the Clean Water Act) (33 U.S.C. 1251 to 1387), specifically including, but not
limited to Section 508 (33 U.S.C. 1368). Executive Order 11738, and Environmental Protection
Agency regulations (40 CFR Part 32), which prohibit the use under non-exempt Federal contracts,
grants or loans of facilities included on the EPA List of Violating Facilities. Violations shall be
reported to DHS, DHHS and the appropriate Regional Office of the Environmental Protection
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Contract #129162 Exhibit E Page 130 of 241
Agency. Contractor shall include and cause all subcontractors to include in all contracts with
subcontractors receiving more than $100,000, language requiring the subcontractor to comply with
the federal laws identified in this section.
5. Energy Efficiency
Contractor shall comply and cause all subcontractors to comply with applicable mandatory standards
and policies relating to energy efficiency that are contained in the Oregon energy conservation plan
issued in compliance with the Energy Policy and Conservation Act, 42 U.S.C. 6201 et seq. (Pub. L.
94-163).
6. Truth in Lobbying
The Contractor certifies, to the best of the Contractor's knowledge and belief that:
a. No federal appropriated funds have been paid or will be paid, by or on behalf of Contractor, to
any person for influencing or attempting to influence an officer or employee of an agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any federal contract, the making of any federal
grant, the making of any federal loan, the entering into of any cooperative agreement, and the
extension, continuation, renewal, amendment or modification of any federal contract, grant,
loan or cooperative agreement.
b. If any funds other than federal appropriated funds have been paid or will be paid to any
person for influencing or attempting to influence an officer or employee of any agency, a
Member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with this federal contract, grant, loan or cooperative agreement, the
Contractor shall complete and submit Standard Form LLL, "Disclosure Form to Report
Lobbying" in accordance with its instructions.
c. The Contractor shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subcontracts, subgrants, and contracts
under grants, loans, and cooperative agreements) and that all subrecipients and subcontractors
shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this
Contract was made or entered into. Submission of this certification is a prerequisite for making or
entering into this Contract imposed by Section 1352, Title 31, U.S. Code. Any person who fails to
file the required certification shall be subject to a civil penalty of not less than $10,000 and not more
than $100,000 for each such failure.
7. Health Insurance Portability and Accountability Act (HIPAA)
a. Contractor is a “covered entity” for the purposes of the provisions of the Health Insurance
Portability and Accountability Act (HIPAA), Title II, Subtitle F, Administrative
Simplification, or the federal regulations implementing the Act. Contractor shall develop and
implement such policies and procedures for maintaining the privacy and security of records
and authorizing the use and disclosure of records consistent with HIPAA and/or other federal,
state, and local laws, rules and regulations applicable to the work performed under this
Contract.
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Contract #129162 Exhibit E Page 131 of 241
b. Contractor, its agents, employees, Providers and subcontractors shall ensure that confidential
records are secure from unauthorized disclosure. Electronic storage and transmission of
confidential OHP Member information and records shall assure accuracy, backup for
retention, and safeguards against tampering, back dating, or alteration.
c. Guidelines to ensure the security of the electronic transmission of OHP Member confidential
information shall be developed by DHS. Within the available resources, and consistent with
DHS’s testing schedule, Contractor shall initiate a request to DHS for testing and review of
security measures.
d. Contractor shall comply with HIPAA standards for electronic transactions published in 65
Fed. Reg. 50312 (August 17, 2000) and consistent with the Administrative Simplification
Compliance Act (extending the deadline for compliance with transaction and code set
requirements until October 12, 2003, subject to submission of a compliance plan to DHHS).
Contractor shall initiate a request to DHS for the testing of systems and the implementation of
such policies and procedures as may be required to comply with HIPAA standards.
8. Resource Conservation and Recovery
Contractor shall comply and cause all subcontractors to comply with all mandatory standards and
policies that relate to resource conservation and recovery pursuant to the Resource Conservation and
Recovery Act (codified at 42 USC 6901 et. seq.). Section 6002 of that Act (codified at 42 USC
6962) requires that preference be given in procurement programs to the purchase of specific products
containing recycled materials identified in guidelines developed by the Environmental Protection
Agency. Current guidelines are set forth in 40 CFR Parts 247.
9. Audits
Contractor shall comply and, if applicable, cause a subcontractor to comply, with the applicable audit
requirements and responsibilities set forth in the Office of Management and Budget Circular A-133
entitled "Audits of States, Local Governments and Non-Profit Organizations."
10. Debarment, Suspension and Terminated Providers
Contractor shall not permit any person or entity to be a subcontractor if the person or entity is listed
on the non-procurement portion of the General Service Administration's "List of Parties Excluded
from Federal Procurement or Nonprocurement Programs" in accordance with Executive Orders No.
12549 and No. 12689, "Debarment and Suspension". (See 45 CFR Part 76). This list contains the
names of parties debarred, suspended, or otherwise excluded by agencies, and contractors declared
ineligible under statutory authority other than Executive Order No. 12549. Subcontractors with
awards that exceed the simplified acquisition threshold shall provide the required certification
regarding their exclusion status and that of their principals prior to award.
The Covered Services provided by Contractor under this Contract shall not be rendered by
individuals or entities who are currently excluded from Medicaid participation under Section 1128 or
Section 1128A of the Social Security Act. Contractor shall not refer OHP Members to such
Providers and shall not accept billings for Services to OHP Members submitted by such Providers.
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Contract #129162 Exhibit E Page 132 of 241
11. Drug-Free Workplace
Contractor shall comply and cause all subcontractors to comply with the following provisions to
maintain a drug-free workplace: (i) Contractor certifies that it will provide a drug-free workplace by
publishing a statement notifying its employees that the unlawful manufacture, distribution,
dispensation, possession or use of a controlled substance, except as may be present in lawfully
prescribed or over-the-counter medications, is prohibited in Contractor's workplace or while
providing services to DHS clients. Contractor's notice shall specify the actions that will be taken by
Contractor against its employees for violation of such prohibitions; (ii) Establish a drug-free
awareness program to inform its employees about: The dangers of drug abuse in the workplace,
Contractor's policy of maintaining a drug-free workplace, any available drug counseling,
rehabilitation, and employee assistance programs, and the penalties that may be imposed upon
employees for drug abuse violations; (iii) Provide each employee to be engaged in the performance of
services under this Contract a copy of the statement mentioned in Paragraph 10(i) above; (iv) Notify
each employee in the statement required by Paragraph 10(i) that, as a condition of employment to
Provide Services under this Contract, the employee will: abide by the terms of the statement, and
notify the employer of any criminal drug statute conviction for a violation occurring in the workplace
no later than five (5) days after such conviction; (v) Notify DHS within ten (10) days after receiving
notice under subparagraph 10(iv) from an employee or otherwise receiving actual notice of such
conviction; (vi) Impose a sanction on, or require the satisfactory participation in a drug abuse
assistance or rehabilitation program by any employee who is so convicted as required by Section
5154 of the Drug-Free Workplace Act of 1988; (vii) Make a good-faith effort to continue a drug-free
workplace through implementation of subparagraphs 10(i) through 10(vi); (viii) Require any
subcontractor to comply with subparagraphs 10(i) through 10(vii); 10(ix) Neither Contractor, or any
of Contractor's employees, officers, agents or subcontractors may Provide any Service required under
this Contract while under the influence of drugs. For purposes of this provision, "under the
influence" means: observed abnormal behavior or impairments in mental or physical performance
leading a reasonable person to believe the Contractor or Contractor's employee, officer, agent or
subcontractor has used a controlled substance, prescription or non-prescription medication that
impairs the Contractor or Contractor's employee, officer, agent or subcontractor's performance of
essential job function or creates a direct threat to DHS clients or others. Examples of abnormal
behavior include, but are not limited to: hallucinations, paranoia or violent outbursts. Examples of
impairments in physical or mental performance include, but are not limited to: slurred speech,
difficulty walking or performing job activities; (x) Violation of any provision of this subsection may
result in termination of this Contract.
12. Pro-Children Act
Contractor shall comply and cause all subcontractors to comply with the Pro-Children Act of 1994
(codified at 20 USC Section 6081 et. seq.).
13. Additional Medicaid and SCHIP Requirements
Contractor shall comply with all applicable federal and state laws and regulation pertaining to the
provision of OHP Services under the Medicaid Act, Title XIX, 42 USC Section 1396 et. seq., and
SCHIP benefits under Title XXI under the Social Security Act including without limitation:
a. Keep such records as are necessary to fully disclose the extent of the services provided to
individuals receiving OHP assistance and shall furnish such information to any state or federal
agency responsible for administering the OHP program regarding any payments claimed by
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Contract #129162 Exhibit E Page 133 of 241
such person or institution for providing OHP Services as the state or federal agency may from
time to time request. 42 USC Section 1396a(a)(27); 42 CFR 431.107(b)(1) & (2); 42 CFR
457.950(a)(3)..
b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart (B);
42 CFR 457.900(a)(2)..
c. Maintain written notices and procedures respecting advance directives in compliance with 42
USC Section 1396(a)(57) and (w), 42 CFR 431.107(b)(4), and 42 CFR 489 subpart I.
d. Certify when submitting any claim for the provision of OHP Services that the information
submitted is true, accurate and complete. Contractor shall acknowledge Contractor's
understanding that payment of the claim will be from federal and state funds and that any
falsification or concealment of a material fact may be prosecuted under federal and state laws.
e. Entities receiving $5 million or more annually (under this Contract and any other OHP
contract) for furnishing Medicaid health care items or services shall, as a condition of
receiving such payments, adopt written fraud, waste and abuse policies and procedures and
inform employees, contractors and agents about the policies and procedures in compliance
with Section 6032 of the Deficit Reduction Act of 2005, 42 USC § 1396a(a)(68).
14. Agency-based Voter Registration
If applicable, Contractor shall comply with the Agency-based Voter Registration sections of the
National Voter Registration Act of 1993 that require voter registration opportunities be offered where
an individual may apply for or receive an application for public assistance.
15. Clinical Laboratory Improvements
Contractor and any laboratories used by Contractor shall comply with the Clinical Laboratory
Improvement Amendments (CLIA 1988) which require that:
All laboratory testing sites providing Services under this Contract shall have either a Clinical
Laboratory Improvement Amendments (CLIA) certificate of waiver or a certificate of registration
along with CLIA identification number. Those laboratories with certificates of waiver will provide
only the eight types of tests permitted under the terms of their waiver. Laboratories with certificates
of registration may perform a full range of laboratory tests.
16. Advance Directives
Contractor shall comply with 42 CFR Part 422.128 for maintaining written policies and procedures
for advance directives. This includes compliance with 42 CFR 489, Subpart I “Advance Directives”
and OAR 410-120-1380, which establishes, among other requirements the requirements for
compliance with Section 4751 of the Omnibus Budget Reconciliation Act of 1991 (OBRA) and ORS
127.649, Patient Self-Determination Act. Contractor shall maintain written policies and procedures
concerning advance directives with respect to all adult OHP Members receiving medical care by
Contractor. Contractor shall provide adult OHP Members with written information on advance
directive policies and include a description of Oregon law. The written information provided by
Contractor must reflect changes in Oregon law as soon as possible, but no later than 90 days after the
effective date of any change to Oregon law. Contractor must also provide written information to
adult OHP Members with respect to the following:
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Contract #129162 Exhibit E Page 134 of 241
a. Their rights under Oregon law; and
b. Contractor’s policies respecting the implementation of those rights, including a statement of
any limitation regarding the implementation of advance directives as a matter of conscience.
c. The Contractor must inform OHP Members that complaints concerning noncompliance with
the advance directive requirements may be filed with DHS.
17. Office of Minority, Women and Emerging Small Businesses
If Contractor lets any subcontracts, Contractor shall take affirmative steps to: include qualified small
and minority and women’s businesses on solicitation lists, assure that small and minority and
women’s businesses are solicited whenever they are potential sources, divide total requirements into
smaller tasks or quantities when economically feasible so as to permit maximum small and minority
and women’s business participation, establish delivery schedules when requirements permit which
will encourage participation by small and minority and women’s businesses, and use the Services and
assistance of the Small Business Administration, the Office of Minority Business Enterprise of the
Department of Commerce and the Community Services Administration as required.
18. Practitioner Incentive Plans
Contractor may operate a Practitioner Incentive Plan only if no specific payment is made directly or
indirectly under the plan to a Provider as inducement to reduce or limit Medically Appropriate
Covered Services provided to an OHP Member. Contractor shall comply with all requirements of
Exhibit M, Practitioner Incentive Plans, to ensure compliance with Sections 4204 (a) and 4731 of the
Omnibus Budget Reconciliation Act of 1990 that concern physician incentive plans.
19. Risk HMO
If Contractor is a Risk HMO and is sanctioned by CMS under 42 CFR 434.67, payments provided for
under this Contract will be denied for OHP Members who enroll after the imposition of the sanction,
as set forth under 42 CFR 434.42.
20. Conflict of Interest Safeguards
a. Contractor shall not recruit, promise future employment, or hire any DHS employee (or their
relative or member of their household) who has participated personally and substantially in
the procurement or administration of this Contract as a DHS employee.
b. Contractor shall not offer to any DHS employee (or any relative or member of their
household) any gift or gifts with an aggregate value in excess of $50 during a calendar year or
any gift of payment of expenses for entertainment. “Gift” for this purpose has the meaning
defined in ORS 244.020(5) and OAR 199-005-0005 to 199-005-0035.
c. Contractor shall not retain a former DHS employee to make any communication with or
appearance before DHS on behalf of Contractor in connection with this Contract if that person
participated personally and substantially in the procurement or administration of this Contract
as a DHS employee.
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Contract #129162 Exhibit E Page 135 of 241
d. If a former DHS employee authorized or had a significant role in this Contract, Contractor
shall not hire such a person in a position having a direct, beneficial, financial interest in this
Contract during the two year period following that person’s termination from DHS.
e. Contractor shall develop appropriate policies and procedures to avoid actual or potential
conflict of interest involving DMAP members, DHS employees, and sub-contractors. These
policies and procedures shall include safeguards:
(1) against the Contractor’s disclosure of applications, bids, proposal information, or
source selection information; and
(2) requiring the Contractor to:
i. promptly report any contact with an applicant, bidder or offeror in writing to
DHS; and
ii. reject the possibility of possible employment; or disqualify itself from further
personal and substantial participation in the procurement if Contractor contacts
or is contacted by a person who is an applicant, bidder or offeror in a
procurement involving federal funds regarding possible employment for the
Contractor.
f. The provisions of this section on Conflict of Interest are intended to be construed to assure the
integrity of the procurement and administration of this Contract. For purposes of this Section:
(1) “Contract” includes any similar contract between Contractor and DHS for a previous
term.
(2) Contractor shall apply the definitions in the State Public Ethics Law, ORS 244.020,
for “actual conflict of interest”, “potential conflict of interest”, “relative” and “member
of household”.
(3) “Contractor” for purposes of this section includes all Contractor’s affiliates, assignees,
subsidiaries, parent companies, successors and transferees, and persons under common
control with the Contractor; any officers, directors, partners, agents and employees of
such person; and all others acting or claiming to act on their behalf or in concert with
them.
(4) “Participates” means actions of a DHS employee, through decision, approval,
disapproval, recommendation, the rendering of advice, investigation or otherwise in
connection with the Contract.
(5) “Personally and substantially” has the meaning set forth in 5 CFR 2637.201.
21. Non-Discrimination
Contractor shall comply with all Federal and State laws and regulations including Title VI of the
Civil Rights Act of 1964, Title IX of the Education Amendments of 1972 (regarding education
programs and activities) the Age Discrimination Act of 1975, the Rehabilitation Act of 1973, the
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Contract #129162 Exhibit E Page 136 of 241
Americans with Disabilities Act of 1990, and all amendments to those acts and all regulations
promulgated thereunder. Contractor shall also comply with all applicable requirements of state civil
rights and rehabilitation statutes and rules.
22. Federal Grant Requirements
The federal Medicaid rules establish that DHS is a recipient of federal financial assistance, and
therefore is subject to federal grant requirements pursuant to 42 CFR 430.2(b). To the extent
applicable to Contractor or to the extent DHS requires Contractor to supply information or comply
with procedures to permit DHS to satisfy its obligations federal grant obligations or both, Contractor
must comply with the following parts of 45 CFR:
a. Part 74, including Appendix A (uniform federal grant administration requirements);
b. Part 80 (nondiscrimination under Title VI of the Civil Rights Act);
c. Part 84 (nondiscrimination on the basis of handicap);
d. Part 91 (nondiscrimination on the basis of age);
e. Part 95 (Medicaid and SCHIP federal grant administration requirements); and
f. Contractor shall not expend, and Contractor shall include a provision in any Subcontract that
its subcontractor shall not expend, any of the funds paid under this Contract for roads,
bridges, stadiums, or any other item or service not covered under the Oregon Health Plan.
23. Provider’s Opinion
OHP Members are entitled to the full range of their health care Provider’s opinions and counsel about
the availability of Medically Appropriate services under the Oregon Health Plan.
Contractor shall not prohibit or otherwise restrict a Health Care Professional from advising an OHP
Member who is a patient of that professional about the health status of the OHP Member or treatment
for the OHP Member’s condition or disease, regardless of whether benefits for such care or treatment
are provided under the Plus or Standard Benefit Package of Covered Services or if a co-payment may
be required, if the professional is acting within the lawful scope of practice.
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Contract #129162 Exhibit F Page 137 of 241
Exhibit F – Insurance Requirements
During the term of this Contract, Contractor shall and shall require that all persons and entities performing
services under this Contract, maintain in force at its own expense, each insurance noted below:
1. Required by DHS of Contractors with one or more workers, as defined by ORS 656.027.
Workers’ Compensation. All employers, including Contractor, that employ subject workers, who
work under this Contract, as defined in ORS 656.027, shall comply with ORS 656.017, and provide the
Workers’ Compensation insurance coverage for those workers, unless they meet the requirements for
and exemption under ORS 656.126(2). Contractor shall require and ensure that each of its
subcontractors complies with these requirements.
2. [X] Required by DHS [ ] Not required by DHS.
Professional Liability. Insurance of not less than $1,000,000 per person per incident and $1,000,000 in
the aggregate, except to the extent that the Oregon Tort Claims Act, ORS 30.260 through 30.300, is
applicable and imposes lesser limitations. This is to cover direct and vicarious liability relating to any
damages caused by an error, omission or any negligent acts related to the professional services provided
under this Contract.
3. [ ] Required by DHS [X] Not required by DHS.
General Liability. Insurance with a combined single limit, or the equivalent, of not less than
$1,000,000, each occurrence for Bodily Injury and Property Damage. It shall include contractual
liability coverage for the indemnity provided under this Contract. It shall provide that the State of
Oregon, Department of Human Services (DHS), and its divisions, and its officers and employees are
Additional Insureds but only with respect to Contractor’s services to be provided under this Contract.
4. [ ] Required by DHS [X] Not required by DHS.
Automobile Liability. Insurance with a combined single limit, or the equivalent, of not less than the
Oregon Financial Responsibility Law (ORS 806.060), for each accident, for Bodily Injury and Property
Damage, including coverage for owned, hired or non-owned vehicles, as applicable.
5. Notice of Cancellation or Change. There shall be no cancellation, Material Change, reduction of limits
or intent not to renew the insurance coverage(s) without thirty (30) days prior written notice from
Contractor or its insurers to DHS.
6. Certificate of Insurance. As evidence of the insurance coverages required by this Contract, Contractor
shall furnish acceptable insurance certificates to DHS upon request. The certificate will specify all of the
parties who are Additional Insureds. Insuring companies or entities are subject to DHS acceptance. If
requested, complete copies of insurance policies, trust agreements, etc. shall be provided to DHS. The
Contractor shall be financially responsible for all pertinent deductibles, self insured retentions, or self
insurance, as applicable.
7. Self-insurance . Contractor may fulfill its insurance obligations herein through a program of self
insurance, provided that Contractor’s self insurance program complies with all applicable laws, and
provides insurance coverage equivalent in both type and level of coverage to that required in this Exhibit
F. Notwithstanding Section 6 of this Exhibit F, Contractor shall furnish an acceptable insurance
certificate to DHS for any insurance coverage required by this Contract that is fulfilled through self-
insurance.
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Contract #129162 Exhibit G Page 138 of 241
Exhibit G – Solvency Plan and Financial Reporting
Contractor shall maintain sound financial management procedures, maintain protections against insolvency
commensurate with the number of OHP Members and level of risk assumed, and generate periodic financial
reports for submission to AMH (OAR 410-141-0340). Financial management, solvency protection, and
reporting shall occur as specified below.
1. Contractor agrees to include all of its OHP financial activities under Corporate Activity when
completing Reports G.2 through G.5. Any changes to the reporting of Corporate Activity shall be
approved by AMH in writing before implementation.
2. Contractor shall protect itself against catastrophic and unexpected expenses related to Covered Services
by either self-insuring or by obtaining stop-loss protection from a private insurer in an amount sufficient
to cover estimated risk for the duration of this Contract. Contractor shall provide proof of such coverage
to AMH within 30 days after the effective date of this Contract.
3. Restricted Reserve Fund
Contractor shall maintain a Restricted Reserve Fund balance no less than $250,000 and provide
evidence of the required restricted reserve account balance to AMH within 60 calendar days after the
end of each calendar quarter as outlined below. Contractor shall identify where and by whom the
restricted reserve account is held.
a. If Contractor subcontracts any work to be performed under this Contract using a subcapitated
reimbursement arrangement, Contractor may choose to require its subcontractor to maintain a
Restricted Reserve Fund for the subcontractor’s portion of the risk assumed or may maintain a
Restricted Reserve Fund for all risk assumed under this Contract. Regardless of the choice
made, Contractor shall assure that the combined total Restricted Reserve Fund balance meets the
requirements of this Contract.
b. If the Restricted Reserve Fund is held in a combined account or pool with other entities,
Contractor, and its subcontractors as applicable, shall provide a statement from the pool or
account manager that the Restricted Reserve Fund is available to Contractor, or its
subcontractors as applicable, and has not been obligated elsewhere.
c. If Contractor must use its Restricted Reserve Fund to finance Covered Services, Contractor shall
provide advance written notice to AMH of the amount to be withdrawn, the reason for
withdrawal, when and how the Restricted Reserve Fund will be replenished, and steps to be
taken to avoid the need for future Restricted Reserve Fund withdrawals.
d. Contractor shall provide AMH access to its Restricted Reserve Fund if insolvency occurs.
e. Contractor shall have written policies and procedures to ensure that, if insolvency occurs, OHP
Members and related Clinical Records are transitioned with minimal disruption.
4. Contractor shall provide TPR collection information, using Report G.2, Current OHP Members with
Third Party Resources (Quarterly Report), on a quarterly basis within 60 calendar days after the end of
each calendar quarter. Contractor shall make reasonable efforts to identify and pursue such Third Party
Resource without regard to any Capitation Payments. Contractor shall keep records of such efforts,
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Contract #129162 Exhibit G Page 139 of 241
successful or unsuccessful, to ensure accuracy of such reports and make records available for audit and
review upon request. Contractor shall report all TPR including amounts recovered by capitated
subcontract Providers.
5. Contractor shall provide financial information, using Report G.3, Quarterly Balance Sheet, within 60
calendar days after the end of each calendar quarter. Contractor shall have systems that capture, compile,
and evaluate information and data concerning financial operations including, but not limited to, the
determination of future budget requirements and for determining, managing and accounting for claims
payable and “Incurred But Not Reported” expenses.
6. Contractor shall provide financial information, using Reports G.4, Contractor’s Quarterly Statement of
Revenue and Expenses, G.4A, Health Care Expenses By Service Type, and G.4B,
Prevention/Education/Outreach Activities, on a quarterly basis within 60 calendar days after the end of
each calendar quarter.
In addition to the quarterly reports, Contractor shall provide a Report G.4 based on Contractor’s fiscal
year which shall include a detailed description of how a net loss was covered or how a net income will
be used during the next fiscal year.
7. Contractor shall provide financial information, using Report G.5, Fiscal Year Cash Flow Analysis for
Corporate Activity within 90 calendar days after the end of Contractor’s fiscal year.
8. Contractor shall submit an Annual Audited Financial Statement to AMH within 180 days after the end
of the Contractor fiscal year. The audited financial statement shall be prepared by an independent
accounting firm. In conducting the audit of the financial statements, the auditor will apply sufficient
procedures to conclude that, in all material respects:
a. the assumptions and methods used in determining loss reserves, actuarial liabilities, or other
related accounting items are appropriate in the circumstances, and
b. the information on the Contractor's G.3, G.4, G.4A, G.4B and G.5 reports is accurately included
within the amounts presented in the Contractor's financial statements and footnote disclosures.
9. Contractor shall notify AMH of any significant change to the information provided in the quarterly
financial reports. If the change requires restatement of a prior quarterly financial report, Contractor shall
amend the report and submit to AMH within 30 working days of the date the change is identified.
10. Contractor shall supply AMH with a spreadsheet, or other mutually agreed upon format, containing the
quarterly financial reports either electronically or by mailing a 3.5" computer disk, CD, spreadsheet,
hard copy or facsimile. Contractor shall send these reports to AMH, Medicaid Policy Unit, 500 Summer
St. NE, Salem, Oregon 97301-1118.
11. If Contractor has questions about these reports, Contractor may call the AMH, Medicaid Policy Unit,
OHP Coordinator at (503) 947-5522.
12. If Contractor wants these reports electronically, on a 3.5" computer disk, CD, spreadsheet, hard copy or
facsimile, Contractor may call (503) 947-5522.
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Contract #129162 Exhibit G – Attachment 1 – Report G.2 Page 140 of 241
Exhibit G – Attachment 1
Report G.2: Current OHP Members with Third Party Resources (Quarterly Report)
Contractor:
Contract Year:
Report Period:
Report Period: □ 1 st Quarter (Jan-Mar) □ 2 nd Quarter (Apr-Jun)
□ 3 rd Quarter (Jul-Sep) □ 4 th Quarter (Oct-Dec)
Report due within 60 calendar days after the end of each calendar quarter.
Instructions:
1. Provide TPR information for Covered Services, including all TPR recovered by sub-
capitated Providers.
2. Separate amounts collected by Medicare, other insurance collections, and tort and estate
collections, and Capitation rate category.
3. If the accounts receivable system cannot capture collections by Capitation rate category,
do the following:
a. Record total collections by Medicare, other insurance, and tort and estate
recoveries.
b. Keep detailed records of all collections by OHP Member name, prime number
and Third Party Resource.
c. Provide a written statement with the report indicating when Third Party Resource
collection information will be available by Capitation rate category.
Capitation Rate Category Medicare
Collections
Other
Insurance
Collections
Tort and
Estate
Collections
Total
Collections
1. TANF
2. General Assistance
3. PLM Adults under 100%
FPL
4. PLM Adults over 100%
FPL
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Contract #129162 Exhibit G – Attachment 1 – Report G.2 Page 141 of 241
Capitation Rate Category Medicare
Collections
Other
Insurance
Collections
Tort and
Estate
Collections
Total
Collections
5. SCHIP Children Aged 0 - 1
6. PLM Children Aged 0 - 1
7. PLM or SCHIP Children
Aged 1- 5
8. PLM or SCHIP Children
Aged 6 - 18
9. OHP Families
10. OHP Adults & Couples
11. AB/AD with Medicare
12. AB/AD without Medicare
13. OAA with Medicare
14. OAA with Medicare Part B
Only
15. OAA without Medicare
16. CAF Children
17. Total Collections
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
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Contract #129162 Exhibit G – Attachment 2 – Report G.3 Page 142 of 241
Exhibit G – Attachment 2
Report G.3: Quarterly Balance Sheet
Contractor:
Contract Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year End
Report due within 60 calendar days after the end of each calendar quarter.
Full Accrual Modified Accrual Cash Basis
Category OHP Activities Under
this Contract
CURRENT ASSETS
1. Cash and Cash Equivalents
2. Short-Term Investments
3. Investment Income Receivables
4. Health Care Receivables
5. Prepaid Expenses
6. Other Current Assets
7. Total Current Assets
OTHER ASSETS
8. Restricted Cash and Restricted Securities
9. Other Long-Term Investments
10. Other Assets (Please specify)
(a)
(b)
(c)
11. Total Other Assets
PROPERTY AND EQUIPMENT
12. Land, Buildings and Improvements
13. Furniture and Equipment
14. Leasehold Improvements
15. Other Property and Equipment
16. Total Property and Equipment
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Contract #129162 Exhibit G – Attachment 2 – Report G.3 Page 143 of 241
Category OHP Activities Under
this Contract
17. TOTAL ASSETS
CURRENT LIABILITIES
18. Accounts Payable
19. Claims Payable
20. Incurred but Not Reported
21. Accrued Medical Incentive Pool
22. Loans and Notes Payable
23. Other Current Liabilities
24. (Reserved)
25. Total Current Liabilities
OTHER LIABILITIES
26. Loans and Notes Payable
27. Other Liabilities
28. Total Other Liabilities
29. TOTAL LIABILITIES
NET WORTH
30. Contributed Capital
31. Contingency Reserves
32. Retained Earnings/Fund Balance
33. Other Net Worth
34. Total Net Worth
35. TOTAL LIABILITIES AND NET WORTH
Revised, November 2009
Notes:
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.3 Definitions Page 144 of 241
Report G.3 – Quarterly Balance Sheet
Definitions for this report:
Balance Sheet: A financial statement that has been developed using generally accepted accounting principles
and that shows the financial position of a business on a particular date.
If separate accounts are not kept for Covered Services, balance sheet information for such Covered Services
may be allocated using an estimation procedure. Such procedure and all assumptions must be disclosed in
Notes. This estimation procedure must be used throughout the report.
1. Cash and Cash Equivalents: Cash in the bank or on hand, available for current use. Cash equivalents
are investments maturing 90 calendar days or less from date of purchase.
2. Short-Term Investments: Principal amounts of investments in securities that are readily marketable,
maturing one year or less from date of purchase.
3. Investment Income Receivables: Income, including interest accrued or dividends earned on short term
or long term investments.
4. Health Care Receivables: Includes FFS, coordination of benefits, subrogation, copayments,
Reinsurance recoveries and non-affiliated provider receivables.
5. Prepaid Expenses: Any expenses paid and recorded in advance of its use or consumption in the
business, which properly represents a portion as an expense of the current period and a portion as an
asset on hand at the end of the period.
6. Other Current Assets: Other assets not included in the asset categories listed above, including any
other accounts receivable.
7. Total Current Assets: The sum of lines 1 through 6.
8. Restricted Cash and Restricted Securities: Assets restricted for statutory insolvency requirements
held for contract (per contract $250,000 minimum).
9. Other Long-Term Investments: Principal amounts of investments with a maturity longer than one
year from date of purchase or no stated maturity date.
10. Other Assets: Other assets, such as aggregate write-ins, bonds, preferred stocks, receivables from
securities, etc. (Please specify)
11. Total Other Assets: The sum of lines 8 through line 10.
12. Land, Buildings and Improvements: Net book value of land and buildings owned by Contractor, and
any improvements made to buildings, or improvements in progress.
13. Furniture and Equipment: Net book value of office equipment, including computer hardware and
software (where permitted), and furniture owned by Contractor.
14. Leasehold Improvements: Net book value of improvements to facilities not owned by Contractor.
Provide net amount (gross amount less amortization).
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.3 Definitions Page 145 of 241
15. Other Property and Equipment: Net book value of other tangibles and, fixed assets that are not
included on Lines 12, 13, and 14.
16. Total Property and Equipment: The sum of lines 12 through line 15.
17. Total Assets: The sum of lines 7, 11 and 16.
18. Accounts Payable: Amounts due to creditors for the acquisition of goods and services (trade and
vendors rather than health care practitioners) on a credit basis.
19. Claims Payable: Claims reported and booked as payables claims (minus incentives and stop loss).
20. Incurred But Not Reported (IBNR): An estimate for claims which have been incurred as of the last
date of the report period for which Contractor is responsible but has not yet determined the specific
amount of liability.
21. Accrued Medical Incentive Pool: Liability for arrangements whereby Contractor agrees to share
Utilization savings with Individual Practice Associations, physician groups, or other providers.
22. Loans and Notes Payable: The principal amount on loans or notes due within one year.
23. Other Current Liabilities: Any payable amount other than direct health care services to affiliates and
any liabilities not included in the current liabilities categories listed above.
24. (reserved)
25. Total Current Liabilities: The sum of lines 18 through 24.
26. Loans and Notes Payable: Loans and notes signed by Contractor, not including current portion
payable, that are of a long term nature (liquidation not expected to occur within one year of the date of
the statement).
27. Other Liabilities: Other liabilities not included in the liabilities categories listed above.
28. Total Other Liabilities: The sum of lines 26 and 27.
29. Total Liabilities: The sum of lines 25 and 28.
30. Contributed Capital: Capital donated to Contractor.
31. Contingency Reserves: Reserves held beyond contingency purposes reported on Report G.3, line 8 as
defined in state statutes and regulations.
32. Retained Earnings/Fund Balance: The undistributed and unappropriated amount of surplus.
33. Other Net Worth: Other net worth items not reported on any other lines.
34. Total Net Worth: The sum of line 30 through 33.
35. Total Liabilities and Net Worth: The sum of lines 29 and 34.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 3 – Report G.4 Page 146 of 241
Exhibit G – Attachment 3
Report G.4: Contractor’s Quarterly Statement of Revenue and Expenses
Contractor:
Contract Year:
Subcontractor:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year
Report due within 60 calendar days after the end of each quarter to be submitted for both
Contractor and risk based subcontractors.
Full Accrual Modified Accrual Cash Basis
Category OHP Activity under this
Contract
REVENUES
1. Capitation
2. Other Health Care Revenues (please specify)
(a)
(b)
(c)
3. Total Revenues
HEALTH CARE EXPENSES
4. Health Care Expenses
(a) Staff Model
(b) Fee-for-Service
(c) Risk Models
(d) Other payment arrangements
5. Incentive Pool and Withhold Adjustments
6. Subcapitation Payments
7. Other health care expenses not included above.
(please specify)
8. LESS DEDUCTIONS FOR HEALTH CARE EXPENSES
(a) Third Party Resource (TPR) Recoveries
(b) Reinsurance Recoveries
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 3 – Report G.4 Page 147 of 241
Category OHP Activity under this
Contract
(c) Subrogation Recoveries
9. TOTAL HEALTH CARE EXPENSES
ADMINISTRATIVE EXPENSES
10. Contractor
11. Subcontractor
12. MCO Provider Tax
13. Total Administrative Expenses
14. TOTAL EXPENSES
15. NET INCOME (LOSS)
16. Beginning Balance (ending balance from last quarterly report)
Retained Earnings/Fund Balances
17. Increase (Decrease) in Retained Earnings/Fund Balance
18. Other Changes
19. Balance at End of Current Reporting Period Retained Earnings/Fund
Balances
Accounting of Net Income (Loss) Recorded on Line 15:
Contractor shall submit a detailed description of how a net loss (quarterly or fiscal year end) and the impact to
the Contractor operations and what fiscal changes were necessary to cover the loss.
Additionally, describe how a fiscal year end net income will be utilized during the next fiscal year. This shall
include the amount to be retained, the amount to be reinvested, the timeline of reinvestment and a narrative
describing how the reinvestment will benefit the OHP Members and support mental health Stakeholders.
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.3 - Definitions Page 148 of 241
Report G.4 – Contractor’s Quarterly Statement of Revenue and Expenses
Definitions for this report:
Statement of Revenue and Expenses: A financial statement reporting fully accrued revenues
and expenses under this Contract for the period. Contractor shall indicate the accounting method
used for this report: Full accrual, modified accrual, or cash basis. Expenses should be
appropriately reported for health care and administrative expenses.
When a Contractor reports an expense on Report G.4 Line 6 “Subcapitation payments”, the
Contractor shall have subcontractors receiving subcapitation funds complete Reports G.4, G.4A,
and G.4B. Contractor shall attach subcontractor’s Reports G.4, G.4A, and G.4B with
Contractor’s quarterly statements when submitting them to AMH.
OHP Activity: The financial position of Contractor relating to activities that are associated with
Covered Services provided under the Oregon Health Plan (OHP) under this Contract.
Allocation of expenditures between OHP and other line of business is permitted. If separate
accounts are not kept for the OHP, revenue and expenses for the OHP may be allocated using an
estimation procedure. Such a procedure and all assumptions must be disclosed in Notes to
Report G.4. This estimation procedure must be used throughout the reports. The assumptions
underlying the allocation must be based on a methodology that clearly represents the costs
associated with providing Covered Services to OHP Members.
Revenues
1. Capitation: The amount received by Contractor on a per member per month basis in
advance of and as payment for the provision of Covered Services to OHP Members
enrolled with Contractor over a defined period of time.
2. Other Health Care Revenues: Other revenues recognized as a result of other non-
capitated arrangements between Contractor and AMH related to Covered Services
provided under this Contract for OHP Members not included in the previous revenue
categories such as interest income on required OHP reserves, etc. Only OHP related
revenue is to be reported on this Report G.4.
3. Total Revenues: The sum of lines 1 and 2.
Health Care Expenses: These are the costs that can be identified specifically with activities
associated with providing health care services to OHP Members. Examples of health care costs
are compensation of clinical employees for the time devoted to activities associated with
providing covered health care Services to OHP Members, the cost of material acquired,
consumed, or expended specifically for the purpose of such activities, equipment and capital
expenditures specifically identified with such activities, and travel expenses incurred specifically
to carry out such health care service activities.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.3 - Definitions Page 149 of 241
4. Health Care Expenses:
a. Staff Model: Amounts paid by Contractor for the provision of Covered Services
to enrolled OHP Members. Include salaries, fringe benefits, other compensations
to staff engaged in the delivery of Covered Services and to personnel engaged in
activities in direct support of the provision of Covered Services and other
expenses as defined in health care expenses above. Exclude expenses for
personnel time devoted to administrative tasks.
b. Fee for Service: Amounts paid for the provision of Covered Services dependent
on the actual number and nature of services provided to each OHP Member.
c. Risk Models: Amounts paid where the Provider receives a fixed amount and
assumes financial liability for the provision of Covered Services for OHP
Members, such as DRGs or Case Rates.
d. Other Payment Arrangements: Amounts paid under other Service payment
arrangements not included in above categories.
5. Incentive Pool and Withhold Adjustments: Adjustments made to expenses that reflect
the incentive pool and withhold activities.
6. Subcapitation Payments: Amounts paid by Contractor to a Provider in advance of and
as payment for actual receipt of Covered Services, either on a per-member-per-month
basis, or on the basis of a formula for allocation whereby the Provider assumes risk for
the provision of all Medically Appropriate Covered Services to OHP Members who are
enrolled with that Provider during the month.
7. Other health care expenses not included above. (please specify)
8. Deductions From Health Care Expenses:
a. TPR: Income earned from Medicare, third party resources, and other insurance
collections through coordination of benefits activities.
b. Reinsurance Recoveries: Amounts received from the reinsurer and those amounts
that have been billed to the reinsurer and not yet received.
c. Subrogation and other Tort/Estate Recoveries: Amounts received from other
liability insurance recoveries, including tort and estate collections.
9. Subtotal Health Care Expenses: The sum of lines 4 through 7 minus line 8a, 8b and 8c.
Administrative Expenses: Administrative costs are those associated with the overall
management and operations of Contractor related to OHP line of business.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.3 - Definitions Page 150 of 241
10. Contractor : All expenses by Contractor for administrative services such as claims and
encounter processing, contract services, financial services, member services, provider
relations, utilization management, and quality management.
11. Subcontractor : All expenses by subcontractor for administrative services such as claims
and encounter processing, contract services, financial services, member services, provider
relations, utilization management, and quality management.
12. MCO Provider Tax: Payment made for managed care taxes.
13. Total Administrative Expenses: The sum of lines 10 and 12.
14. Total Expenses: The sum of lines 9 and 13.
15. Net Income (Loss): The result of line 3 minus 14.
Contractor shall submit a detailed description of a net loss (quarterly or fiscal year end)
and the impact to the Contractor operations and what fiscal changes were necessary to
cover the loss.
Additionally, describe how a fiscal year end net income will be utilized during the next
fiscal year. This shall include the amount to be retained, the amount to be reinvested, the
timeline of reinvestment and a narrative describing how the reinvestment will benefit the
OHP Members and support mental health Stakeholders.
16. Beginning Balance of Period (ending balance from last quarterly report): The total
contributed capital, surplus notes, retained earnings/fund balance, and other items at the
beginning of the report period.
17. Increase (Decrease) in Retained Earnings/Fund Balance: Changes in retained
earnings/fund balance from the last report period to the current report period.
18. Other Changes: Changes in other items from the last report period to the current report
period.
19. Balance at End of Quarterly Reporting Period: Contributed capital, retained
earnings/fund balance and other items at the end of the report period.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 4 – Report G.4.A Page 151 of 241
Exhibit G – Attachment 4
Report G.4.A: Health Care Expenses by Service Type
Contractor:
Subcontractor:
Calendar Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
□ Fiscal Year
Report due at the same time as Report G.4 for both Contractor and risk based
subcontractors, within 60 calendar days after the end of each quarter.
Category OHP Activity under this
Contract
Outpatient
Sub Acute & Other 24 hour Services
Inpatient
Prevention, Education and Outreach 1
Treatment Support Services & Supplies
Consumer Operated Services
Other Non-Encountered Services
TOTAL HEALTH CARE EXPENSES 2
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
1 When an expense is reported on Report G.4A Line 4, complete and attach Report G.4B-Prevention/Education/Outreach
Activities
2 Total of line 8 “TOTAL HEALTH CARE EXPENSES” on Report G.4A must equal line 9 “Total Health Care
Expenses” on Report G.4.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.4.A - Definitions Page 152 of 241
Report G.4.A – Health Care Expenses by Service Type
Definitions for this report:
Contractor: Complete and attach Report G.4A with its completed Report G.4. Include all
completed Reports G.4, G.4A and G.4B submitted by its subcontractors with its own Reports
G.4, G.4A, and G.4B.
Subcontractor: Complete and attach Report G.4A with its completed Report G.4, then submit
the completed G.4, G.4A and G.4B reports to the Contractor.
1. Outpatient: Expenses for outpatient covered health care services. Exclude expenses for
personnel time devoted to administrative tasks.
2. Sub Acute & Other 24 hour Services: Expenses for services provided in lieu of
hospitalization or as a step down from Acute Care hospitalization.
3. Inpatient: All inpatient hospital expenses costs while confined to an Acute Inpatient
Hospital Psychiatric Care Setting.
4. Prevention, Education and Outreach: Outreach, Education and Prevention to OHP
Members, not otherwise reportable as a service Encounter, treatment support services and
supplies, or Consumer operated services. This category does not include marketing
activities, provider training, or development and distribution of member handbooks.
5. Treatment Support Services & Supplies: Items or direct services provided to
individuals as alternatives to Traditional Services and Flexible Services that are not
otherwise reported as CPT or HCPCS codes.
6. Consumer Operated Services: Supportive services provided by one or more Consumers
or a Consumer run agency to groups and Family members which cannot be captured as
CPT or HCPCS codes. (e.g., a drop in center, telephone warm line, support group, etc.)
7. Other Non-Encountered Services: Other health care expenses for services not reported
in above categories
8. Total Health Care Expenses: The sum of lines 1 through 7. Total of line 8 “TOTAL
HEALTH CARE EXPENSES” on Report G.4A must equal line 9 “Total Health Care
Expenses” on Report G.4.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 5 – Report G.4.B Page 153 of 241
Exhibit G – Attachment 5
Report G.4.B: Prevention/Education/Outreach Activities
Contractor:
Subcontractor:
Calendar Year:
Report Period: □ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
Report due at the same time as Report G.4 and G.4A - within 60 calendar days after the
end of each quarter, to be submitted for both Contractor and risk based subcontractors.
1. Provide information on Prevention/Education/Outreach activities for OHP enrolled members.
2. Report only those activities that cannot be otherwise reported using CPT codes.
No. Activity Number of
Activities
Time 1
Cost 2 No. of Members
(actual or estimate)
1 PEO 1- Public Information
2 PEO 2 – Community Education
3 PEO 3 – Parent/Family Education
4 PEO 4 – Alternative Activities
5 PEO 5 – Community Mobilization
6 PEO 6 – Life Skills Development
7 PEO 7 – Prevention Support Activities
8 PEO 8 – Community Based Outreach
9 PEO 9 – Services Integration
10 OTHER
11 TOTAL PEO EXPENSES
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
1 Actual time spend with members, reported in 15 minute increments. Time does not apply for PEO1.
2 Cost allocation for activity to include preparation, travel, equipment, and level of staff person.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.4.B – Definitions Page 154 of 241
Report G.4.B – Prevention/Education/Outreach Activities
Definitions for this report:
1. PEO 1 Public Information: Presentation of accurate targeted messages and promotional material on
mental health and substance abuse issues, such as suicide and teen pregnancies, to increase awareness of
behavioral health. May include information seminars, electronic and print media. (Time does not apply
for this activity)
2. PEO 2 Community Education: Community educational sessions with clear goals and objectives
designed for a specific group that promotes a change in attitude and behaviors that may lead to
behavioral health problems. May be ongoing and sequential.
3. PEO 3 Parent/Family Education: Educational sessions aimed at parents and Family members. May
be one time only or ongoing, sequential sessions or workshops with defined goals and objectives. May
include early childhood development, parenting skills, parent/child communication, and health families.
4. PEO 4 Alternative Activities: Alternative activities that provide challenging positive growth
experiences, leading to the development of self-reliance and independence. Programs offer healthy
alternatives for leisure/free time within the community Setting, e.g., hiking club, ropes course.
5. PEO 5 Community Mobilization: Community mobilization activities to deal effectively with
behavioral health issues within the community, such as developing partnerships with schools/businesses,
developing neighborhood coalitions, or training and technical assistance to coalitions.
6. PEO 6 Life Skills Development: Life skills development activities that assist individuals in developing
or improving critical life skills. Must be ongoing, sequential learning activities or sessions that focus on
the development of skills in decision making, coping with stress, values awareness, problem solving,
conflict resolution, resistance skills, and self esteem.
7. PEO 7 Prevention Support Activities: Activities that support individuals in daily living or coping
skills, such as warm lines and peer supports.
8. PEO 8 Community Based Outreach: Activities provided in community Settings that attempt to engage
individuals who might not otherwise access or seek out Traditional Services, such as Outreach to
homeless individuals.
9. PEO 9 Services Integration: Includes participation in multi-disciplinary teams and community
meetings where services are being discussed for an OHP Member who is not currently in services with a
mental health provider.
10. OTHER: Expenses for other Prevention, Education, Outreach activities not reported in above
categories.
11. TOTAL PEO EXPENSES: The sum of lines 1 through 10.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 6 – Report G.5 Page 155 of 241
Exhibit G – Attachment 6
Report G.5: Fiscal Year Cash Flow Analysis for Corporate Activity-Indirect Method
Contractor:
Report Period: through
Report is due within 90 calendar days after the end of Contractor’s fiscal year.
Provide the cash flow information for Corporate Activity. Note that cash flow resulting from an increase in
operating assets, a decrease in operating liabilities, and a payment out is a debit. Note that cash flows resulting
in receipt of cash or proceeds are credits.
Cash Flows Provided by Contractor
Corporate
Activity
1. Net Income (loss)
Adjustment to reconcile
net income (loss to net
cash)
2. Depreciation and
Amortization
3. Health Care
Receivables
4. Other Operating Assets
(Increase)/Decrease in
Operating Assets
5. Unearned Capitation
Amounts
6. Accounts Payable
7. Accrued Incentive Pool
OPERATING
ACTIVITIES
Increase (Decrease) in
Operating Liabilities
8. Other Operating
Activities
9. Claims Payable /IBNR
10. NET CASH PROVIDED (USED) FROM OPERATING ACTIVITIES
11. Receipts from Sale of Investments
12. Receipts for Sales of Property and Equipment
13. Payments for Purchases of Investments
14. Payments for Purchase of Property and Equipment
INVESTING
ACTIVITIES
15. Other Increase (Decrease) in Cash Flow for
Investing Activities
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 6 – Report G.5 Page 156 of 241
Cash Flows Provided by Contractor
Corporate
Activity
16. NET CASH PROVIDED (USED) BY INVESTING ACTIVITIES
17. Proceeds from Paid in Capital or Issuance of Stock
18. Loan Proceeds
19. Principal Payments on Loans
20. Dividends Paid
21. Principal Payments under Lease Obligations
FINANCING
ACTIVITIES
FINANCING
ACTIVITIES cont.
22. Other Cash Flow Provided by Financing Activities
23. NET CASH PROVIDED (USED) by FINANCING ACTIVITIES
24. NET INCREASE/(DECREASE) in CASH and CASH EQUIVALENTS from
OPERATING, INVESTING and FINANCING ACTIVITIES
25. CASH and CASH EQUIVALENTS at BEGINNING OF REPORT PERIOD
(BEGINNING OF FISCAL YEAR)
26. CASH and CASH EQUIVALENTS at END of REPORT PERIOD
27. CHANGE in CASH/CASH EQUIVALENTS for FISCAL YEAR
REPORTING
Revised, November 2009
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.5 - Definitions Page 157 of 241
Report G.5 – Fiscal Year Cash Flow Analysis for Corporate Activity Indirect Method
Definitions for this report:
Contractor shall provide a Cash Flow Analysis report for the corporate fiscal year for OHP
business within 90 days after the end of that fiscal year.
Contractor Corporate Activity: Total financial information of any relevant organization,
partnership, or joint venture incorporated under or subject to the provisions of ORS Chapters 60,
65, 190 and 732.005. The Corporate Activity for each Contractor is defined in Part III of this
Contract.
Cash Flow Provided by Operating Activities: Financial report estimating cash generated or
lost from operating activities.
1. Net Income (Loss): Report OHP Corporate Activity from Report G.4, Line 15 (fiscal
year end).
2. Depreciation and Amortization: Depreciation on property, plant and equipment, and
amortization on land.
3. Health Care Receivable: Report any cash flow generated or lost by changes in health
care receivables. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
4. Other Operating Assets: Report any cash flow generated or lost by changes in other
operating assets. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
5. Unearned Capitation Amounts: Report any cash flow generated or lost by changes in
unearned capitation. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
6. Accounts Payable: Report any cash flow generated or lost by changes in accounts
payable. Include non-cash or non-cash equivalent transactions. Remove the effects of all
deferrals of receipts and payments and accruals of receipts and payments.
7. Accrued Incentive Pool: Report any cash flow generated or lost by changes in accrued
incentive pool. Include non-cash or non-cash equivalent transactions. Remove the
effects of all deferrals of receipts and payments and accruals of receipts and payments.
8. Other Operating Liabilities: Report any other cash flow generated or lost by changes
in other operating liabilities. Include non-cash or non-cash equivalent transactions.
Remove the effects of all deferrals of receipts and payments and accruals of receipts and
payments.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.5 - Definitions Page 158 of 241
9. Claims Payable/IBNR : Report any cash flow generated or lost by changes in claims
payable. Included non –cash or non-cash equivalent transactions. Remove the effects of
all deferrals or receipts and payments and accruals of receipts and payments.
10. Net Cash Provided (Used) from Operating Activities: Sum of lines 1 through 9. To
arrive at net cash provided by operating activities, remove from net income the effects of
all deferrals of receipts and payments.
Cash Flows Provided by Investing Activities: Financial report showing the cash generated or
lost from different investing activities.
11. Receipts from Sale of Investments: Cash generated by the transfer of cash out of either
short-term or long-term investment transactions, including restricted cash reserves and
other assets that relate to transactions reported in Report G.3.
12. Receipts for Sales of Property and Equipment: Cash generated by the transfer of cash
into property and equipment sales transactions reported in Report G.3. Include any
advance payments, down payments or other payments made at the time of purchase or
shortly before or after the purchase of the property and equipment and productive assets
including leasehold improvements.
13. Payments for Purchases of Investments: Cash lost by the transfer of cash into either
short-term or long-term investment transactions reported in Report G.3. Include cash lost
by transfer of cash into restricted cash reserves and other assets that relate to transactions
reported in Report G.3.
14. Payments for Purchases of Property and Equipment: Cash lost by the transfer of cash
into property and equipment sales transactions reported in Report G.3. Include advance
payments, down payments or other amounts paid at the time of purchase or shortly before
or after the purchase of the property and equipment.
15. Other Increase (Decrease) in Cash Flow for Investing Activities: Report any other
cash flow generated or lost by changes in investing activities.
16. Net Cash Provided (Used) by Investing Activities: Sum of lines 11 through 15.
17. Cash Flows Provided by Financing Activities: Financial report showing the cash
generated or lost from different financing activities.
18. Proceeds from Paid in Capital or Issuance of Stock: Cash generated from paid in
capital surplus or issuance of stock.
19. Loan Proceeds: Cash generated by the transfer of cash from loan proceeds transactions.
20. Principal Payments of Loans: Cash payments for loan obligations.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Report G.5 - Definitions Page 159 of 241
21. Dividends Paid: Cash payment for dividends reported in Report G.3.
22. Principal Payments under Lease Obligations: Cash payments for lease obligations.
23. Other Cash Flow Provided by Financing Activities: Any cash flow generated or lost
by the transfer of cash in a financial transaction.
24. Net Cash Provided (Used) by Financing Activities: Sum of lines 17 through 22.
25. Net Increase/(Decrease) in Cash and Cash Equivalents: From operation, investing
and financial activities. The sum of lines 10, 16 and 23.
26. Cash and Cash Equivalents at Beginning of Report Period: The total net cash
provided by operating activities, by investing activities, and by financing activities at the
beginning of the fiscal year specified in the last fiscal year Report G.5, line 24.
27. Cash and Cash Equivalents at End of Reporting Period: Line 24 of the latest fiscal
year Report G.5.
28. Change in Cash/Cash Equivalents for Fiscal Year: Line 25 minus Line 26.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit G – Attachment 7 – Report G.6 Page 160 of 241
Exhibit G – Attachment 7
Report G.6 – Disclosure of Compensation
Contractor:
This report shall be completed at the end of the contract year and is due within 90 days following the end
of the contract year. The compensation and benefit amounts are the total for the contract year. As
specified in ORS 414.725, prepaid health care plans must report the three (3) highest executive salary and
benefit expenses paid to any executive as defined below:
"Executive" means a person having administrative or supervisory authority in the Contractor's organization,
without regard to title, including but not limited to the chief executive, financial, administration, or information
officer; chairperson; directors including the medical director; vice presidents; and managers.
OHP Line of Business
(1) (2) (3) (4) (5)
Name and Principal Position Gross Salary* 1 Payroll-Related All Other * 3
Benefits* 2 Compensation TOTALS ___________ ___________ ___________ ___________
Name and Position of Highest
Compensated Executive
Name:
Position:
Name and Position of Highest
Compensated Executive
Name:
Position:
Name and Position of Highest
Compensated Executive
Name:
Position:
*1 Disclose the amounts of OHP compensation (W2 Reportable) paid by Contractor for Executives. If an
Executive performs OHP work and non-OHP work compensation must be reasonably allocated between OHP
and non-OHP businesses. Method of allocation must be disclosed. Please attach narrative of allocation method
utilized. Only OHP related compensation is disclosed on this form.
*2 Including, but not limited to, health, life and disability insurance premiums and retirement plan contributions
paid by Contractor for the Executive’s benefit.
*3 Anything of value that the Executive received because of the relationship, not already reported in Column
(2) or Column (3) including items reported on the employee W2 that are not wages or benefits.
Preparer’s Signature Phone Number
Preparer’s Printed Name Date
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 161 of 241
Exhibit H – Encounter Minimum Data Set Requirements
Introduction
The information in this Exhibit H applies to Encounter Data procedures for dates of service in effect
on and after the date this Contract was signed. The parties to this Contract acknowledge and agree
that not later than the Encounter Transaction Implementation Date, which shall be January 1, 2010
or such other implementation date as may be authorized by DHS (referred to as the “Encounter
Transaction Implementation Date”), the Contractor will transmit data to DHS using the Health
Insurance Portability and Accountability Act (HIPAA) Transaction Standards for Health Care
Claims Data as specified in 45 CFR 162.1101 and 162.1102 and as specified in DHS Encounter
Data Companion Guides.
· Contractor shall take all necessary actions required by DHS to become a trading partner and
to register and conduct data transactions. The parties shall comply with DHS Electronic
Data (ED) Rules, OAR 407-120-0100-407-120-0220, applicable to the conduct of HIPAA
Standard Transactions with trading partners.
· Upon Contractor’s compliance with testing and other requirements in the DHS ED rules,
and when DHS determines that Encounter Transactions may be placed into the production
environment, Contractor shall submit encounter data and complies with the data
requirements of this Exhibit.
1. General Provisions:
a. Contractor shall submit accurate and complete Encounter data to DHS pursuant to
this Exhibit H. Contractor shall ensure that the data received from Providers is
accurate and complete by:
(1) Verifying the accuracy and timeliness of reported data,
(2) Screening the data for completeness, logic and consistency, and
(3) Collecting Service information in standardized formats to the extent feasible
and appropriate.
Contractor shall use the most current DSM Multi-axial classification system,
inclusive of a complete five Axis diagnosis, and an ICD coding system, reported to
the highest level of specificity.
b. DHS shall process Encounter data through the Medicaid Management Information
System (MMIS). DHS shall “pend” all Encounters that cannot be processed because
of missing or erroneous data.
(1) DHS shall notify Contractor of the status of all Encounter claims processed.
Notification of all Pended Encounter Claims shall be provided to the
Contractor each week that an Encounter claim remains Pended.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 162 of 241
(2) Contractor shall correct all pended Encounters, within the time period
identified in 1.c.(3), below.
c. Timelines
(1) Contractor must submit Encounter claims at least once per calendar month.
The Encounter claims must represent at least 50% of all claim types
(professional and institutional) received and adjudicated by Contractor that
month.
(2) Contractor shall submit all original and unduplicated Encounter data to DHS
within 180 days of the date of service. Circumstances not subject to the 180
day time frame include 1) Member's failure to give provider necessary claim
information, 2) third party liability coordination, and 3) delays associated
with resolving local and out-of-area claims, (4) hardware/software
modifications specific to the mechanisms for processing encounter data and
(5) Issues identified by AMH regarding DHS’ encounter data processing
system that make it problematic for Contractor to submit data (AMH will
notify Contractor of such identified problems). Contractor shall structure its
subcontracts and Participating and non-Participating Provider reimbursement
arrangements to ensure timely submission of billings.
(3) Contractor shall submit all corrections to pended Encounters to DHS within
63 calendar days of the date that DHS notifies Contractor that the Encounters
were pended. Claims for correction that are not submitted within 63 days are
subject to Corrective Action. (See Exhibit B, Part VI, Section 2 entitled
“Remedies Short of Termination” of this Contract.)
(4) Contractor shall submit Encounter data for Covered Services known to have
been provided to OHP Members. Contractor shall submit such Encounters
regardless of the reimbursement method used, claim payment status (the
claim was denied), placement on the Prioritized List of Health Services, or
Third Party Resource status.
d. Data Transmission and Format
(1) Contractor must submit all Encounter Data to DMAP electronically.
Contractor must submit all data in an 837 HIPAA Compliant format and as
set forth in HIPAA’s Implementation Guides, DHS’ 837 Companion Guides
and system specifications supplied by DHS.
(2) Contractor shall submit all data in a format approved by DHS.
(3) Contractor may have another entity submit Encounter data on its behalf,
however, Contractor shall request approval of such arrangement from the
designated Operations Section, Claims Unit, DMAP, DHS. Contractor shall
remain responsible for Encounter data accuracy, timeliness and completeness
regardless of the entity submitting the Encounter data.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 163 of 241
2. Data Set Requirements
a. The data elements specified in this section constitute the required minimum data set.
Contractor is required to submit all of the data specified in this section.
b. Contractor shall submit the following identifying information for all Encounters:
(1) Contractor's DHS Prepaid Health Plan Provider Number
(2) OHP Member Name
(3) Medicaid Recipient Number, also known as the OHP Prime Number
(4) Disposition of the claim (accepted/rejected)
(5) Disposition Reason valid Claim Adjustment Reason Code(s) (CARC)
(Contractor’s determination at the service line that a liability exists).
c. For outpatient mental health Encounters, in addition to the identifying information
listed in Subsection 2.b., DHS requires a HIPAA 837 Professional Transaction
(837P) Form and the following minimum data elements for DHS processing of
Encounter data claims:
(1) NPI for a performing or rendering Provider
(a) Contractor shall use the NPI assigned, including any Provider
Taxonomy Code, for the CMHP or AMH certified organization
employing the Health Care Professional delivering Covered Services
to the OHP Member. If Covered Services are rendered by Health Care
Professionals not associated with a CMHP or AMH certified
organization, Contractor shall also an NPI as required by 45 CFR
162.410 for submissions.
(b) The use of default Provider numbers are not acceptable as a Provider
number. Only an NPI and a Provider Taxonomy Code registered with
DHS are allowed for use on Encounter data claims for covered
entities. Proprietary Provider numbers are allowed for DHS enrolled
Atypical Providers only.
(2) Diagnosis Codes
Contractor shall submit diagnostic coding using the most current listing of the
DSM/ICD. DSM/ICD codes shall be reported to the highest level of
specificity.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 164 of 241
(3) Date(s) of Service
(4) Procedure Codes (HCPC or CPT Codes or other codes approved by DHS for
use in submitting Encounter data)
(5) Number of Units of Service Provided
(6) Line item charge(s) based on Usual and Customary Charges, even though a
Third Party Resource has made a complete or partial payment.
(7) Amount paid by Contractor to Provider pursuant to OAR 410-120-1295 for
Non-Participating Providers or the rate so deemed agreeable between
Participating Provider and Contractor.
(8) Any third party liability payments.
d. For Acute Inpatient Hospital Psychiatric Care Encounters, in addition to the
identifying information listed in Subsection 2.b., Contractor is required to submit a
HIPAA Compliant 837I format and the following minimum data elements for DHS
processing of claims:
(1) The NPI as required by 45 CFR 162.412 for submissions
(2) Type of Admission Code
(3) Patient Discharge Status Code
(a) Contractor shall use discharge codes established by DHS in its
Hospital Services Guide.
(b) If the OHP Member is found Appropriate for Long Term Psychiatric
Care during the Acute Inpatient Hospital Psychiatric Care stay,
Contractor shall use a discharge code of 05.
(4) Dates of Service (dates from admission through discharge)
(5) Revenue Codes
(a) Contractor shall use revenue codes specific to the services provided.
If Contractor has a limited number of special "package" services for
which it pays an all-inclusive fee and is unable to provide specific
revenue codes for those services, Contractor may use revenue codes
approved in advance by the DHS Technical/Encounter Data Services
Subunit, Program Operations Unit.
(b) Contractor shall submit a list and description of packaged services to
DHS for which Contractor is seeking a special revenue code. DHS
may request additional information about "package" services or
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 165 of 241
Encounters using "package" revenue codes at any time and may
discontinue the use of "package" revenue codes at its discretion with
30 calendar days notice to Contractor.
(6) Line Item Charges
(7) Total Charges
(8) Diagnosis Code(s) at the highest level of specificity.
(9) ICD-9 Procedure Codes when a procedure is performed
(10) Attending Physician’s NPI as required by 45 CFR 162.412 for submissions.
The Provider’s license number is not acceptable as a Provider number.
(11) Amount paid by Contractor to Provider pursuant to OAR 410-120-1295 for
Non-Participating Providers or the rate so deemed agreeable between
Participating Provider and Contractor.
(12) Any third party liability payments
e. For Outpatient Hospital Encounters, in addition to the identifying information listed
in Subsection 2.b., DHS requires an 837I format and the following minimum data
elements for DHS processing of claims:
(1) The NPI as required by CFR 162.412 for submissions
(2) Revenue Center Code(s) (National Uniform Billing Committee (NUBC)
Rule)
(3) Date of Service for each line item
(4) Quantity of units of service provided
(5) Line-item Charge(s) based on the usual and customary fee even though a
Third Party Resource has made complete or partial payment.
(6) Diagnosis Code(s) at the highest level of specificity
(7) Procedure Codes for the Revenue Center Codes
(8) The NPI as required by 45 CFR 162.412 for submissions. The Provider’s
license number is not acceptable as a Provider number.
(9) Amount paid by Contractor to Provider pursuant to OAR 410-120-1295 for
Non-Participating Providers or the rate so deemed agreeable between
Participating Provider and Contractor.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H Page 166 of 241
(10) Any third party liability payments
f. Contractors must submit one claim per hospitalization. The claim must represent all
hospital services delivered to the OHP Member. Interim and late billings are
prohibited. Additional services or revisions to the original claim must be handled
through the adjustment process.
g. Contractors must make adjustments to claims when any required data elements
change or Contractor discovers the data was incorrect or no longer valid.
3. Data Certification and Validation
a. Contractor or designee must certify, based on best knowledge, information, and
belief that the Encounter data submitted for OHP Members is accurate and complete.
b. Contractor shall submit the Data Certification and Validation Signature
Authorization Form, Report H.1, within 30 days following the effective date of this
Contract, and immediately following any changes.
c. Contractor shall submit a Data Certification Form, Report H.2, with each Encounter
submission.
d. Contractor shall submit a Encounter Claim Count Verification Acknowledgement
and Action form, Report H.3, within ten (10) business days of receipt of the Out of
Balance Data Verification Claim Count Verification Report Notice.
Attachments 1 through 4, entitled “Instructions for Report Forms H.1, H.2 and H.3” and
Report Form H.1, Report Form H.2 and Report Form H.3 are attached hereto and
incorporated herein by this reference.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H – Attachment 1 Page 167 of 241
EXHIBIT H – Attachment 1
Instructions for Report Forms H.1, H.2 and H.3
1. Contractor shall demonstrate to DHS through proof of Data Certification and Validation that
Contractor is able to attest to the accuracy, completeness and truthfulness of Information required
by DHS. The requirements in this Exhibit are intended to implement the requirements of 42 CFR
§§ 438.604 and 438.606.
The Data and Information that must be certified include, but are not limited to, Encounter Data.
Contractor shall submit to DHS all reports specified in this Contract and this Exhibit.
2. Required Data Certification and Validation Report Forms
Contractor shall submit the report forms listed below to DHS in the manner described in this
Exhibit and on each form or report.
H.1 Signature Authorization Report Form
H.2 Data Certification and Validation Report Form
H.3 Encounter Claim Count Verification Acknowledgement and Action Report
Form
Form H.2 – A Data Certification and Validation Report Form must be submitted concurrently with each
Encounter Data submission. DHS will notify Contractor if Form H.2 does not meet the requirements.
Contractor shall submit missing or erroneous Report Form H.2 Data Certification and Validation Report
Forms immediately upon notification from DHS that the Data Certification and Validation Report Form
was not complete or not received.
Submission of each complete and accurate Data Certification and Validation Report Form is a material
requirement of this Exhibit and this Contract, as specified in 42 CFR §§ 438.604 and 438.606. Contractor
non-compliance as specified above will be considered a breach of Contract and subject to sanctions as
described in Exhibit B, Part VI, Section 2- Remedies Short of Termination in this Contract.
After MMIS processing, DHS will return the following reports, as applicable, to provide detail
information identifying any claim counts out of balance and claim counts that will not be used for
Rate or Risk Calculations:
Data Validation – Encounter Claim Count Verification Form
Data Validation – Weekly Balancing
Data Validation – Cumulative Pends
Data Validation – Duplicate Check Criteria
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H – Attachment 2 – Report Form H.1 Page 168 of 241
EXHIBIT H – Attachment 2 - Report Form H.1 – Signature Authorization Form
This form is due within 30 days of effective date of this Contract and immediately upon changes thereafter.
Contracted Plan
Name __________________________ OHP Assigned Plan Number: ______________
Encounter Data information submitted to DHS must be certified by one of the following:
1. Chief Executive Officer, or similar top executive officer of the Contractor, however designated (CEO);
2. Chief Financial Officer, or similar top financial officer of the Contractor, however designated (CFO); or
3. An individual who has delegated authority to sign for and reports directly to the CEO or CFO.
Print name and title of CEO or CFO Signature Date
As CEO or CFO I authorize the following designated person(s) to certify Encounter Data Transactions:
Full name and title of the person(s) other than the CEO or CFO identified above who has delegated authority to
sign for and who reports directly to the CEO or CFO and to certify the data and information submitted to DHS:
Print Name and Title Print Name and Title
Signature Date Signature Date
Telephone number Telephone number
(Submit more than one form if more than two persons are delegated to complete the Data Certification and
Validation Report Form)
Content and Timing of Certification : The Data Certification and Validation Report Form must attest, based on
best knowledge, information and belief, as follows:
1. To the accuracy, completeness and truthfulness of the data and/or information submitted to DHS,
2. To the accuracy, completeness and truthfulness of the information contained in the Form H.2, Data
Certification and Validation Report Form and
3. The Data Certification and Validation Report Form must be submitted concurrently with Contractor’s
certified data.
Send this complete, original Signature Authorization Form to your OHP Mental Health Specialist, Contractor
must complete a new Signature Authorization Form immediately each time there is a change to any one of the
designated certifying person(s).
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H – Attachment 3 – Report Form H.2 Page 169 of 241
EXHIBIT H – Attachment 3 - Report Form H.2 –Data
Certification and Validation Report Form*
This form must be submitted concurrently with each Encounter Data submission, if by facsimile
to phone number 503-947-5359. If you experience any difficulty faxing this form to the number
indicated contact your Encounter Data Liaison.
Plan Name: Plan DMAP Number:
Week Ending: Type of submission:
Month/Day/Year Encounter
Total Claim Count** Total Billed Amount
**
$
I, the undersigned, hereby attest that I have authority to certify the data and information on
behalf of Contractor, as authorized by Form H.1, Signature Authorization Form; and I, the
undersigned, hereby certify based on best knowledge, information and belief that the data and
information submitted to DHS are accurate, complete and truthful; and that the data and
information contained in this Form H.2, Data Certification and Validation Form, are accurate,
complete and truthful.
Print Name Print Title
Authorized signature (from Form H.1) Transmission Date
Contractor may, at Contractor’s discretion, submit more detailed submission totals than the
minimum necessary required above. To do so contact your designated Encounter Data Liaison.
* If you have the ability to send an “electronic signature document” please contact your
Encounter Data Liaison
** Total Claim Count and Total Amount Billed includes all claims sent to DHS for processing
(new, adjustments or deletes)
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit H – Attachment 4 – Report Form H.4 Page 170 of 241
EXHIBIT H - Attachment 4 - Report Form H.3 – Encounter
Claim Count Verification Acknowledgement and Action Form
Contractor shall complete this Acknowledgement and Action Form and return it Contractor’s
designated Encounter Data Liaison within ten (10) Business Days of receipt of the Out of
Balance Data Validation–Claim Count Verification Report notice.
For week ending date: _______________________ the following explanation is given for DHS
identified out of balances.
Include any action Contractor will take to adjust or resolve the out of balance.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I, the undersigned, hereby attest that a copy of this Form H.3, Claim Count Verification
Acknowledgment and Action Form has been provided to the individual who has authority to
certify data by Report Form H.1, Signature Authorization Form.
Print Name Print Title
Signature Date
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit I Page 171 of 241
Exhibit I – Third Party Resources and Personal Injury Liens
Capitation rates(s) specified in this Contract are based in part on projected third party recoveries. Contractor's
failure to submit third party recovery data or pursue recoverable third party recovery obligations during the term
of this Contract may create a claim for reimbursement to the extent that would be limited to the requirements of
federal law.
1. Contractor shall take all reasonable actions to pursue recovery of Third Party Resources for Covered
Services provided during the period covered by this Contract. “Third Party” means any individual,
entity, or program that is, or may be, liable to pay all or part of the cost of any Covered Service
furnished to an OHP Member and as defined in Exhibit A of this Contract.
2. Contractor will develop and implement written policies describing its procedures for Third Party
Resource recovery consistent with Third Party Resource recovery requirements in 42 USC 1396a(a)(25)
and 42 CFR 433 Subpart D. At a minimum, the policies and procedures shall include the following
information.
a. Identifying Third Party Resource.
(1) Contractor shall notify the Health Insurance Group, P.O. Box 14023, Salem, Oregon
97309, within thirty (30) days from the time that Contractor learns that an OHP Member
might have other health insurance.
(2) Contractor shall immediately report that OHP Member has a potential third party claim
for personal injuries, or has made a claim or begun an action to enforce such claim, as
those terms are defined in ORS 416.510, to the OHP Member’s caseworker and DHS’
Personal Injury Liens Unit, P.O. Box 14512, Salem, OR 97309-0416.
(3) To the extent authorized by law, DHS will share client and claim information they
receive with Contractor to assist in identifying Third Party Resources.
b. Determining the liability of Third Party Resource.
(1) Contractor shall request OHP Members to cooperate in securing payment from Third
Party Resources, except when the client asserts good cause as defined in OAR 461-120-
0350.
(2) If Contractor is unable to gain cooperation from the OHP Member or OHP Member
Representative or a Third Party Resource in pursuing the Third Party Resource, or if the
OHP Member asserts good cause; Contractor shall notify the Medical Payment Recovery
Unit, P.O. Box 14023, Salem Oregon 97309, of their refusal to cooperate, and provide
such records and documentation as may be requested from the Medical Payment
Recovery Unit.
c. Cost-avoidance.
(1) Cost-avoidance is defined as a method for avoiding payment of Medicaid claims when
Medicare or other insurance resources are available to the OHP Member. Using this
method, whenever Contractor is billed first, claims are denied and returned to the
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit I Page 172 of 241
provider who is instructed to bill and collect from liable Third Party Resources. Cost-
avoidance also includes payment avoided when the provider bills the Third Party
Resource first.
(2) Contractor may not refuse payment for Covered Services based solely on a Diagnosis
code if there is no documentation of a potential Third Party Resource other than the
Diagnosis.
(3) Contractor may not delay payment after a provider notifies Contractor that the provider
cannot obtain recovery from a Third Party Resource after making reasonable efforts, or
cannot obtain information or cooperation needed from OHP Member or a Third Party
Resource to obtain recovery from a Third Party Resource. Upon such notification,
Contractor shall process the claim as a Valid Claim however, Contractor may pursue
alternative remedies under Subsection b of this Section 2, or may seek to recover
payment as provided in Subsection d of this Section 2.
d. Pay and Chase
Pay and Chase is defined as a method used where Contractor pays the claim and then attempts to
recover from liable Third Party Resources.
e. Procedures for identifying and requesting payment from a Third Party Resource that applies to a
personal injury.
(1) Contractor’s recourse for obtaining timely assignment of the rights to recovery or the
assignment of lien rights shall be the process provided in ORS 416.510 to 416.610 and
OAR 461-195-0301 to 461-195-0350. Contractor shall not request an assignment of right
to recovery or assignment of a lien right from an OHP Member or OHP Member
Representative.
(2) When another party may be liable for a personal injury, Contractor may make the
payments and (consistent with Paragraph a, of this Subsection e) place a lien against a
judgment, settlement or compromise. Once Contractor has made the payment for
Covered Services and a lien has been sought, no additional billing or claim for enhanced
reimbursement (e.g., balance billing) to the third party or to the OHP Member or their
financially responsible representative is permitted.
f. Contractor shall maintain records of Contractor’s actions and subcontractors’ actions related to
Third Party Resource recovery, and make those records available for review and review
consistent with the provisions of this Contract.
(1) Contractor shall report all Third Party Resource payments to AMH using Report G.2,
Current OHP Members with Third Party Resources (Quarterly Report), on a quarterly
basis within 60 calendar days after the end of each calendar quarter.
(2) Contractor shall maintain records of Third Party Resource recovery actions that do not
result in recovery, including Contractor’s written policy establishing the threshold for
determining that it is not cost effective to pursue recovery action.
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Contract #129162 Exhibit I Page 173 of 241
(3) Contractor shall provide documentation about personal injury recovery actions and
documentation about personal injury liens to the DHS Personal Injury Liens Unit
consistent with OAR 461-195-0301 to 461-195-0350.
3. Contractor may not refuse to Provide Covered Services, and shall require that its subcontractors may not
refuse to Provide Covered Services, to an OHP Member because of a Third Party Resource’s potential
liability for payment for the Covered Service.
4. Contractor is the payer of last resort when there is other insurance or Medicare in effect. At AMH
discretion or at the request of the Contractor, AMH may retroactively disenroll an OHP Member to the
time the OHP Member acquired Third Party Resource insurance. If the Member’s Enrollment is
inconsistent with OHP managed care Enrollment rules 410-141-0060 through 410-141-0080, an OHP
Member is retroactively disenrolled and AMH will Recoup all Capitation Payments to Contractor after
the effective date of the Disenrollment. Contractor and its subcontractors may not seek to collect from
the OHP Member (or any financially responsible representative of the OHP Member) or any Third Party
Resource, any amounts paid for any Covered Services provided on or after the date of Disenrollment.
5. Contractor shall comply with 42 USC 1395y(b), which gives Medicare the right to recover its benefits
from employers and workers’ compensation carriers, liability insurers, automobile or no fault insurers,
and employer group health plans before any other entity including Contractor or its subcontractor.
a. Where Medicare and Contractor have paid for services, and the amount available from the Third
Party Resource is not sufficient to satisfy the claims of both programs to reimbursement, the
Third Party Resource must reimburse Medicare the full amount of its claim before any other
entity, including Contractor or its subcontractor, may be paid.
b. If the Third Party Resource has reimbursed Contractor or its subcontractor, or if an OHP
Member, after receiving payment from the Third Party Resource, has reimbursed Contractor or
its subcontractor, the Contractor or its subcontractor must reimburse Medicare up to the full
amount the Contractor/subcontractor received, if Medicare is unable to recover its payment from
the remainder of the Third Party Resource payment.
c. Any such Medicare reimbursements described in this section are the Contractor’s responsibility
on presentation of appropriate request and supporting documentation from the Medicare carrier.
Contractor shall document such Medicare reimbursements in its report to AMH, described in
Section 2, Subsection f, Paragraph (1), of this Exhibit.
6. When engaging in Third Party Resource recovery actions, Contractor and subcontractors shall comply
with federal and state confidentiality requirements pursuant to Exhibit E, Section 7, (HIPAA), including
without limitation, the federal (42 CFR Part 2) and state (ORS 426.460 and ORS 179.505)
confidentiality laws and regulations governing the identity and client records of OHP Members. AMH
considers the disclosure of OHP Member claims information in connection with Contractor’s Third
Party Resource recovery actions a purpose that is directly connected with the administration of the OHP
program.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit J Page 174 of 241
Exhibit J – Prevention and Detection of Fraud, Waste and Abuse
Contractor shall have in place administrative and management arrangements, internal controls, policies or
procedures and a mandatory compliance plan that are designed to prevent, detect and guard against fraud, waste
and abuse as they relate to the OHP. This may include operational policies and controls in areas such as
Grievance and Appeal resolution, provider Credentialing and contracting, provider and staff education, and
Corrective Action Plans to prevent potential fraud, waste and abuse activities. Contractor shall review its fraud,
waste and abuse policies annually. If Contractor is also a Medicare contractor, the fraud, waste and abuse
policies established by Contractor to meet CMS standards shall be deemed sufficient to meet DHS’
requirements for fraud, waste and abuse prevention and monitoring. Fraud, waste and abuse policies and
procedures shall be reviewed annually. Contactor shall submit to DHS for review and approval written fraud,
waste and abuse policies and procedures, due within 30 days of the effective date of this agreement.
1. Contractor’s fraud, waste and abuse activities shall include, at minimum, the following:
a. Written policies, procedures, and standards of conduct that articulate Contractor’s commitment
to comply with all applicable Federal and state standards to guard against fraud, waste and abuse;
b. Provide detailed information about the False Claims Act established under sections 3729 through
3733 of title 31, United States Code, administrative remedies for false claims and statements
established under chapter 38 of title 31, United States Code, any Oregon laws pertaining to civil
or criminal penalties for false claims and statements, and whistleblower protections under such
laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in
Federal health care programs (as defined in 42 USC 1320a-7b);
Such Oregon laws shall include the following: ORS 411.670 to 411.690 (submitting wrongful
claim or payment prohibited; liability of person wrongfully receiving payment; amount of
recovery); ORS 646.505 to 646.656 (unlawful trade practices); ORS chapter 162 (crimes related
to perjury, false swearing and unsworn falsification); ORS chapter 164 (crimes related to theft);
ORS chapter 165 (crimes involving fraud or deception), including but not limited to ORS
165.080 (falsification of business records) and ORS 165.690 to 165.698 (false claims for health
care payments); ORS 166.715 to 166.735 (racketeering – civil or criminal); ORS 659A.200 to
659A.224 (whistleblowing); ORS 659A.230 to 659A.233(whistleblowing); OAR 410-120-1395
to 410-120-1510 (program integrity, sanctions, fraud, waste and abuse); and common law claims
founded in fraud, including Fraud, Money Paid by Mistake and Money Paid by False Pretenses).
Contractor understands that this description of the laws that must be included in the employee
handbook under this section of this Contract does not limit the authority of DMAP or any health
oversight agency or law enforcement entity from fully exercising its legal authority or from
pursuing legal recourse to the full extent of the law.
c. Provide as part of the written policies, detailed provisions regarding the Contractor’s policies and
procedures for detecting and preventing fraud, waste and abuse.
d. Include in any employee handbook for the Contractor, a specific discussion of the laws described
in Subsection b., of this section, the rights of employees to be protected as whistleblowers, and
the Contractor’s policies and procedures for detecting and preventing fraud, waste and abuse.
e. The designation of a compliance officer and a compliance committee that are accountable to
senior management, to monitor fraud, waste and abuse activities;
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit J Page 175 of 241
f. Effective training and education for the compliance officer and Contractor’s employees;
g. Effective lines of communication between the compliance officer and Contractor’s employees;
h. Enforcement of standards that guard against fraud, waste and abuse through well publicized
disciplinary guidelines;
i. Provision for internal monitoring and auditing; and
j. Provision for prompt response to detected offenses and for development of corrective action
initiatives relating to this Contract.
2. Services under this Contract may not be provided by the following persons (or their affiliates as defined
in the Federal Requisition Regulations): (a) Persons who are currently suspended, debarred or otherwise
excluded from participating in procurement activities under the Federal Acquisition Regulation or from
participating in non-procurement activities under regulations issues pursuant to Executive Order No.
12549 or under guidelines implementing such order, (b) Persons who are currently excluded from the
Medicaid participation under Section 1128 or Section 1128A of the Act.
3. Contractor shall not refer OHP Members to such persons and shall not accept billings for services to
OHP Members by such persons.
4. Contractor may not knowingly: (1) have a person described in (a) above as a director, officer, partner, or
person with beneficial ownership of more than 5% of Contractor’s equity, or (2) have an employment,
consulting, or other agreement with a person described in 1(a) above for the provision of items and
services that are significant and material to Contractor’s obligations under this Contract.
5. Contractor is required to promptly refer all verified cases of fraud, waste and abuse, including fraud by
employees and subcontractors of the organization to the Medicaid Fraud Control Unit (MFCU),
consistent with the Memorandum of Understanding between DHS and the MFCU. Contractor may also
refer cases of suspected fraud, waste and abuse to the MFCU prior to verification.
6. Examples of cases that should be referred:
a. Providers who consistently demonstrate a pattern of intentionally reporting encounters or
services that did not occur. A pattern would be evident in any case where 20% or more of
sampled or audited services are not supported by documentation in the Clinical Records;
b. Providers who consistently demonstrate a pattern of intentionally reporting overstated or up-
coded levels of service. A pattern would be evident by 20% or more of sampled or audited
services that are billed at a higher level procedure code than is documented in the Clinical
Records;
c. Any verified case where the provider purposefully altered, falsified, or destroyed Clinical Record
documentation for the purpose of artificially inflating or obscuring compliance rating or
collecting Medicaid payments not otherwise due;
d. Providers who intentionally or recklessly make false statements about the credentials of persons
rendering care to OHP Members;
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit J Page 176 of 241
e. Providers who intentionally fail to render Medically Appropriate Covered Services to OHP
Members;
f. Providers who knowingly charge OHP Members for services that are covered or intentionally
balance bill an OHP Member the difference between the service charge and Contractor’s
payment, in violation of DHS rules;
g. Any case of theft, embezzlement or misappropriation of Title XIX or Title XXI program money.
7. An incident with any of the referral characteristics listed above should be referred to the MFCU.
Contractor may also refer cases of suspected fraud, waste and abuse to the MFCU.
8. The MFCU phone number is (971) 673-1880, address 1515 SW 5th Avenue, Suite 410, Portland,
Oregon 97201, and fax (971) 673-1890.
9. Incidents of verified or suspected fraud, waste or abuse by an OHP Member should be reported to DHS
Fraud Investigation Unit, P.O. Box 14150, Salem, Oregon 97309-5027, phone number (503) 378-6826,
facsimile number (503) 373-1525.
10. Contractor shall promptly report all fraud, waste and abuse as required under this section to the MFCU.
Contractor shall also notify DHS of referrals to MFCU of complaints of fraud, waste and abuse that
warrant investigation. This notification shall include the following information:
11. Contractor shall promptly report all fraud, waste and abuse as required under this section to the MFCU.
Contractor shall also notify DHS of referrals to MFCU of complaints of fraud, waste and abuse that
warrant investigation. This notification shall include the following information:
a. Provider’s name, Oregon Medicaid Provider Number, and address;
b. Type of Provider
c. Source of complaint;
d. Nature of complaint;
e. The approximate range of dollars involved;
f. The disposition of the complaint when known; and
g. Number of complaints for the time period.
12. Contractor shall cooperate with the MFCU and the DHS Fraud Unit and allow them to inspect, evaluate,
or audit books, records, documents, files, accounts, and facilities as required to investigate an incident of
fraud, waste or abuse.
13. In the event that Contractor reports suspected fraud, or learns of an MFCU or DHS Fraud Unit
investigation, Contractor shall not notify or otherwise advise its subcontractors of the investigation so as
not to compromise the investigation.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit K Page 177 of 241
Exhibit K –Provider Capacity Assurance Report
Contractor shall submit to AMH this report as follows:
· Upon effective date of this Contract and immediately upon significant changes; and
· At any time there has been a significant change (as defined by DHS) in the Contractor’s
operations that would affect adequate capacity and services, including:
* Changes in Contractor’s services, benefits, geographic service area or payments,
or;
* Enrollment of a new population with the Contractor.
42 CFR 438.206 “Availability of Services” and 42 CFR 438.207 “Assurances of Adequate
Capacity and Services” require Contractor to ensure to DHS, with supporting documentation,
that all Services covered under this Contract are available and accessible to OHP Members and
that the Contractor demonstrates adequate Provider capacity.
Provide the following information of how Contractor requires and monitors adequate mental
health Provider capacity. If any of the activities are subcontracted, describe how Contractor
provides oversight and monitoring of the activities as well.
1.
a. How does Contractor or delegate(s) maintain a network of appropriate Providers
to sufficiently Provide adequate access to all Services covered under this Contract
including Special Health Care Needs?
b. How does Contractor or delegate(s) monitor the network of appropriate Providers
to sufficiently Provide adequate access to all Services covered under this Contract
including Special Health Care Needs?
2. If the network is unable to Provide necessary Services, covered under this Contract, to a
particular OHP Member, how does Contractor or delegate(s) Provide adequate and timely
Services out of network for an OHP Member, for as long as the Contractor or delegate(s)
is unable to Provide them within the network?
3.
a. How does Contractor or delegate(s) require Providers to meet DHS standards for
timely access to routine, urgent and emergent care and Services, taking into
account the urgency of the need for Services?
b. How does Contractor or delegate(s) monitor compliance by Providers of timely
access to care and Services?
c. How does Contractor or delegate(s) monitor availability of Services when
medically necessary routine, urgent and emergent Services?
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit K Page 178 of 241
4. What corrective actions has Contractor or delegate(s) taken if there was a failure to
comply with any provision or timeliness of Services during the prior contract year? If,
any, what is the current status of the corrective action and compliance?
5. In the current contract year, what is Contactor or delegate(s) doing to Provide delivery of
Services in a culturally competent manner to all OHP Members, including those with
limited English proficiency and diverse cultural and ethnic backgrounds?
6. What does Contractor do to monitor subcontracted activities related to Provider capacity?
Be specific to each activity subcontracted.
7. Provide date of data set completion
8. Contractor shall submit a list of participating Qualified Mental Health Professional
practitioners and participating facilities to include the following elements:
Practioner List
Name
Agency/Location
Telephone Number
Non-English Language Spoken
Facility List
Name of Facility
Psychiatric Day Treatment Facility
Psychiatric Residential Treatment Services Facility
Hospitals
As specified in Exhibit B, Part II, 1.b., Contractor shall have contracts with hospitals.
Describe how hospitals are used on a non-participating basis.
Provide a list of all hospitals with whom you have had admissions and the number at each during
the previous contract year.
List those hospitals with whom you contract, those hospitals with whom you have a
Memorandum of Understanding and those hospitals with whom you have Letters of Agreement.
Data Date Range: ______________
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit L Page 179 of 241
Exhibit L – Reserved
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M Page 180 of 241
Exhibit M – Practitioner Incentive Plans
1. Contractor shall comply with all requirements of this Exhibit to ensure compliance with Sections
4204(a) and 4731 of the Omnibus Budget Reconciliation Act of 1990 that concern practitioner
incentive plans. The purpose of this Act is to ensure that OHP Members are not being denied
access to Medically Appropriate referral services based on financial incentives. Contractor shall
not set into place any financial incentives which reduce or limit provision of Covered Services to
OHP Members as specified in this Contract.
2. Contractor shall complete and submit to AMH Report M.1: Practitioner Incentive Plan
Disclosure, under the following circumstances:
a. On the effective date of this Contract;
b. At least 45 calendar days before the effective date of changes to the referral incentive
arrangements which results in a change in the amount of risk or Stop Loss Coverage or a
change in the risk formula to include coverage of services not provided by the practitioner
or practitioner group which were not previously included in the formula;
c. Within 30 calendar days of AMH request; and
d. On the effective date of any amendment to this Contract that extends Contractor’s Service
Area.
3. Contractor shall provide to any OHP Member who requests it the following information:
a. Whether the Contractor uses a practitioner incentive plan that affects the use of referral
services;
b. The type of incentive arrangement;
c. Whether Stop Loss Coverage is provided; and
d. If a survey is required to ensure access to services is not being denied based on the
practitioner incentive plan, a summary of the survey results.
4. If Contractor practitioner incentive plans meet the definition appearing in Report M.1:
Practitioner Incentive Plan Disclosure, Contractor shall complete and submit to AMH, on the
effective date of this Contract and at least 45 calendar days before the effective date of changes to
the practitioner incentive plans, Report M.2: Practitioner Incentive Plan Detail. AMH will use
information reported to determine whether Contractor incentive arrangements place the
practitioner or practitioner group at risk for amounts beyond a specified risk threshold.
a. Risk threshold means the maximum risk to which a practitioner or practitioner group may
be exposed under a practitioner incentive plan without being at substantial financial risk. It
applies to incentive arrangements involving referral services. The specified risk threshold
is set at 25 percent of potential earnings of the practitioner or practitioner group.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M Page 181 of 241
b. Substantial financial risk applies to those practitioners and practitioner groups with a
patient panel size of less than 25,001 OHP Members or a patient panel size of more than
25,000 OHP Members as a result of pooling OHP Members. A substantial financial risk
exists for these practitioners and practitioner groups if the incentive arrangement described
above in 4.a. places the practitioner or practitioner group at risk of losing more than the
risk threshold.
c. An incentive arrangement shall be determined as causing substantial financial risk under
the following circumstances:
(1) Withholds are greater than 25 percent of the maximum anticipated total incentive
payments (salary, FFS payments, Capitation Payments, returned withhold and
bonuses);
(2) Withholds less than 25 percent of potential payments if the practitioner or
practitioner group is potentially liable for amounts exceeding 25 percent of
potential payments;
(3) Bonus that is greater than 33 percent of potential payments minus the bonus;
(4) Withholds plus bonuses if this sum equals more than 25 percent of potential
payments. The threshold bonus percentage for a particular withhold percentage
may be calculated using the formula:
withhold percentage - 0.75(bonus percentage)+25%
(5) For Capitation arrangements, if the difference between the maximum possible
payments and minimum possible payments is more than 25 percent of the
maximum possible payments; or the maximum and minimum possible payments
are not clearly explained in the practitioner's or practitioner group's contract; and
(6) Any other incentive arrangements that have the potential to hold a practitioner or
practitioner group liable for more than 25 percent of potential payments.
5. If Contractor is found to have referral incentive arrangements which place its practitioners or
practitioner groups at substantial financial risk, Contractor shall conduct a survey of OHP
Members to address satisfaction with the quality of services provided and degree of access to the
services. Such survey may be conducted as part of survey administration occurring based on
Contractor's QA Program. Contractor shall provide AMH with survey data and results within 60
calendar days of the survey due date. The survey shall:
a. Include either all current OHP Members of Contractor and those who have disenrolled for
reasons other than loss of OHP eligibility or relocation outside the service Areas; or all
those OHP Members enrolled during the past twelve months or a sample of these OHP
Members;
b. Be designed, implemented and analyzed in accordance with commonly accepted principles
of survey design and statistical analysis;
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M Page 182 of 241
c. Address the satisfaction of OHP Members and disenrolled OHP Members with the quality
of services provided and their degree of access to the services; and
d. Be conducted no later than one year after the effective date of the incentive arrangement
and at least every two years thereafter.
6. Contractor shall ensure that all practitioners and practitioner groups determined to be at substantial
financial risk have either aggregate or per OHP Member Stop Loss Coverage in accordance with
the following requirements:
a. If aggregate Stop Loss Coverage is provided, Contractor shall cover 90 percent of referral
service costs (beyond allocated amounts) that exceed 25 percent of potential earnings of
the practitioner or practitioner group; or
b. If per patient Stop Loss Coverage is provided, Contractor shall provide Stop Loss
Coverage based on patient panel size as reflected in the following table:
Patient Panel Size
Per Patient Stop Loss
Coverage Limit
Less than 1,000
$10,000
1,000 to 10,000
$30,000
10,001 to 25,001
$200,000
More than 25,000 (No Pooling)
No specification
More than 25,000 (Pooling)
$200,000
7. CMS may impose a penalty of up to $25,000 in addition to or in lieu of other remedies available
under law if CMS determines that the Contractor either misrepresented or falsified information
furnished to AMH or an OHP Member in regard to the Practitioner Incentive Plan provisions or
failed to comply with the Practitioner Incentive Plan provisions specified in this Contract.
8. DHS will suspend payment for new OHP Members until it is satisfied that the basis for the
determination by CMS is not likely to recur.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M – Attachment 1 – Report M.1 Page 183 of 241
Exhibit M – Attachment 1
Report M.1: Practitioner Incentive Plan Disclosure
Contractor: Date Prepared:
Signature and Title of Authorized Representative:
Practitioner Incentive Plan: Any incentive arrangement between an eligible organization and a
practitioner or practitioner group that may directly or indirectly have the effect of reducing or
limiting Covered Services furnished with respect to individuals enrolled in the organization. The
compensation arrangement may include a variety of payment methods that create financial
incentives to influence the use of referral services which are arranged, but not directly provided,
by the practitioner subject to the practitioner incentive plan. Such incentive arrangements may
hold a practitioner or a practitioner group at risk for all or a portion of the cost of referral
services and may provide additional compensation to the practitioner or practitioner group if the
practitioner or practitioner group is successful at controlling the level of referral services.
Question or Requirement Response
1. Does said organization use practitioner
incentive plans as defined above for work
performed under this Contract?
2. If the answer to item 1 is yes, answer these
additional questions.
a. Does the plan reference services that
are not provided by the practitioner
or practitioner group?
b. Does the plan involve a withhold
and/or bonus?
If yes, what is the percent or dollar
amount of the withhold and/or
bonus?
c. Does the plan require Stop Loss
Coverage?
If yes, what type of Stop Loss
Coverage is required?
If yes, what amount of Stop Loss
Coverage is required?
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M – Attachment 1 – Report M.1 Page 184 of 241
Question or Requirement Response
d. What is the patient panel size?
If the panel size is based on a
pooling of patients, describe the
pooling method used.
Practitioner Type Percent of
Total
Capitation
Paid
PCPs
Referral Services to
Specialists
Hospital
Other Types of Providers
Services
e. Does the plan involve Capitation of
practitioners or groups?
If yes, complete the table to the right
using information from the most
recent year.
Total
f. Does said organization conduct
surveys of OHP Members to
measure the impact of practitioner
incentive plans on quality of
services and access to services?
If yes, when was the last survey
conducted and who was surveyed?
If yes, when will the next survey be
conducted and who will be
surveyed?
If yes, describe how the survey was
designed, implemented and
analyzed.
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OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit M – Report M.2 - Definitions Page 186 of 241
Other Definitions for Report M.2 – Practitioner Incentive Plan Detail
Bonus: A payment made to a practitioner or practitioner group beyond any salary, FFS
payments, capitation, or returned withhold.
Capitation Withhold: An incentive arrangement where a certain amount is removed from the
negotiated Capitation Payment and might or might not be returned to the Participating Providers
within the health care delivery system to cover a specified set of services and administrative
costs at a given point in time on the basis of certain criteria and/or factors.
Fee-for-Service Withhold: An incentive arrangement where a certain percentage of the service
fee is removed from the base amount of the service fee and might or might not be returned to the
Participating Providers within the health care delivery system on the basis of certain criteria
and/or factors.
Practitioner Liability: An incentive arrangement where payments are made to or by
Participating Providers within the health care delivery system at a given point in time on the
basis of certain performance criteria. Practitioner liability does not include those items defined
elsewhere on this page.
Referral: Any specialty, inpatient, outpatient, or laboratory services that a practitioner or
practitioner group orders or arranges, but does not furnish directly.
Referral Withhold: An arrangement between Contractor and Participating Providers in a health
care delivery system to provide an incentive for that system to take on additional financial
responsibility in covering probable, future expenses incurred from providing referral health care
services to Contractor's OHP Members. These arrangements consist of any amounts Contractor
pays Participating Providers for services provided, including the amounts paid for
administration. These arrangements may control levels or costs of referral services. These
payments should only include arrangements based on referral levels. Arrangements made
between Contractor and an intermediate entity who in turn subcontracts with one or more
practitioner groups are to be reported.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit N Page 187 of 241
Exhibit N - Grievance System
The purpose of this Exhibit is to describe Contractor’s obligations to create and maintain a Grievance
System consistent with the requirements of 42 CFR 438.400 through 438.424.
1. Grievance System Requirements
a. Contractor shall have written policies and procedures for a Grievance System that ensures
Contractor’s compliance with OAR 410-141-0260 through OAR 410-141-0266.
b. Contractor shall provide information to all OHP Members that includes at least:
(1) Written material describing the Contractor’s Grievance and Appeals procedures,
and how to make a Grievance or file an Appeal and ask for an Administrative
Hearing; and
(2) Assurance in all written, oral, and posted material of OHP Member confidentiality
in the Grievance, Appeal and Administrative Hearing processes.
c. An OHP Member or an OHP Member Representative may file a Grievance and an Appeal
orally or in writing, and may request an Administrative Hearing. The OHP Member or an
OHP Member Representative may withdraw and Appeal or Administrative Hearing
request at any time.
d. Contractor shall keep all information concerning an OHP Member's Grievance, Appeal or
Administrative Hearing confidential, as specified in OAR 410-141-0261 through 410-141-
0264.
e. Consistent with confidentiality requirements, the Contractor's staff person who is
designated to receive Grievances or Appeals, or both, shall begin to obtain documentation
of the facts concerning the Grievance or Appeal upon receipt of the Grievance or Appeal.
f. Contractor shall afford OHP Members full use of the Grievance System procedures. The
Contractor shall cooperate by providing to AMH, relevant information that may be
required for the Appeal and Administrative Hearing process.
g. Contractor shall treat as an Appeal an OHP Member’s request for an Administrative
Hearing made to AMH outside of the Contractor’s Appeal procedures upon notification by
AMH as provided for in OAR 410-141-0264.
h. Under no circumstances shall Contractor discourage an OHP Member or an OHP Member
Representative from using the Administrative Hearing process.
i. Contractor shall not request Disenrollment of an OHP Member on the basis of
implementation of an Administrative Hearing decision or an OHP Member's request for an
Appeal or Administrative Hearing.
j. Contractor shall make available a supply of blank Grievance forms (OHP 3001) in all
Contractor administrative offices and in those medical offices where staff have been
designated by the Contractor to respond to Grievances. Contractor shall develop an Appeal
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Contract #129162 Exhibit N Page 188 of 241
form that includes the elements of the Administrative Hearing Request form (DHS 0443)
and shall make the forms available in all Contractor administrative offices and in those
medical offices where staff have been designated by the Contractor to respond to Appeals.
Contractor shall also make available a supply of blank Administrative Hearing Request
forms (DHS 0443) and Notice of Hearing Rights forms (DMAP 3030).
k. The Contractor shall provide information about the Grievance System to all Participating
Providers and subcontractors at the time they enter into a contract with Contractor.
l. The Contractor shall maintain logs that are in compliance with OAR 410-141-0266 to
document Grievances and Appeals received by the Contractor, and Contractor shall review
the information as part of its Quality Improvement strategy.
m. An authorized OHP Member Representative, pursuant to 42 CFR 438.402(b) (ii), may act
for the OHP Member at any stage in the Grievance System. Contractor shall document the
basis on which an individual acts as an OHP Member Representative of the OHP Member.
2. Contractor Grievance Procedures
a. A Grievance procedure applies only to those situations in which the OHP Member or OHP
Member Representative expresses concern or dissatisfaction about any matter other than an
“Action.” As per 42 CFR, 438.408, Contractor shall have written procedures to
acknowledge the receipt, disposition and documentation of each Grievance from OHP
Members. The Contractor’s written procedures for handling Grievances, shall, at a
minimum:
(1) Address how the Contractor will accept, process and respond to each Grievance
from an OHP Member or OHP Member Representative, including:
(a) Acknowledgment to the OHP Member or OHP Member Representative of
receipt of each Grievance.
(b) Ensuring that OHP Members who indicate dissatisfaction or concern are
informed of their right to file a Grievance and how to do so;
(c) Ensuring that each Grievance is transmitted timely to staff who have
authority to act upon it;
(d) Ensuring that each Grievance is investigated and resolved in accordance
with all applicable rules; and
(e) Ensuring that the Contractor’s staff person(s) who make decisions on the
Grievance must be persons who are:
(i) Not involved in any previous level of review or decision-making;
and
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(ii) Health Care Professionals who have appropriate clinical expertise in
treating the OHP Member’s condition or disease, if the Grievance
concerns denial of expedited resolution of an Appeal or if the
Grievance involves clinical issues and qualified to make denials
based on lack of medical necessity.
(2) Describe how the Contractor informs OHP Members, both orally and in writing,
about the Contractor’s Grievance procedures;
(3) Designate the Contractor’s staff member(s) or a designee who shall be responsible
for receiving, processing, directing, and responding to Grievances; and
(4) Include a requirement for Grievances to be documented in the log to be maintained
by the Contractor in a manner that is consistent with OAR 410-141-0266.
b. The Contractor shall provide OHP Members with any reasonable assistance in completing
forms and taking other procedural steps related to filing and disposition of a Grievance.
This includes, but is not limited to, providing interpreter services and toll free phone
numbers that have adequate TTY/TTD and interpreter capabilities.
c. The Contractor shall assure OHP Members that Grievances are handled in confidence
consistent with Exhibit D, Section 13.d of this Contract and with ORS 411.320, 42 CFR
431.300 et seq, the HIPAA Privacy Rules, the Oregon counterpart of HIPAA Privacy
Rules at ORS 192.518 to 192.524, and other applicable federal and state confidentiality
laws and regulations. The Contractor shall safeguard the OHP Member’s right to
confidentiality of information about the Grievance as follows:
(1) Contractor shall implement and monitor written policies and procedures to ensure
that all information concerning an OHP Member’s Grievance is kept confidential,
consistent with appropriate use or disclosure as Treatment, payment, or health care
operations of the Contractor, as those terms are defined in 45 CFR 164.501 and
ORS 192.519. As specified in OAR 410-141-0261 (3)(a), the Contractor and any
Provider whose Services, items or Quality of Care is alleged to be involved in the
Grievance have a right to use this information for purposes of the Contractor
resolving the Grievance, for purposes of maintaining the log required in OAR 410-
141-0266, and for health oversight purposes, without a signed authorization from
the OHP Member; and
(2) Except as provided in Paragraph (1) of this Subsection c, or as otherwise permitted
by all other applicable confidentiality laws, Contractor shall ask the OHP Member
to authorize a release of information regarding the Grievance to other individuals as
needed for resolution. Before any information related to the Grievance is disclosed
under this subsection, the Contractor shall have an authorization for release of
information documented in the Grievance file. Copies of the form for authorizing
the release of information shall be included in the Contractor’s written process.
d. The Contractor’s procedures shall provide for the disposition of Grievances within the
following timeframes:
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(1) The Contractor shall resolve each Grievance, and provide notice of the disposition,
as expeditiously as the OHP Member’s health condition requires, within the
timeframes established below;
(2) For standard disposition of Grievances and notice to the affected parties, within 5
working days from the date of the Contractor’s receipt of the Grievance, the
Contractor shall either:
(a) Make a decision on the Grievance and notify the OHP Member; or
(b) Notify the OHP Member in writing that a delay in the Contractor’s decision,
of up to 30 calendar days from the date the Grievance was received by the
Contractor, is necessary to resolve the Grievance. The written notice shall
specify the reasons the additional time is necessary.
e. The Contractor's decision about the disposition of a Grievance shall be communicated to
the OHP Member orally or in writing within the timeframes specified in Section 2,
Subsection d of this Exhibit:
(1) An oral decision about a Grievance shall address each aspect of the OHP Member’s
Grievance and explain the reason for the Contractor's decision;
(2) A written decision must be provided if the Grievance was received in writing. The
written decision on the Grievance shall review each element of the OHP Member’s
Grievance and address each of those concerns specifically, including the reasons
for the Contractor’s decision.
f. All Grievances made to the Contractor’s staff person designated to receive Grievances
shall be entered into a log and addressed in the context of Quality Improvement activity
(OAR 410-141-0200) as required in OAR 410-141-0266.
g. All Grievances that the OHP Member chooses to resolve through another process, and that
the Contractor is notified of, shall be noted in the Grievance log.
h. An OHP Members who is dissatisfied with the disposition of a Grievance may present the
Grievance to the DHS Ombudsman.
3. Contractor Appeal Procedures
a. The Contractor shall have a system in place for OHP Members that includes an Appeal
process. An Appeal means a request to the Contractor for review of an Action, and if the
Appeal is not resolved in favor of the OHP Member, includes the right to ask for and
Administrative Hearing by AMH to review of the Notice of Appeal Resolution. If the
OHP Member initiates an Appeal, it shall be documented in writing by the Contractor and
handled as an Appeal. If the OHP Member asks for an Administrative Hearing made to
AMH, the hearing request should be immediately transmitted to AMH’s Hearing Unit.
Upon notification by AMH after receipt of a hearing request, the Contractor must review it
through the Contractor’s Appeal procedures as provided for in Section 5 of this Exhibit
and OAR 410-141-0264.
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Contract #129162 Exhibit N Page 191 of 241
b. An Appeal must be filed with the Contractor no later than 45 calendar days from the date
on the Notice of Action required under OAR 410-141-0263. For service authorization
decisions not reached within the time frames established in 42 CFR 438.210(d) (which
constitutes a denial and is thus an adverse Action), an Appeal must be filed within 45
calendar days of the date that the time frames expire. If Contractor failed to provide a
timely Notice of Action, the Appeal may be filed no later than 45 calendar days after
Contractor actually mails its Notice of Action. Appeals reviewed by the Contractor upon
notification by AMH based on an Administrative Hearing Request form must be timely
filed as required under OAR 410-141-0264.
c. The OHP Member or OHP Member Representative, or a Provider acting on behalf of the
OHP Member with the Member’s written consent, may file an Appeal with the Contractor
either orally or in writing and, unless he or she requests expedited resolution, must follow
an oral filing with a written and signed Appeal.
d. Contractor shall adopt written policies and procedures for handling Appeals that, at a
minimum, meet the following requirements:
(1) Give OHP Members any reasonable assistance in completing forms and taking
other procedural steps related to filing and resolution of an Appeal. This includes,
but is not limited to, providing interpreter services and toll-free numbers that have
adequate TTY/TTD and interpreter capacity;
(2) Address how the Contractor will accept, process and respond to such Appeals,
including how the Contractor will acknowledge receipt of each Appeal;
(3) Ensure that OHP Members who receive a Notice of Action described in OAR 410-
141-0263 are informed of their right to file an Appeal or Administrative Hearing
request, and how to do so;
(4) Ensure that each Appeal is transmitted timely to staff that have authority to act on
it;
(5) Ensure that each Appeal is investigated and resolved in accordance with all
applicable rules; and
(6) Ensure that the individuals who make decisions on Appeals:
(a) Were not involved in any previous level of review or decision making; and
(b) Are Health Care Professionals who have the appropriate clinical expertise in
treating the OHP Member’s condition or disease, if an Appeal of a denial is
based on lack of Medical Appropriateness or if an Appeal involves clinical
issue.
(7) Document Appeals in the log to be maintained by the Contractor in a manner
consistent with the requirements of OAR 410-141-0266.
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Contract #129162 Exhibit N Page 192 of 241
e. The Contractor shall assure OHP Members that Appeals are handled in confidence
consistent with Exhibit D, Section 13.d and with ORS 411.320, 42 CFR 431.300 et seq, the
HIPAA Privacy Rules, the Oregon counterpart of HIPAA Privacy Rules at ORS 192.518 to
192.524, and other applicable federal and state confidentiality laws and regulations. The
Contractor shall safeguard the OHP Member’s right to confidentiality of information about
the Appeal as follows:
(1) Contractor shall implement and monitor written policies and procedures to ensure
that all information concerning an OHP Member’s Appeal is kept confidential
consistent with appropriate use or disclosure as Treatment, payment, or health care
operations of the Contractor, as those terms are defined in 45 CFR 164.501 and
ORS 192.519. The Contractor and any Provider whose authorization, Treatment,
Services, items, Quality of Care, or request for payment are alleged to be involved
in the Appeal have a right to use this information for purposes of resolving the
Appeal, for purposes of maintaining the log required in OAR 410-141-0266, and
for health oversight purposes by AMH, without a signed authorization from the
OHP Member. The information may also be disclosed to AMH if the OHP Member
requests an Administrative Hearing regarding the Appeal without a signed
authorization from the OHP Member, pursuant to OAR 410-141-0264;
(2) Except as provided in Paragraph (1), of this Subsection e, or as otherwise permitted
by all other applicable confidentiality laws, Contractor shall ask the OHP Member
to authorize a release of information regarding the Appeal to other individuals.
Before any information related to the Appeal is disclosed under this subsection, the
Contractor shall have an authorization for release of information documented in the
Appeal file.
f. The process for Appeals must:
(1) Provide that oral inquiries seeking to Appeal an Action are treated as Appeals with
a written notice to all affected parties within five (5) working days from the date of the
Contractor’s receipt of the Appeal (to establish the earliest possible filing date for the
Appeal) and must be confirmed in writing, unless the person making the Appeal
requests expedited resolution;
(2) Provide the OHP Member a reasonable opportunity to present evidence and
allegations of fact or law in person as well as in writing. (The Contractor shall
inform the OHP Member or the OHP Member Representative of the limited time
available in the case of an expedited resolution);
(3) Provide the OHP Member and the OHP Member Representative an opportunity,
before and during the Appeals process, to examine the OHP Member’s file,
including medical records and any other documents or records to be considered
during the Appeals process; and
(4) Include as parties to the Appeal, the OHP Member and the OHP Member
Representative, or the legal Representative of a deceased OHP Member’s estate;
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Contract #129162 Exhibit N Page 193 of 241
g. The Contractor shall resolve each Appeal and provide the notice of the Appeal resolution
described in Subsections (h) and (i) of this Section 3, as expeditiously as the OHP
Member’s health condition requires and within the time frames in this section:
(1) For the standard resolution of Appeals, the Contractor shall resolve the Appeal and
provide a notice of Appeal resolution to the OHP Member or OHP Member
Representative no later than 16 days from the day the Contractor receives the
Appeal. This timeframe may be extended pursuant to Paragraph (3) of this
Subsection g;
(2) When the Contractor has granted a request for expedited resolution of an Appeal,
the Contractor shall resolve the Appeal and provide a notice of Appeal resolution to
the OHP Member or OHP Member Representative no later than 3 working days
after the Contractor receives the Appeal. This timeframe may be extended pursuant
to Paragraph (3) of this Subsection g;
(3) The Contractor may extend the timeframes from Paragraphs (1) or (2) of this
Subsection g, by up to 14 calendar days if:
(a) The OHP Member requests the extension; or
(b) The Contractor shows (to the satisfaction of AMH, upon its request) that
there is need for additional information and how the delay is in the OHP
Member’s interest.
(4) If the Contractor extends the timeframes, it shall, for any extension not requested
by the OHP Member, give the OHP Member a written notice of the reason for the
delay.
h. For all Appeals, the Contractor shall provide written notice of Appeal resolution to the
OHP Member or the OHP Member Representative. For notice on an expedited resolution,
the Contractor shall also make reasonable efforts to provide oral notice.
i. The written notice of Appeal resolution must include the following:
(1) The results of the resolution process and the date it was completed; and
(2) For Appeals not resolved wholly in favor of the OHP Member, the notice must also
include the following information:
(a) Reasons for the resolution and a reference to the particular sections of the
statutes and administrative rules involved for each reason identified in the
notice of Appeal resolution relied upon to deny the Appeal;
(b) Unless the Appeal was referred to the Contractor from AMH as part of an
Administrative Hearing process, the right to request a AMH Administrative
Hearing and how to do so, which includes attaching the “Notice of Hearing
Rights (DMAP 3030) and the Hearing Request Form (DHS 443);
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Contract #129162 Exhibit N Page 194 of 241
(c) The right to continue to receive benefits pending an Administrative
Hearing;
(d) How to request the continuation of benefits, and
(e) If the Contractor’s action is upheld in an Administrative Hearing, the OHP
Member may be liable for the cost of any continued benefits.
(3) If the Appeal was referred to the Contractor from AMH as part of an
Administrative Hearing process, the Contractor must immediately (within two
business days) transmit the Notice of Appeal Resolution and the complete record of
the Appeal to the AMH Hearings Unit.
j. Contractor shall establish and maintain an expedited review process for Appeals,
consistent with OAR 410-141-0265.
k. Contractor shall maintain records of Appeals, enter Appeals and their resolution into a log,
and address the Appeals in the context of Quality Improvement activity (OAR 410-141-
0200) as required in OAR 410-141-0266.
l. Continuation of benefits pending Appeal and Administrative Hearing:
(1) As used in this section, “timely” filing means filing on or before the later of the
following:
(a) Within 10 calendar days after the Contractor mails the Notice of Action; or
(b) The intended effective date of the Contractor’s proposed Action.
(2) The Contractor shall continue the OHP Member’s benefits if:
(a) The OHP Member or OHP Member’s Representative files the Appeal or
Administrative Hearing request timely;
(b) The Appeal or Administrative Hearing request involves the termination,
suspension, or reduction of a previously authorized course of Treatment;
(c) The Services were ordered by an authorized Provider;
(d) The original period covered by the original authorization has not expired;
and
(e) The OHP Member requests extension of benefits.
(3) Continuation of benefits pending Administrative Hearing if, at the OHP Member’s
request, the Contractor continues or reinstates the OHP Member’s benefits while
the Appeal is pursuant to OAR 410-141-0264 in accordance with 42 CFR
438.420(c) the benefits must be continued until one of the following occurs:
(a) The OHP Member withdraws the Appeal; or
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Contract #129162 Exhibit N Page 195 of 241
(b) The OHP Member does not request an Administrative Hearing within 10
days from when the Contractor mails an adverse decision; or
(c) An Administrative Hearing decision adverse to the OHP Member is made;
or
(d) The authorization expires or authorization service limits are met.
m. If the final resolution of the Appeal after Administrative Hearing is adverse to the OHP
Member, that is, upholds the Contractor’s Action, the Contractor may recover from the
OHP Member the cost of the Services furnished to the OHP Member while the Appeal and
Administrative Hearing was pending, to the extent that they were furnished solely because
of the requirements of Section 3, Subsection l, Paragraph (2) of this Exhibit and in
accordance with the policy set forth in 42 CFR 431.230(b).
n. The Contractor shall promptly correct the Action taken up to the limit of the original
request or authorization, retroactive to the date the Action was taken, if the Contractor
decides in the OHP Member’s favor, even if the OHP Member has lost OHP eligibility or
the benefit package has changed after the date the Action was taken, including the
following:
(1) If the Contractor reverses a decision to deny, limit, or delay Services that were not
furnished while the Appeal and Administrative Hearing were pending, the
Contractor shall authorize or Provide, and shall pay for, the disputed Services
promptly, and as expeditiously as the OHP Member’s health condition requires.
(2) If the Contractor reverses a decision to deny authorization of Services, and the
OHP Member received the disputed Services while the Appeal and Administrative
Hearing were pending, the Contractor or AMH shall pay for the Services in
accordance with AMH policy and rules.
4. Notice of Action
a. When Contractor (or authorized subcontractor or Participating Provider acting on behalf of
the Contractor) takes or intends to take any Action (including, but not limited, to denials or
limiting prior authorizations of a requested Covered Service(s) in an amount, duration, or
scope that is less than requested, or reductions, suspension, discontinuation or termination
of a previously authorized Service), the Contractor (or authorized subcontractor or
Participating Provider acting on behalf of the Contractor) shall mail a written Notice of
Action in accordance with Section 4, Subsection b of this Exhibit to the OHP Member
within the timeframes specified in Section 4, Subsection c of this Exhibit.
b. The written Notice of Action must be an AMH approved format and it must be used for all
denials of a requested Covered Service(s), reductions, discontinuations or terminations of
previously authorized Covered Services, denials of claims payment, or other Action. The
Notice of Action must meet the language and format requirements in Exhibit B, Part III,
Section 1, entitled “Informational Materials and Education of OHP Members and Potential
OHP Members,” and must inform the OHP Member of the following:
(1) Relevant information including, but not limited to, the following:
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Contract #129162 Exhibit N Page 196 of 241
(a) Date of Notice of Action;
(b) Contractor name;
(c) Provider name;
(d) OHP Member’s name and ID number;
(e) Date of Service or item requested or provided;
(f) Who requested or provided the item or Service; and
(g) Effective date of the Action.
(2) The Action the Contractor or its subcontractor or Participating Provider has taken
or intends to take;
(3) Reasons for the Action, including, but not limited to, the following reasons:
(a) Treatment is not a Covered Service;
(b) The item requires pre-authorization and it was not pre-authorized;
(c) The Service is not Medically Appropriate;
(d) The Service or item is received in an emergency care setting and does not
qualify as an Emergency Service;
(e) The person was not an OHP Member at the time of the Service or is not an
OHP Member at the time of a requested Service; or
(f) The Provider is not on the Contractor’s panel and prior approval was not
obtained (if such prior authorization would be required under the Oregon
Health Plan Rules).
(4) A reference to the particular sections of the statutes and administrative rules
involved for each reason identified in the Notice of Action pursuant to Section 4,
Subsection b, of this Exhibit;
(5) The OHP Member’s right to file an Appeal or Administrative Hearing with the
Contractor and how to exercise that right as required in OAR 410-141-0262;
(6) The circumstances under which expedited Appeal resolution is available and how
to request it;
(7) The OHP Member’s right to have benefits continue pending resolution of the
Appeal or Administrative Hearing, how to request that benefit(s) be continued, and
the circumstances under which the OHP Member may be required to pay the costs
of these Services; and
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Contract #129162 Exhibit N Page 197 of 241
(8) The telephone number to contact the Contractor for additional information.
c. The Contractor or subcontractor or Participating Provider(s) acting on behalf of the
Contractor shall mail the Notice of Action within the following time frames:
(1) For termination, suspension, or reduction of previously authorized Covered
Services, the following time frames apply:
(a) The notice must be mailed at least 10 calendar days before the date of
Action, except as permitted under Section 4, Subsections c, Paragraph (1),
Items (b) or (c) of this Exhibit;
(b) The Contractor (or authorized subcontractor or Participating Provider acting
on behalf of the Contractor) may mail a notice not later than the date of
Action if:
(i) The Contractor, subcontractor or Participating Provider receives a
clear written statement signed by the OHP Member that he or she no
longer wishes Services or gives information that requires
termination or reduction of Services and indicates that he or she
understands that this must be the result of supplying the information;
(ii) The OHP Member has been admitted to an institution where he or
she is ineligible for Covered Services from the Contractor;
(iii) The OHP Member’s whereabouts are unknown and the post office
returns Contractor, subcontractor or Participating Provider’s mail
directed to him or her indicating no forwarding address;
(iv) The Contractor establishes the fact that another state, territory, or
commonwealth has accepted the OHP Member for OHP Services;
(v) There is a change in the level of medical care that is prescribed by
the OHP Member’s Provider;
(vi) The date of Action will occur in less than 10 calendar days, in
accordance with 42 CFR 483.12(a)(5), related to discharges or
transfers and long-term care facilities;
(vii) There is factual information confirming the death of the OHP
Member;
(viii) There is an adverse determination made with regard to the
preadmission screening requirements for Nursing Facility
admissions; or
(ix) The safety or health of individuals in the facility would be
endangered, the OHP Member’s health improves sufficiently to
allow a more immediate transfer or discharge, an immediate transfer
or discharge is required by the OHP Member’s urgent medical
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Contract #129162 Exhibit N Page 198 of 241
needs, or an OHP Member has not resided in the Nursing Facility
for 30 days (applies only to adverse actions for Nursing Facility
transfers).
(c) The Contractor may shorten the period of advance notice to 5 calendar days
before the date of the Action if the Contractor has facts indicating that an
Action should be taken because of probable fraud on the part of the OHP
Member. Whenever possible, these facts should be verified through
secondary sources.
(2) For denial of payment, at the time of any Action affecting the claim;
(3) For standard prior authorizations that deny a requested Service or that authorize a
Service in an amount, duration, or scope that is less than requested, the Contractor
shall provide Notice of Action as expeditiously as the OHP Member’s health
condition requires and within 14 calendar days following receipt of the request for
Service, except that:
(a) The Contractor may have a possible extension of up to 14 additional
calendar days if the OHP Member or the Provider requests the extension; or
if the Contractor justifies (to AMH upon request) a need for additional
information and how the extension is in the OHP Member’s interest;
(b) If the Contractor extends the timeframe, in accordance with Section 4,
Subsection c, Paragraph (3), Item (a) of this Exhibit, it shall give the OHP
Member written notice of the reason for the decision to extend the
timeframe and inform the OHP Member of the right to file a Grievance if he
or she disagrees with that decision. The Contractor shall issue and carry out
its prior authorization determination as expeditiously as the OHP Member’s
health condition requires and no later than the date the extension expires.
d. For prior authorization decisions not reached within the timeframes specified in Section 4,
Subsection c, Paragraph (3) of this Exhibit, (which constitutes a denial and is thus an
adverse Action), on the date that the timeframes expire;
e. For expedited prior authorizations, within the timeframes specified in OAR 410-141-0265.
5. Contractor Responsibilities in Relation to AMH Administrative Hearings
a. An individual who is or was an OHP Member at the time of the Notice of Action is entitled
to an Administrative Hearing by AMH if a Contractor that has denied requested services,
payment of a claim, or terminates, discontinues or reduces a course of treatment, or any
other Action.
(1) If the OHP Member initiates an Administrative Hearing directly with AMH, the
decision in the Notice of Action is the document that will trigger the right to
request a Administrative Hearing.
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Contract #129162 Exhibit N Page 199 of 241
(2) If the OHP Member requests an Administrative hearing after receiving a Notice of
Appeal Resolution, the decision in the Notice of Appeal Resolution is the document
that will trigger the right to request a state administrative hearing.
b. If, at the OHP Member’s request for an Appeal or Administrative Hearing, the Contractor
continued or reinstated Services while the Appeal was pending, the benefits must be
continued pending the Administrative Hearing until one of the following occurs:
(1) The OHP Member withdraws the request for an Administrative Hearing;
(2) A final order is issued in an Administrative Hearing adverse to the OHP Member;
or
(3) The time period or Service limits of a previously authorized Service have been met.
c. If the OHP Member files an Administrative Hearing Request form (DHS 0443) with
Contractor, Contractor shall immediately transmit the request to the AMH Hearings Unit.
Upon notification by AMH after receipt of the hearing request, Contractor must review the
request as an Appeal in accordance with Section 3 of this Exhibit.
d. If the OHP Member files an Administrative Hearing Request form (DHS 0443) with
AMH, AMH will promptly (within two (2) business days) send a copy of the
Administrative Hearing Request form , to the Contractor, and ask the Contractor to treat it
as an Appeal in accordance with Section 3 of this Exhibit.
e. The AMH Hearings Unit shall review each Administrative Hearing Request,
documentation related to the Administrative Hearing, and computer records to determine
whether the claimant or the person for whom the request is being made is or was an OHP
Member at the time the Action was taken, whether the Administrative Hearing request was
timely, and whether benefit continuation has been timely requested. If the AMH Hearings
Unit finds that the person for whom the review request was made is not an OHP Member
or that the Administrative Hearing request was untimely or that a request for continuation
of benefit was untimely, the AMH Hearings Unit follow the process described in OAR
410-120-1860(4).
f. The AMH Hearings Unit will refer the case to the Office of Administrative Hearings and
the hearing will be scheduled unless the OHP Member withdraws the request for review.
(1) The parties to the hearing include the Contractor, as well as the OHP Member and
the OHP Member Representative, or the Representative of a deceased OHP
Member’s estate.
(2) The procedures applicable to the hearing shall be conducted consistent with OAR
410-120-1865.
(3) A final order should be issued or the case otherwise resolved by AMH ordinarily
within 90 calendar days from the earlier of the following: the date the OHP
Member filed the Appeal request form with the Contractor or the date the OHP
Member filed the Hearing Request form. The final order is the final decision of
AMH.
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Contract #129162 Exhibit N Page 200 of 241
g. If the final resolution of the Administrative Hearing is adverse to the OHP Member, that is,
if the final order upholds the Contractor’s Action, the Contractor may recover the cost of
the Services furnished to the OHP Member while the Administrative Hearing is pending,
to the extent they were furnished solely because of the requirements of this section, and in
accordance with the policy set forth in 42 CFR 438.420.
f. The Contractor shall promptly correct the Action taken up to the limit of the original
request or authorization, retroactive to the date the Action was taken, if the Administrative
Hearing decision is favorable to the OHP Member, or AMH or the Contractor decides in
the OHP Member’s favor before the Administrative Hearing even if the OHP Member has
lost OHP eligibility or the benefit package has changed after the date the Action was taken,
including the following:
(1) If the Contractor, or an Administrative Hearing decision reverses a decision to
deny, limit, or delay Services that were not furnished while the Administrative
Hearing was pending, the Contractor shall authorize or provide, and shall pay for,
the disputed Services promptly, and as expeditiously as the OHP Member’s health
condition requires;
(2) If the Contractor, or the Administrative Hearing decision reverses a decision to
deny authorization of Services, and the OHP Member received the disputed
Services while the Administrative Hearing was pending, the Contractor shall pay
for the Services in accordance with AMH policy and regulations in effect when the
OHP Member made the request for Services.
6. Request for Expedited Appeal or Expedited Administrative Hearing
a. Contractor shall establish and maintain an expedited review process for Appeals, when the
Contractor determines (upon request from the OHP Member) or the Provider indicates (in
making the request on an OHP Member’s behalf or supporting the OHP Member’s request)
that taking the time for a standard resolution could seriously jeopardize the OHP Member’s
life, health, or ability to attain, maintain or regain maximum function.
b. The OHP Member, the OHP Member Representative or Provider may file an expedited
Appeal either orally or in writing. No additional OHP Member follow-up is required.
c. The Contractor shall ensure that punitive action is not taken against a Provider who
requests an expedited resolution or supports an OHP Member’s Appeal or Administrative
Hearing Request.
d. If the Contractor provides an expedited Appeal, but denies the Services or items requested
in the expedited Appeal, the Contractor shall transmit the denial decision to the AMH
Hearings Unit for review as an expedited hearing;
e. If the Contractor denies a request for expedited resolution on Appeal, it shall:
(1) Transfer the Appeal to the time frame for standard resolution in accordance with
OAR 410-141-0262; and
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit N Page 201 of 241
(2) Make reasonable efforts to give the OHP Member prompt oral notice of the denial,
and follow-up within two calendar days with a written notice. The written notice
must state the right of an OHP Member, who believes that taking the time for a
standard resolution of an Appeal and Administrative Hearing, could seriously
jeopardize the OHP Member’s life or health or ability to attain, maintain or regain
maximum function, to request an expedited Administrative Hearing.
e. The Contractor shall submit relevant documentation to AMH's Medical Director within, as
nearly as possible, two working days following the OHP Member’s expedited
Administrative Hearing request for a decision as to the necessity of an expedited
Administrative Hearing.
7. The Contractor’s Responsibility for Documentation and Quality Improvement Review of the
Grievance System
a. The Contractor’s documentation shall include, at minimum, a log of all oral and written
Grievances and Appeals received by the Contractor. The log shall identify the OHP
Member and the following additional information:
(1) For Grievances, the date of the Grievance, the nature of the Grievance, the
disposition and date of disposition of the Grievance;
(2) For Appeals, the date of the Notice of Action, the date of the Appeal, the nature of
the Appeal, whether continuing benefits were requested and provided, the
resolution and date of resolution of the Appeal. If an Administrative Hearing was
provided, whether continuing benefits were provided, and the effect of the final
order of the Administrative Hearing.
b. The Contractor shall also maintain a record, in a central location for each of the Grievances
and Appeals included in the log. The record shall include records of the review or
investigation and resolution, including all written decisions and copies of correspondence
with the OHP Member. The Contractor shall retain documentation of Grievances and
Appeals for 7 (years) to permit evaluation. This requirement survives the termination or
expiration of this Contract.
c. The Contractor shall have written procedures for the review and analysis of the Grievance
System, including all Grievances and Appeals received by the Contractor. The analysis of
the Grievance System shall be forwarded to the Quality Improvement committee as
necessary to comply with the Quality Improvement standards:
(1) Contractor shall monitor the completeness and accuracy of the written log, on a
monthly basis; and
(2) Contractor’s monitoring of Grievances and Appeals shall include, at minimum,
review of completeness, accuracy, timeliness of documentation, and compliance
with written procedures for receipt, disposition, and documentation of Grievances
and Appeals, and compliance with OHP rules
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit N – Attachment 1 Page 202 of 241
Exhibit N – Attachment 1 - Grievance Log
1. Grievance means an oral or written communication, submitted by an OHP Member or an OHP Member
Representative, which addresses issues with any aspect of the Contractor’s or Provider’s operations,
activities, or behavior that pertains to 1) the availability, delivery, or Quality of Care, including
Utilization review decisions, that are believed to be adverse by the OHP Member; or 2) the denial,
reduction, or limitation of Covered Services under this Contract. The expression may be in whatever
form or communication or language that is used by the OHP Member or the OHP Member
Representative, but must state the reason for the dissatisfaction and the OHP Member’s desired
resolution.
2. An OHP Member, or OHP Member Representative, may relate any incident or concern to Contractor,
Provider, or subcontractor, by indicating or expressing dissatisfaction or concern, or by stating this is a
Grievance that needs resolution.
3. Grievances are a source of information that may be used to evaluate the quality of access, Provider
service, clinical care, or Contractor Service to OHP Members. Contractor shall have written policies
and procedures for the thorough, appropriate and timely resolution of OHP Member Grievances, which
include:
a. Documentation of the nature of the Grievance which shall include, at minimum:
(1) A log of formal Grievances;
(2) A file of written formal Grievances, and
(3) Records of their resolution.
b. Analysis and investigation of the Grievance; and
c. Notification to the OHP Member of the disposition of the Grievance and the OHP Member’s
right to Appeal the outcome of the Grievance or handling of a Grievance.
4. Contractor shall complete and submit the Grievance Log on a quarterly basis within 60 calendar days of
the end of each calendar quarter. Contractor shall record each Grievance once on the Grievance Log. If
the Grievance covers more than one category, Contractor shall record the Grievance in the predominant
category.
5. Contractor shall send the Grievance Log to AMH, Medicaid Policy Unit, 500 Summer St. NE, E86,
Salem, OR 97301-1118.
6. If Contractor has questions about this report, Contractor may call the Quality Improvement Coordinator
at (503) 945- 9829.
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OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit O Page 204 of 241
Exhibit O – Enrollment Reconciliation
1. Contractor shall reconcile the DHS Enrollment transaction file, sent by DHS to
Contractor, monthly, to Contractor’s current OHP Member information in its Health
Information System (HIS) for the same period.
2. Contractor shall report to the designated AMH staff person, using the Enrollment
Reconciliation Certification Forms, which are attached hereto and incorporated herein by
this reference as Attachment, 1 to this Exhibit. Contractor’s determination that
discrepancies between each DHS Enrollment transaction file to Contractor’s HIS
Enrollment file do or do not exist shall report either:
a. That no discrepancy exists, using Attachment 1, Form 1, of the Enrollment
Reconciliation Certification, by completing, signing, dating and submitting to the
designated AMH staff person with 10 (ten) business days of receipt of DHS’
enrollment transaction file, or
b. That discrepancies do exist on Attachment 2, Form 2, of the Enrollment
Reconciliation Certification, by completing, signing, dating and submitting the
designated AMH staff person within 10 (ten) business days of receipt of DHS’
enrollment transaction file.
3. DHS will verify and correct, if found to be applicable, all discrepancies reported to DHS
on Attachment 2, Form 2, prior to the next enrollment transaction file.
4. The submission of Attachment 2, Form 2 by Contractor or its designated representative
will serve as notification to DHS of a discrepancy in OHP Member Enrollment file
generation or transmission. DHS will send to Contractor, all MMIS system Enrollment
information for each OHP Member specified on Attachment 1, Form 2 as having a
discrepancy between DHS’ database and the Contractor’s system. This is in order to
assist Contractor with claim system eligibility correction. (This will be a manual process
for AMH, until further notice.) AMH will deliver, via secure email sent to the
Contractor’s designated staff person, the corrections to the OHP Member Enrollment file,
prior to the next Enrollment transaction.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit O – Attachment 1 – Form 1 Page 205 of 241
Exhibit O – Attachment 1
Enrollment Reconciliation Certification – Form 1
Use this form when there are no discrepancies as described in the instructions to this form.
Contractor shall complete this Form 1 and submit to the designated AMH staff person within 10
(ten) business days from the receipt of DHS’ enrollment transaction file.
Contractor Name:
For month ending date:
I, the undersigned, hereby attest that I have determined that the DHS enrollment transaction file
and Contractor’s HIS enrollment files have no discrepancies, and I, hereby certify based on best
knowledge, information and belief that this determination submitted to DHS is accurate,
complete and truthful.
_____________________________ ________________________
Print Name Print Title
_____________________________ _______________________
Authorized Signature Date
* If you have the ability to send an “electronic signature document” please contact the designated
AMH staff person.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Exhibit O – Attachment 2 – Form 2 Page 206 of 241
Exhibit O – Attachment 2
Enrollment Reconciliation Certification – Form 2
Use this form when there are discrepancies as described in the instructions to this form.
Contractor shall complete this Form 2 and submit to the designated AMH staff person 10 (ten)
business days from the receipt of DHS’ enrollment transaction file.
Contractor Name:
For month ending date:
Specify Discrepancy:
OHP Client Prime Number OHP Client Name Identify Discrepancy
I, the undersigned, hereby attest that I have determined the DHS enrollment transaction file and
the Contractor’s HIS enrollment files have discrepancies that I have noted in this Form 2, and I,
hereby certify based on best knowledge, information and belief that this determination submitted
to DHS is accurate, complete and truthful.
_____________________________ ________________________
Print Name Print Title
_____________________________ _______________________
Authorized Signature Date
* If you have the ability to send an “electronic signature document” please contact the designated
AMH staff person.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 1 Page 207 of 241
Schedule 1 – Client Process Monitoring System (CPMS)
The CPMS tracks community-based treatment services for persons with mental illness, persons
with developmental disabilities, and persons with substance abuse problems. Information from
this system is combined with other information from other systems to create one integrated
database under a single unique client identifier. The integrated database contains Consumer
specific data across programs statewide and provides a Continuity of Care picture for individual
Consumers. This information allows AMH to manage publicly funded mental health services,
respond to legislative inquiries, and demonstrate cost effectiveness under the federal requirement
for the OHP.
Contractor shall submit CPMS data for OHP Members consistent with the CPMS Manual
Instructions.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 1 Page 208 of 241
Data Element
Treatment Begin
Treatment
End
Reported Quarterly
Client County of Residence
X
Clinic or Service Provider
X
Date of Birth
X
Diagnosis
X
X
Education
X
Employment Status
X
Gender
X
Level of Functioning
X
X
X
Living Arrangement
X
MHIS Number
X
Name, Birth
X
Name, Full
X
Plan or Contractor Identifier
X
Presenting Dangers
X1
Prime Number
X
Provider or Clinic Case No.
X
Race/Ethnicity
X
Referred From
X
Termination Referral
X
Termination Type/Reason
X
Data element to be reported upon end of Urgent/Emergency Service only.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.1 Page 209 of 241
Schedule 2.1 – Procedure for Long Term Psychiatric Care Determinations for OHP Members 18 to 64
Actor Action
Contractor 1. Determines whether the situation of the OHP Member meets both of
the following criteria:
a. There is a need for either Intensive Psychiatric Rehabilitation
or other Tertiary Treatment in a State Hospital or Extended
Care Program, or Extended and Specialized Medication
Adjustment (psychotropic) in a secure or otherwise highly
supervised environment; and
b. The OHP Member has received all Usual and Customary
Treatment including, if Medically Appropriate, establishment
of a medication program and use of a Medication Override
Procedure.
2. If the situation of the OHP Member meets both criteria listed above in
step 1, does the following with assistance from Acute Inpatient
Hospital Psychiatric Care or Subacute Psychiatric Care or Other
Inpatient Services staff:
a. Contacts the AMH ECMU Long Term Care Coordinator at
(503) 947-5542, during normal business hours (Monday
through Friday, 8 a.m. to 5 p.m.).
b. Completes a Request for LTPC Determination for Persons
Age 18 to 64 (request form).
c. Obtains the following documents:
(1) Physician's history and physical;
(2) Copies of legal documents (hospital hold, commitment
paperwork or appoint of guardian);
(3) Current medications, dosages, and length of time on
medication;
(4) Reports of other Consultations;
(5) Psychosocial histories; and
(6) Current week's physician and progress notes.
3. Sends, by facsimile, the request form and supporting documents to
the AMH ECMU Screener at (503)947-5542, Attention: ECMU
Long Term Care Coordinator.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.1 Page 210 of 241
Actor Action
ECMU Long Term Care
Coordinator
4. Within three working days of receiving a completed request form,
does the following:
a. Reviews the request form and documentation for compliance
with criteria for LTPC with the following facilities:
(1) OSH, Portland Campus;
(2) OSH, Salem Campus;
(3) Blue Mountain Recovery Center;
(4) Efficacious alternatives in the community.
b. If necessary, visits the Acute Care Inpatient Hospital Care or
Subacute Care or Other Inpatient Psychiatric Services facility
to interview staff and the OHP Member.
c. Indicates determination and, if authorized for LTPC, the date
of authorization on the form.
d. Discuss findings, determination and placement alternatives
with the Contractor.
5. Sends, by facsimile, the completed request form including
determination and rationale to Contractor.
Contractor
6. If the OHP Member does not meet LTPC criteria and is denied
services or if the OHP Member is found appropriate for LTPC but on
a date other than that specified in Exhibit B, Part II, Section 1,
Subsection c, Paragraph (10) (c) (i) of this Contract, Contractor shall
do one of the following:
a. Agree with the ECMU Long Term Care Coordinator’s
decision and provide appropriate Treatment or initiates
transfer of the OHP Member to a Setting recommended as of
the specified date; or
b. Disagree with the ECMU Long Term Care Coordinator’s
decisions and requests an expedited clinical review within
three working days of the denial. This request must be in
writing and contain documentation in accordance with Step
2.c. of this Section to AMH via facsimile at (503) 378-8467.
AMH 7. If the Contractor requests a clinical review, sends, by facsimile, the
request form and documentation submitted by the Contractor in
accordance with Step 2.c. of this Exhibit to the Clinical Reviewer.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.1 Page 211 of 241
Actor Action
Clinical Reviewer
8. Does the following within three working days of receiving the
clinical review packet:
a. Reviews all documentation submitted by the Contractor in
accordance with Step 2.c. of this Exhibit
b. Decides whether the OHP Member is appropriate for LTPC.
c. Determines the effective date of LTPC as specified in Exhibit
B, Part II, Section 1, Subsection c, Paragraph (10) (c) of this
Contract, if applicable.
d. Updates the request form.
e. Notifies, by phone, the Contractor, AMH and the ECMU
Long Term Care Coordinator of the determination.
f. Sends, by facsimile, the completed request form to the
Contractor, AMH and the ECMU Long Term Care
Coordinator.
ECMU Long Term Care
Coordinator
9. If the OHP Member is found appropriate for LTPC, coordinates with
the physician and admission staff the transfer to the Setting
recommended as of the date specified.
AMH 10. If transfer to the LTPC Setting will not occur on the date the OHP
Member is appropriate for LTPC, DHS will assume payment
responsibility for charges related to the Acute Inpatient Hospital
Psychiatric or Other Inpatient Services stay from the effective date of
LTPC until the OHP Member is discharged from such Setting. The
responsibility for payment is subject to the terms and conditions of
the Contract between AMH and each acute Inpatient Hospital.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.1 Page 212 of 241
Determination
Patient's Name:
Prime No.:
Referral Date:
Name of Clinical Decision Maker:
Date of Determination:
□ Approved
□ Denied
Approval Date:
Date Patient Admitted to State Hospital:
Criteria for Long Term Psychiatric Inpatient Care
□ Primary DSM Diagnosis is severe psychiatric disorder
□ Documented need for 24-hour hospital level medical supervision
□ At least one of the following conditions is met:
□ Need for extended (more than 21 days) regulation of medications due to significant complications
arising from severe side effects of medications.
□ Need for continued treatment with electroconvulsive therapy where an extended (more than 21
days) inpatient environment is indicated and the inappropriateness of a short-term or less
restrictive treatment program is documented in the Clinical Record.
□ Continued actual danger to self, others or property that is manifested by at least one of the
following:
□ The OHP Member has continued to make suicide attempts or substantial (life-threatening)
suicidal gestures or has expressed continuous and substantial suicidal planning or
substantial ongoing threats.
□ The OHP Member has continued to show evidence of danger to others as demonstrated by
continued violent acts to person or imminent plans to harm another person.
□ The OHP Member has continued to show evidence of severe inability to care for basic
needs but has potential for significant improvement with treatment.
□ Failure of intensive extended care services evidenced by documentation in the Clinical Record of:
□ An intensification of symptoms and/or behavior management problems beyond the
capacity of the extended care service to manage within its programs; and
□ Multiple attempts to manage symptom intensification or behavior management problems
within the local Acute Inpatient Hospital Psychiatric Care unit.
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Contract #129162 Schedule 2.1 Page 213 of 241
Outcome of Clinical Review
Upheld
Name of Clinical Reviewer:
Reversed
Transfer Date:
Date of Decision:
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Contract #129162 Schedule 2.1 Page 214 of 241
Request for Long Term Psychiatric Care Determination for Persons Ages 18 to 64
Request
Contractor:
Referral Date:
OHP Member Name:
DOB:
Prime No (Required):
DSM
Axis I
DSM
Axis II
DSM
Axis III
Admission Date:
Proposed Transfer
Date:
Basis for Request (NOTE: All documents must be attached.)
There is a need for either:
Intensive Psychiatric Rehabilitation or other Tertiary Treatment in an State Hospital or
Extended Care Program, or
Extended and Specialized Medication Adjustment (psychotropic) in a secure or otherwise
highly supervised environment; and
The OHP Member has received all Usual and Customary Treatment including, if Medically
Appropriate, establishment of a medication program and use of a Medication Override
Procedure.
Documentation Supporting Request (NOTE: All documents must be attached.)
Physician's history and physical
List of current medications, dosages and length of time on medication
Reports of other Consultations
Social histories
Current week's progress notes
Analysis of Documentation Supporting Request
Update 10/02
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.2 Page 215 of 241
Schedule 2.2 – Procedure for Long Term Psychiatric Care
Determinations for OHP Members 17 and Under
Actor Action
Contractor
1. If the length of stay might exceed Usual and Customary Treatment,
consults with the following regarding a potential need for LTPC:
a. For OHP Members age 17 and under, the AMH
Representative;
2. Determines whether the situation of the OHP Member meets the
criteria listed in step 5.a.
3. If the situation of the OHP Member meets such criteria, does the
following with assistance from Acute Inpatient Hospital Psychiatric
Care or Psychiatric Residential Treatment Services (PRTS) staff:
a. For OHP Members age 17 and under, contacts the AMH
Representative during normal business hours (Monday
through Friday, 8 a.m. to 5 p.m.).
b. Completes a Request for LTPC Determination for Persons
Age 17 and Under which includes the following
documentation:
· The child or adolescent has been referred for ICTS,
date and provider;
· A copy of the current Service Coordination plan;
· A current Child and Adolescent Service
· Intensity Instrument (CASII and ECSII) score.
c. Obtains the following documents:
(1) Face Sheet (from current medical record)
(2) Physician's history and physical;
(3) List of current medications, dosages, and length of
time on medication;
(4) Reports of other Consultations;
(5) Current psychosocial Assessment;
(6) Two weeks of current progress notes;
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Contract #129162 Schedule 2.2 Page 216 of 241
Actor Action
Contractor (cont.)
(7) Current psychological Assessment; if determined
Medically Appropriate ;
(8) Current psychiatric Assessment;
(9) Psychiatric care admission history;
(10) Psychiatrist note recommending level of care; and
(11) Completed consent for release of information from the
most recent residential or PRTS facility in which the
child resided.
4. Sends, by facsimile, the request form and supporting documents to
the AMH Representative.
NOTE: Steps 5 through 11 are completed within seven working days of
receiving a completed request form.
AMH Representative
5. Does the following:
a. Completes an initial screening to decide whether the
Community Coordinating Committee (CCC) LTPC screening
criteria is met. Such criteria includes the following:
(1) The primary DSM Axis I Diagnosis is from the OHP
Prioritized List of Health Services;
(2) There is documented evidence that the child has not
responded to all Usual and Customary Treatment in an
Acute Inpatient Hospital Psychiatric Care Setting or
PRTS level of care; and
(3) There is documented evidence that the child’s
psychiatric symptoms have intensified beyond the
capacity of the Acute Inpatient Hospital or PRTS level
of care; or
(4) In exceptional circumstances a child may be screened
who is not currently in an Acute Care Hospital or
current functioning and documentation of prior
treatment and treatment oriented placements indicate
placement into Acute Care of Psychiatric Residential
Treatment will benefit the child;
(5) There is a documented need for 24-hour hospital level
medical supervision under the direction of a
psychiatrist in order to effectively treat the primary
Diagnosis; and
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Contract #129162 Schedule 2.2 Page 217 of 241
Actor Action
AMH Representative (cont.)
(6) The current CASII and ECSII score indicates a level
of acuity that requires inpatient care.
b. If necessary, visits the Acute Inpatient Hospital Psychiatric
Care or PRTS facility to interview staff and the OHP
Member.
c. If CCC LTPC screening criteria is met, and allocates time to
attend the CCC LTPC screening.
d. If CCC LTPC screening criteria is not met, notifies Contractor
and CCC Chairperson.
CCC Chairperson 6. Schedules a CCC LTPC screening in conjunction with the AMH
Representative.
7. Collects and distributes documentation necessary for the CCC LTPC
screening
8. Invites the CCC LTPC screening persons who possess information
needed to make the LTPC determination and develop the CCC Care
Path Plan. Such persons may include Contractor, Family members of
the OHP Member or legal guardian, and/or treatment providers.
CCC
9. Conducts the CCC LTPC screening.
a. Determine whether admission criteria is met.
b. Identifies efficacious community placement alternatives.
c. Discusses findings, alternatives and determination with the
Contractor and the AMH Representative.
d. Notes the final determination.
e. If admission criteria are met, does the following:
(1) Establishes an admission date and time; and
(2) Develops a CCC Care Path Plan.
f. If admission criteria are not met, determines an appropriate
plan of care.
g. Completes the CCC LTPC Determination for Persons Age 17
and Under form by indicating findings, determination and
planned admission date, if applicable.
10. If the OHP Member is found appropriate for LTPC, sets the effective
date of LTPC as specified in Exhibit B, Part II, Section 1, Subsection
c, Paragraph (10) (c) (i) of this Contract.
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Contract #129162 Schedule 2.2 Page 218 of 241
Actor Action
CCC (cont.)
Sends, by facsimile, the completed CCC LTPC Determination for Persons
Age 17 and Under form to Contractor.
Contractor 11. If the OHP Member is not found appropriate for LTPC or found
appropriate on a date other than the date described in step 10, does
the following:
a. Decides whether to accept the decision.
b. If the decision is not accepted, requests a clinical review
within three working days of receiving notice of the screening
decision. Sends a written request and documentation
submitted in accordance with Step 3.c. of this Exhibit to
AMH, Child and Adolescent Services Section via facsimile at
(503) 378-8467
c. If the decision is accepted, either provides appropriate
Treatment or initiates transfer of the OHP Member to the
Setting recommended as of the date specified.
AMH 12. If a clinical review is requested, send, by facsimile, the request form
and documentation submitted by Contractor in accordance with Step
3.c. of this Exhibit to the Clinical Reviewer.
Clinical Reviewer 13. Does the following within five working days of receiving the clinical
review packet:
a. Reviews all forms and documentation submitted by
Contractor in accordance with Step 3.c. of this Exhibit.
b. Decides whether the OHP Member is appropriate for LTPC.
c. Determines the effective date of LTPC as specified in
V.B.3.i.(3)(a) of this Contract, if applicable.
d. Updates the CCC LTPC Determination form.
e. Notifies by phone, Contractor and AMH Representative of the
determination.
f. Sends, by facsimile, the completed CCC LTPC Determination
form to Contractor and the AMH Representative.
AMH 14. If transfer to LTPC will not occur on the date the OHP Member is
appropriate for LTPC, DHS assumes payment responsibility for
charges related to the Acute Inpatient Hospital Psychiatric stay from
the effective date of LTPC until the OHP Member is discharged from
such Setting.
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Contract #129162 Schedule 2.2 Page 219 of 241
Request for Long Term Psychiatric Care Determination for Persons Age 17 and Under
REQUEST
Child’s Name:
Referral Date:
Parent/Guardian:
Address:
Phone:
City:
County:
Child’s Medicaid Prime No:
Child’s SS#:
Contractor:
DOB:
Current Program:
Admission Date:
DOCUMENTATION SUPPORTING REQUEST:
Referral for ICTS, provider and date of referral
Code:
A copy of the current Service Coordination plan
Code:
A recent Child and Adolescent Service Intensity Instrument (CASII or
ECSII) score
Code:
CLINICAL DOCUMENTS :
□ Physician history and physical;
□ List of current medications, dosages, and length of time on medication;
□ Reports of other Consultations;
□ Current psychosocial Assessment;
□ Current week’s progress notes;
□ Current psychological Assessment (if Medically Appropriate);
□ Completed consent for release of information from the most recent residential or PRTS
facility in which the child resided;
□ Current psychiatric Assessment; and
□ Psychiatric care admission history.
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Contract #129162 Schedule 2.2 Page 220 of 241
SUMMARY OF REASONS FOR REQUEST
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.2 Page 221 of 241
Long-Term Psychiatric Care Determination for Persons Age 17 and Under
Child’s Name:
Mental Health Organization:
Name of AMH Representative:
Name of CCC Chairperson:
CRITERIA FOR LONG TERM PSYCHIATRIC INPATIENT CARE
□ Primary DSM Axis I Diagnosis is from the Prioritized List of Health Services
□ Documented evidence that the child has not responded to all Usual and Customary
Treatment in an Acute Inpatient Hospital Psychiatric Care or PRTS level of care Setting
□ Documented evidence that the child’s psychiatric symptoms have intensified beyond the
capacity of the Acute Inpatient Hospital Psychiatric Care or PRTS level of care Setting
□ Documented need of 24-hour hospital level medical supervision under the direction of a
psychiatrist in order to effectively treat the primary Diagnosis
□ Current CASII and ECSII score indicates a level of acuity that requires secure inpatient
psychiatric care
OUTCOME OF CCC CLINICAL SCREENING
□ Documented evidence that multiple efforts in Treatment approach have been made to manage the
OHP Member’s symptoms and/or behavior in a PRTS program AND the OHP Member could
reasonably be expected to benefit over a short period of time from an increased staffing ratio or
psychiatric management allowing them to remain in the PRTS setting.
OR:
□ The OHP Member is demonstrating emotional and/or behavioral difficulty managing the transition
process from SAIP or SCIP to PRTS AND it can be reasonably expected that the OHP Member will
benefit from additional staffing or increased psychiatric management during the brief period
ensuring a more successful transition.
Outcome of CCC Clinical
Screening
Approved
SCIP
SAIP
STS
Date of Decision:
Start of Care Date:
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.2 Page 222 of 241
Community Coordinating Committee
Care Path Plan
Child’s Name:
DISCHARGE PLAN AND CRITERIA
If LTPC admission criteria are met, include a written plan for discharge to the least restrictive
appropriate Setting with specific discharge criteria linked to resolution of symptoms and behaviors that
justified admission.
SERVICES RECOMMENDED
If LTPC admission criteria are not met, describe services that are recommended.
Signature of AMH Representative Date:________________
Signature of CCC Chairperson Date:
Update 01-09
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.3 Page 223 of 241
Schedule 2.3 – Procedure for Long Term Psychiatric Care Determinations
for OHP Members Requiring Geropsychiatric Treatment
Actor Action
Contractor
1. Determines whether the situation of the OHP Member meets both
of the following criteria:
a. There is a need for either Intensive Psychiatric
Rehabilitation or other Tertiary Treatment in a State
Hospital (or for adults Extended Care Program), or
Extended and Specialized Medication Adjustment
(psychotropic) in a secure or otherwise highly supervised
environment; and
b. The OHP Member has received all Usual and Customary
Treatment including, if Medically Appropriate,
establishment of a medication program and use of a
Medication Override Procedure.
2. If the situation of the OHP Member meets both of the criteria
listed in step 1, determines whether the OHP Member is eligible
for OSH-GTS. To be eligible for these services, the DMAP
Member must be:
a. Age 65 or over, or
b. Ages 18 to 64 and have significant nursing care needs
(e.g., must be bathed, dressed, groomed, fed, and toileted
by staff) due to an Axis III disorder of an enduring nature.
3. With the assistance of Acute Inpatient Hospital Psychiatric Care or
Subacute Psychiatric Care or Other Inpatient Services staff, does
the following:
a. Contacts the OSH Geropsychiatric Outreach and
Consultation Service (OCS) at (503) 945-7136, Monday
through Friday, 8:00 a.m. to 5:00 p.m.;
b. Obtains the Request for Long-Term Care Determination
for Persons Requiring Geropsychiatric Treatment (request
form) from the OSH GTS staff;
c. Assess OHP Member’s capacity to provide informed
consent. If OHP Member is determined unable to provide
informed consent, take appropriate action towards Civil
Commitment for OHP Members not already protected by
guardianship.
d. Obtains all supporting documents listed on the request
form.
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Contract #129162 Schedule 2.3 Page 224 of 241
Actor Action
Contractor (cont.)
4. Sends, by facsimile, the request form and documents to the OSH
Geropsychiatric OCS Screener at (503) 945-2807.
OCS Screener 5. Within three working days of receiving a completed request form,
does the following:
a. Reviews the request form and documentation for
compliance with criteria for LTPC for persons requiring
OSH-GTS.
b. If necessary, visits the Acute Inpatient Hospital Psychiatric
Care or Subacute Psychiatric Care or Other Inpatient
Services facility to interview staff and the OHP Member.
c. Discusses findings, determination, and placement
alternatives with Contractor or Contractor Representative
(i.e., the person who sent the request form or other person
designated on the request form).
d. Indicates findings, determination, and effective date of
LTPC as specified in Exhibit B, Part II, Section 1,
Subsection c, Paragraph (10) (c) (iii) of this Contract on
the request form.
6. If the OHP Member is found appropriate for LTPC at OSH-GTS,
works with OSH-GTS, Contractor, and the Acute Inpatient
Hospital Psychiatric Care or Subacute Psychiatric Care or Other
Inpatient Services facility to set the OSH-GTS admission date and
to coordinate such admission.
7. Sends, by facsimile, the completed request form to Contractor and
requester. Also, forwards a copy of the request form to the
Institutional Revenue Section of DHS.
Contractor
8. If the OHP Member is not found appropriate for LTPC at OSH-
GTS, or is found appropriate on a date other than the date
specified in step 5.d., does one of the following:
a. Accepts the decision of the OCS Screener and provides
appropriate Treatment. Works with Acute Inpatient
Hospital Psychiatric Care or Subacute Psychiatric Care or
Other Inpatient Services staff, Senior and Disabled
Services DHS staff, and in some cases, Enhanced Care
Services staff to develop a plan for continued care and
Treatment.
If the decision is not accepted, requests a clinical review within
three working days of receiving notice of the LTPC determination.
Sends a written request and documentation specified in Step 3.d.
of this Exhibit to the AMH via facsimile at (503) 378-8467.
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Contract #129162 Schedule 2.3 Page 225 of 241
Actor Action
AMH 9. If Contractor requests a clinical review, sends, by facsimile, the
request form and documentation submitted by Contractor in
accordance with Step 3.d. of this Exhibit to the Clinical Reviewer.
Clinical Reviewer 10. Does the following within three working days of receiving the
clinical review packet:
a. Reviews all documentation submitted by Contractor in
accordance with Step 3.d. of this Exhibit.
b. Decides whether the OHP Member is appropriate for
LTPC.
c. Determines the effective date of LTPC as specified in
Exhibit B, Part II, Section 1, Subsection c, Paragraph (10)
(c) of this Contract, if applicable.
d. Updates the request form.
e. Notifies by phone: Contractor, AMH and the OCS
Screener of the determination.
f. Sends, by facsimile, the completed request form to
Contractor, AMH and the OCS Screener.
OCS Screener 11. If the OHP Member is found appropriate for LTPC, coordinates
with the physician and admission staff the transfer to the Setting
recommended as of the date specified.
AMH 12. If transfer to the LTPC Setting will not occur on the effective date
of LTPC, DHS assumes payment responsibility for charges related
to the Acute Inpatient Hospital Psychiatric or Other Inpatient
Services stay from the effective date of LTPC until the OHP
Member is discharged from such Setting
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.3 Page 226 of 241
Request for Long-Term PsychiatricCare Determination for Persons Requiring Geropsychiatric
Treatment
REQUEST
Contractor:
Referral Date:
OHP Member Name:
DOB:
Referral Agent:
DSM
Axis I
DSM
Axis II
DSM Axis III
Admission
Date:
Prime Number:
BASIS FOR REQUEST (NOTE: All criteria must be met.)
□ OHP Member is 65 or older or OHP Member is 64 or younger AND has significant nursing care
needs (e.g., must be fed, dressed, groomed, bathed, and toileted by staff) AND these needs arise
from an Axis III disorder of an enduring nature (e.g., Alzheimer's, Huntington's, TBI, CVA)
(Note: A person 64 or under whose nursing care needs arise from acute decompensation of an Axis
I disorder or are the result of behavioral noncompliance would not be admitted to GTS and should
be referred to ECMU.)
□ There is a need for either:
□ Intensive Psychiatric Rehabilitation or other Tertiary Treatment in an State Hospital or
Extended Care Program, or
□ Extended and Specialized Medication Adjustment (psychotropic) in a secure or otherwise
highly supervised environment; and
□ The OHP Member has received all Usual and Customary Treatment, including if Medically
Appropriate, establishment of a medication program and use of a Medication Override
Procedure.
DOCUMENTATION SUPPORTING REQUEST
(NOTE: All documents must be attached and must document the basis for request criteria.)
Physician's history and physical Diagnostic Test results and Lab reports
List of current medications, dosages Guardianship or Civil Commitment documents (if
and length of time on medication applicable)
Reports of other Consultations Civil Commitment investigation report (if available)
Social histories ADL Assessment (if available)
Current week’s progress notes Advance Directive (if available)
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.3 Page 227 of 241
Please summarize the reason why the patient needs LTPC.
ANALYSIS OF DOCUMENTATION SUPPORTING REQUEST
(Remainder of form to be completed by Gero Outreach staff.)
DETERMINATION
Patient's Name:
Prime No.:
Approved
Date of
Determination:
Name of Clinical Decision Maker:
Denied
Date Patient Admitted to OSH-GTS:
CRITERIA FOR LONG TERM GEROPSYCHIATRIC INPATIENT CARE
□ Person is 65 or older or person is 64 or under and meets nursing care criteria.
□ Person has a psychiatric/neurological disorder causing severe behavioral disturbances with need for
24 hour hospital level medical supervision.
□ At least one of the following conditions is met:
□ Need for extended (more than 21 days) regulation of medications due to significant
complications arising from severe side effects of medications.
□ Need for continued Treatment with electroconvulsive therapy where an extended (more
than 21 days) inpatient environment is indicated and the inappropriateness of a short-term
or less restrictive treatment program is documented in the Clinical Record.
□ Continued actual danger to self, others or property that is manifested by at least one of the
following:
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 2.3 Page 228 of 241
□ The OHP Member has continued to make suicide attempts or substantial life-threatening
behavior or has expressed continuous and substantial suicidal planning or substantial
ongoing threats.
□ The OHP Member has continued to show evidence of danger to others as demonstrated by
continued destructive acts to person or imminent plans to harm another person.
□ For OHP Members 65 and over ONLY: The OHP Member has continued to show evidence
of severe inability to care for basic needs due to significant decompensation of an Axis I
Diagnosis.
□ Failure of intensive Enhanced Care Services evidenced by documentation in the Clinical Record
of:
□ An intensification of symptoms and/or behavior management problems beyond the capacity
of the Enhanced Care Service to manage within its programs; and
□ A minimum of one attempt to manage symptom intensification or behavior management
problems within the local Acute Inpatient Hospital Psychiatric Care unit.
□ Has received all Usual and Customary Treatment including, if Medically Appropriate,
establishment of a medication program and use of a Medication Override Procedure. Has
received medical evaluation and stabilization of acute medical problems.
OUTCOME OF CLINICAL REVIEW
Upheld
Name of Clinical Reviewer:
Reversed
Transfer Date:
Date of Decision:
Update 10/02
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 3 Page 229 of 241
Schedule 3 – Oregon Patient/Resident Care System
The Oregon Patient/Resident Care System (OP/RCS) contains information on all Consumers
served at any of the state psychiatric hospitals, developmental disability training centers and
psychiatric Acute Care facilities.
1. Contractor shall cooperate with AMH in establishing the electronic means to enter
OP/RCS data at the hospital or facility providing Acute Inpatient Hospital Psychiatric
Care Services under this Contract.
a. Contractor shall provide AMH with a list of hospitals to be used in delivering
Acute Inpatient Hospital Psychiatric Care.
b. Contractor shall identify the name, title and phone number of the person within
each hospital with whom AMH will work to establish the computer hook-up to
OP/RCS.
c. Contractor shall identify the names, titles and phone numbers of persons within
each hospital with whom AMH will work to maintain the accuracy, timeliness
and completeness of OP/RCS data submission.
d. Contractor shall work with AMH and hospital contact person in designating a
physically secure (locked doors and limited access) location (floor and room
number within hospital) of the stand alone computer to be used to enter OP/RCS
data.
e. Contractor shall assure that hospital contact persons comply with confidentiality
requirements contained in 45 CFR Parts 160 and 164, Subparts A and E, to the
extent that they are applicable, and consistent with other state law or federal
regulations governing privacy and confidentiality of mental health information,
sign the request for access/assurance of confidentiality form, and return the form
to AMH.
2. Contractor or its subcontractors shall electronically submit, within 12 hours of admission
to Acute Inpatient Hospital Psychiatric Care, OP/RCS information for Acute Inpatient
Hospital Psychiatric Care Services provided to OHP Members as indicated in the
following table.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 3 Page 231 of 241
Data Element Admission Discharge
Commitment Type Code 1 X
County of Residence X
County of Responsibility X
County of Discharge X
County of Commitment X
Date of Commitment X
Date of Admission/Discharge X X
Date of Diagnosis X
Date of Birth X
Discharge Reason Code X
Driving Status X
DSM, Axis V Diagnoses X
DSM, Axis IV Diagnoses X
DSM, Axis I Diagnoses X X
DSM, Axis III Diagnoses X X
DSM, Axis II Diagnoses X X
Education Level Achieved X
Ethnic Category Code X
1The Commitment Type Code is changed/updated as applicable.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 3 Page 232 of 241
Data Element Admission Discharge
Living Arrangement Code X X
Marital Status Code X
Name X
Name, Alias X
Oregon Driver's License Number X
ORS Reference Numbers X
Patient Number X
Referral Source Code X X
Sex X
Social Security Number X
Status of Harm to Property X
Status of Harm to Others X
Status of Suicide X
Status of Harm to Self (Non-Suicide) X
Time of Admission/Discharge X X
Time of Commitment X
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 4 Page 233 of 241
Schedule 4 – Level of Service Intensity Determination Data
Contractor shall use CASII as the statewide tool to assist in the determination for ISA Services for children age
six (6) and older and the ECSII for children birth to five (5).
Contract shall submit a report to AMH, within sixty (60) calendar days after the end of each calendar
quarter of the Level of Need Determination screenings completed in that quarter.
□ 1st Quarter (Jan-Mar) □ 2nd Quarter (Apr-Jun)
□ 3rd Quarter (Jul-Sep) □ 4th Quarter (Oct-Dec)
Formatting CASII and ECSII data for submission to AMH:
Data shall be in a comma-delimited format;
Each child shall be represented by a Medicaid ID number and Level of Need Determination Date;
Complete Data Set : A complete data set will be comprised of a minimum of the following elements:
Eight alphanumeric character Medicaid ID number
Child’s date of birth 00/00/0000)
Child’s gender
Date of referral
Referral Source
Date of Determination
Contractor
Scores for CASII Domains I to VI-B (each score must be in the range 1-5) or ECSII Domains I to V.
Composite CASII score or ECSII score.
ISA eligibility Y/N (circle one).
Levels of Care recommended – (Note: Base the recommended level of care on both CASII or ECSII
data and other data indicative of the child’s and family’s needs and/or functioning
Date the child is determined not to be ISA eligible or the last day the child is considered ISA eligible.
Field will be blank if the child continues to be ISA eligible. A blank field will be considered complete.
Instructions for submission and validation of Level of Service Intensity Determination data shall be
provided by AMH as a separate document.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 5 Page 234 of 241
Schedule 5 - Signature Authorization Form
Contractually required reporting information submitted to AMH must be certified by one of the following:
1. Chief Executive Officer, or similar top executive officer of the Contractor, however designated (CEO);
2. Chief Financial Officer, or similar top financial officer of the Contractor, however designated (CFO); or
3. An individual who has delegated authority to sign for and reports directly to the CEO or CFO.
Print name and title of CEO or CFO Signature Date
This form shall be due upon effective date of this Contract.
* Grievance Systems, including Appeal Form (created by Contractor) and Notice of Denial Letter,
* Third Party Resources and Personal Injury Lien Policy and Procedures,
* Utilization Management Policies and Procedures,
* OHP Member Information Materials, including Member Handbook and Annual Notification to OHP
Members Regarding Ability to Participate in Activities of Contractor,
* Policy and Procedure: CASII and ECSII Administration,
* Policy and Procedure for Level of Service Intensity Determination,
* Policy and Procedure for Prevention and Detection of Fraud, Waste and Abuse, and
* Policy and Procedure for Credentialing.
As CEO/CFO/Contractor I authorize the following designated person(s) to certify AMH contractually required
reporting:
Full name and title of the person(s) other than the CEO, CFO or Contractor identified above who has delegated
authority to sign for and who reports directly to the CEO, CFO or Contractor and to certify the data and
information submitted to DHS:
Print Name and Title Print Name and Title
Signature Date Signature Date
Telephone number Telephone number
(Submit more than one form if more than two persons are delegated to complete the Contractually
Required Reporting Form).
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 5.1 Page 235 of 241
Schedule 5.1 - Attestation of Revision and Submission of Contractually Required Reporting
I, an authorized official of Contractor, certify that the contractually required reporting itemized below have been
reviewed for compliance and content for this Contract period. In so certifying, Contractor is certifying that the
documents in question below have experienced no further revisions from the last submission to and approval by
AMH.
Signature ________________________________________________
Document Date of Original
review and
approval by
AMH
Current
Contract Year
No Revisions
Made -
Authorized
Signatory
Notes
Grievance Systems
Notice of Action
(Boilerplate)
Appeal Form, created by
Contractor pursuant to
CFR 438.400-424
Third Party
Resource/Personal Injury
Lien Policies
&Procedures
Utilization Management
Policies &Procedures
OHP Member
Information Materials and
Plan Member Handbook
Please specify type of
document, eg. Brochure,
etc.
CASII and ECSII
Administration Policies
&Procedures
Level of Service Intensity
Determination Policies
&Procedures
Prevention/Detection of
Fraud, Waste and Abuse
Policies & Procedures
Credentialing Policies &
Procedures
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 6 Page 236 of 241
Schedule 6 – Key Personnel
Contractor shall submit to AMH, on the effective date of this Contract and immediately following
any changes. Information shall include names, telephone numbers, email address and fax number
for the following key personnel: CEO/CFO/Contractor, Director/Manager, Medical Director (if
applicable), Operations Manager (if applicable), Contract Liaison, Quality Assurance/Quality
Improvement Liaison, Children’s Coordinator, Grievance Systems Liaison, Long Term Psychiatric
Care Liaison and Other.
Contractor Contractor Contact Persons
Contractor Name
Address (Mailing and Location, if different)
Telephone Number
Fax Number
Plan Email address (if applicable)
Fiscal Year:
Service
Area
(County)
Plan
No.
(M#)
Client
Access
Phone
No.
ITT/TTY/Oregon
Access No.
CEO/CFO/Contractor
Telephone, Fax and
email
Director/Manager
Telephone, Fax and
email
Operations Manager,
(if applicable)
Telephone, Fax and
email
Medical Director,
(if applicable)
Telephone, Fax and
email
Contract Liaison
Telephone, Fax
and email
Quality
Assurance/Quality
Improvement
Liaison
Telephone, Fax
and email
Administrative
Assistant (or
applicable title)
Telephone, Fax
and email
Children’s
Coordinator
Telephone,
Fax and email
Adult
Coordinator
Telephone,
Fax and email
Grievance
Systems
Liaison
Telephone,
Fax and email
Long Term
Psychiatric
Care Liaison
Telephone,
Fax and email
Other,
(if applicable)
Telephone,
Fax and email
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 7 Page 237 of 241
Schedule 7 – Integrated Service Array (ISA) Progress Review Report
The ISA Progress Review is to be administered for each child found eligible for ISA services
upon admission and discharge to that level of service. A child shall be reviewed no less than
annually, should the child remain in ISA longer than one (1) year.
Submit data at least once every 90 days. Due 60 calendar days following the end of the
calendar quarter.
Complete Data Set: A complete data set will be comprised of the following elements:
1. Child’s last name, first name.
2. Child’s date of birth (00/00/0000).
3. Date ISA Progress Review was completed using 00/00/0000 format.
4. ISA status of child at time of progress review:
“New”, first review.
“Open”, continuing review.
“Close”, final review.
5. Child’s current residence:
Biological/adoptive family member.
Other than relative/friend (Not foster care).
Long-term foster care placement.
Temporary foster care placement.
Residential treatment center.
Other (include statement describing type of residence).
6. Number of times child changed residence for any reason within the last 90 days.
a. Indicate the number of times that the child has changed residence, for any reason,
in the past 90 calendar days. Do not include planned respite. Do not include
Acute Care hospitalizations. Do not include vacations or recreational stays with
friends or relatives that are unrelated to changes in the child’s condition or the
Family’s circumstances. Do include any planned or unplanned stay with friends
or relatives, if the stay lasted more than seven (7) days and was: (a) precipitated
by a worsening of the child’s condition, a change in the Family’s circumstances,
or increased stress in the child’s environment and; (b) the parent or legal guardian
was made aware of and permitted the stay. (Note: Unplanned stays with others not
permitted by the parent or legal guardian should be regarded as runaways rather
than changes of residence). Each time that a child moves out of and then back to,
his or her primary residence is counted as two (2) moves.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 7 Page 238 of 241
b. Parent or legal guardian were made aware of and permitted to stay. Each time that
a child moves out of and back to his/her primary residence, count as two (2) stays.
7. Did parent or adult caregiver participate in current and most recent Child and Family
Team (CFT) meeting? (Include those whose primary role with child is that of paid
provider of services, i.e. clinical, educational or case management services.)
8. Caregiver Rating:
a. Social network over the past thirty (30) calendar days:
(1) No family or social network that could help with raising the child.
(2) Some family or friend social network that could help with raising the
child.
(3) Some family or friend social network that actively helps with the raising
of the child.
(4) Significant family and friend social network that actively helps with
raising the child.
(5) NK (Not Known).
b. Child has been producing schoolwork of acceptable quality for his or her ability
level over the past twenty (20) scheduled school days:
(1) Never.
(2) Seldom.
(3) Sometimes.
(4) Frequently.
(5) Very Frequently or Always.
(6) Not applicable (if child has not been in school over past 20 days).
c. Substance abuse over the past thirty (30) days:
0. None.
1. Suspicion of substance abuse.
2. Clear evidence of substance abuse that is interfering with child’s ability to
function in at least one role or setting.
3. Clear evidence of substance dependence and / or child requires
detoxification.
d. Risk of delinquency in consideration of all acts of delinquency (misdemeanors,
felonies and all status offenses except runaways), with or without awareness by
legal authorities:
0. No History.
1. None in past thirty (30) days.
2. Some in past thirty (30) days.
3. Several in past thirty (30) days.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 7 Page 239 of 241
e. Risk of self-harm (includes reckless or intentional risk taking behavior that may
endanger the child):
0. No history.
1. None in past thirty (30) days.
2. None in past thirty (30) days.
3. Several in past thirty (30) days.
f. History of and risk of danger to others:
0. No history.
1. None in past thirty (30) days.
2. Some in past thirty (30) days.
g. History and risk of running away:
0. No history.
1. None in past thirty days.
2. Some in past thirty (30) days.
3. Several in past thirty (30) days.
9. Behavioral and Emotional Rating Scale, 2 nd Edition (Bers2) Parent/Caregiver Rating
Scale, Raw Scores of Subscales.
Formatting the ISA Progress Review Data for Submission to AMH:
Instructions for submission of the ISA Progress Review Report data shall be provided by AMH
as a separate document.
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 8 Page 240 of 241
Schedule 8 – OHP Services Not Covered Due to Moral or
Religious Reasons Certification Form
As per 42 CFR 438.102, Contractor is not required to provide coverage or reimburse a counseling or referral
service if Contractor objects to the service on moral or religious grounds. Contractor shall notify AMH if there
are any services not provided by the Contractor due to moral or religious reasons or if there is no limitation on
services. Contractor shall provide this notification on the effective date of this Contract. or implementation of a
newly adopted policy. If Contractor has not changed its policy regarding provision of services since the
beginning of the preceding contract year, it shall so notify AMH by submission of this Schedule 8.
I certify that Contractor:
Does not limit the Services provided to OHP Member due to moral or religious reasons, or
Does limit the Services provided to OHP Members due to moral or religious reasons. The following
arrangements are made to facilitate receipt of such Services for OHP Members:
Full name and title of the person(s) other than the CEO or CFO who has delegated authority to sign for and who
reports directly to the CEO or CFO and to certify the information submitted to DHS:
Print Name and Title Print Name and Title
Signature Date Signature Date
Telephone number Telephone number
(Submit more than one form if more than two persons are delegated to complete this Certification Form)
OHP – Mental Health Organization Effective: January 1, 2010
Contract #129162 Schedule 9 Page 241 of 241
Schedule 9 – Subcontracted Activities
On the effective date of this Contract, Contractor shall notify AMH, in writing of activities to be
subcontracted and the entities performing such subcontracted activities. Contractor shall provide
a list which shall include the subcontractor, address, phone number, email address, name of
executive director and activities to be performed. Place an asterisk (*) by those agencies who are
at-risk, subcapitated entities. Contractor shall notify AMH in writing of changes to this list
within thirty (30) calendar days of such change.
Contractor subcontracts the following activities.(Please assign an item number to each
activity):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Subcontracted
Activity – Insert all
item numbers that
apply to each
Agency.
Name of
Administrator or
Executive Director
Agency Name Contact
Information-
Address, Phone
Number