HomeMy WebLinkAboutMental Health CDO Agreement2009 OREGON HEALTH PLAN
PROVIDER SERVICES CONTRACT
CHEMICAL DEPENDENCY ORGANIZATION
Contract # 126667
with
DESCHUTES COUNTY
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Table of Contents Page 2 of 242
Table of Contents
I. Effective Date and Duration........................................................................................................................5
II. Contract in its Entirety.................................................................................................................................5
III. Status of Contractor.....................................................................................................................................6
IV. Service Area.................................................................................................................................................7
V. Enrollment Limits........................................................................................................................................7
VI. Interpretation and Administration of Contract.............................................................................................7
VII. Government Status.......................................................................................................................................8
VIII. Contractor and Data Certification................................................................................................................9
IX. Signatures...................................................................................................................................................11
EXHIBIT A - Definitions......................................................................................................................................12
EXHIBIT B –Statement of Work ..........................................................................................................................18
EXHIBIT B –Statement of Work – Part I - Benefits.............................................................................................19
1. Capitated Services..........................................................................................................................19
2. Plus and Standard Benefit Packages of Covered Services.............................................................19
3. Authorization of Covered Services................................................................................................20
4. Covered Service Detail..................................................................................................................23
5. Emergency and Urgent Care Services ...........................................................................................23
6. Chemical Dependency...................................................................................................................26
EXHIBIT B –Statement of Work – Part II – Providers and Delivery System ......................................................29
1. Delivery System Configuration.....................................................................................................29
2. Adjustments in Service Area or Enrollment..................................................................................34
3. Quality and Performance Improvement Requirements..................................................................36
4. Credentialing..................................................................................................................................41
EXHIBIT B –Statement of Work – Part III – Members........................................................................................42
1. Informational Materials and Education of DMAP Members and Potential DMAP Members......42
2. DMAP Member Rights..................................................................................................................43
3. Grievance System..........................................................................................................................44
4. Enrollment and Disenrollment.......................................................................................................45
5. Identification Cards........................................................................................................................51
6. Marketing.......................................................................................................................................51
EXHIBIT B –Statement of Work – Part IV – Financial Matters...........................................................................53
1. Financial Risk, Management and Solvency...................................................................................53
2. Dual Payment.................................................................................................................................56
3. Claims Payment.............................................................................................................................56
EXHIBIT B –Statement of Work – Part V – Operations.......................................................................................58
1. Record Keeping .............................................................................................................................58
2. [Reserved]......................................................................................................................................59
3. Encounter Data...............................................................................................................................59
4. (Reserved)......................................................................................................................................60
EXHIBIT B –Statement of Work – Part VI – Relationship of Parties..................................................................61
1. DMAP Compliance Review ..........................................................................................................61
2. Sanctions........................................................................................................................................61
EXHIBIT C – Consideration .................................................................................................................................65
1. Payment Types and Rates..............................................................................................................65
2. Payment in Full..............................................................................................................................66
3. Changes in Payment Rates.............................................................................................................66
4. Timing of Capitation Payments.....................................................................................................67
5. Settlement of Accounts..................................................................................................................68
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EXHIBIT C – Consideration - Attachment 1 – Calculation of Capitation Payments ...........................................70
EXHIBIT C – Consideration - Attachment 2 – Capitation Rates..........................................................................71
EXHIBIT D – Standard Terms and Conditions.....................................................................................................72
1. Controlling State Law/Venue ........................................................................................................72
2. Compliance with Applicable Laws and Rules...............................................................................72
3. Independent Contractor..................................................................................................................72
4. Representations and Warranties.....................................................................................................73
5. Funds Available and Authorized ...................................................................................................73
6. Changes/Ownership.......................................................................................................................74
7. Indemnification..............................................................................................................................75
8. Events of Default...........................................................................................................................76
9. Remedies for Default.....................................................................................................................78
10. Termination....................................................................................................................................78
11. Limitation of Liabilities.................................................................................................................80
12. Insurance........................................................................................................................................81
13. Access to Records and Facilities....................................................................................................81
14. Information Privacy/Security/Access............................................................................................82
15. Force Majeure................................................................................................................................82
16. Successors in Interest.....................................................................................................................83
17. Subcontracting...............................................................................................................................83
18. No Third Party Beneficiaries.........................................................................................................87
19. Amendments..................................................................................................................................87
20. Severability....................................................................................................................................88
21. Waiver............................................................................................................................................88
22. Notices...........................................................................................................................................88
23. Construction...................................................................................................................................88
24. Headings/Captions.........................................................................................................................89
25. Merger............................................................................................................................................89
26. Tort Claims....................................................................................................................................89
27. Counterparts...................................................................................................................................89
28. Equal Access..................................................................................................................................89
EXHIBIT E - Required Federal Terms and Conditions.........................................................................................90
1. Miscellaneous Federal Provisions..................................................................................................90
2. Prevention and Detection of Fraud and Abuse..............................................................................90
3. Equal Employment Opportunity....................................................................................................90
4. Clean Air, Clean Water, EPA Regulations....................................................................................90
5. Energy Efficiency..........................................................................................................................91
6. Truth in Lobbying..........................................................................................................................91
7. HIPAA Compliance.......................................................................................................................91
8. Resource Conservation and Recovery...........................................................................................92
9. Audits.............................................................................................................................................92
10. Debarment and Suspension............................................................................................................92
11. Drug-Free Workplace....................................................................................................................93
12. Pro-Children Act............................................................................................................................94
13. Medicaid Services..........................................................................................................................94
14. Agency-based Voter Registration..................................................................................................94
15. Clinical Laboratory Improvements................................................................................................94
16. Advance Directives........................................................................................................................95
17. Office of Minority, Women and Emerging Small Businesses.......................................................95
18. Practitioner Incentive Plans (PIP)..................................................................................................95
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19. Risk HMO......................................................................................................................................96
20. Conflict of Interest Safeguards......................................................................................................96
21. Non-Discrimination.......................................................................................................................97
22. OASIS............................................................................................................................................97
23. Patient Rights Condition of Participation......................................................................................97
24. Federal Grant Requirements..........................................................................................................97
25. Provider’s Opinion.........................................................................................................................98
EXHIBIT F – Insurance Requirements..................................................................................................................99
EXHIBIT G – Solvency Plan and Financial Reporting.......................................................................................101
EXHIBIT G – Attachment 1 Form G.1 ...............................................................................................................147
EXHIBIT G – Attachment 2 - Report G.1 – Restricted Reserves.......................................................................148
EXHIBIT G – Attachment 3 - Report G.2 – DMAP Member Approaching or Surpassing Stop-Loss Deductible151
EXHIBIT G – Attachment 4 - Reserved..............................................................................................................152
EXHIBIT G – Attachment 5 - Report G.4 – OHP Access to Services Statistics ................................................153
EXHIBIT G – Attachment 6 - Report G.4.1 – OHP Chemical Dependency Service Utilization .......................154
EXHIBIT G – Attachment 7 - Report G.5 – Audited Yearly Balance Sheet of Corporate Activity...................155
EXHIBIT G – Attachment 8 - Report G.6 – Audited Yearly Statement of Revenue, Expenses & Net Worth...157
EXHIBIT G – Attachment 9 - Report G.7 – Quarterly Balance Sheet of Corporate Activity ............................159
EXHIBIT G – Attachment 10 - Report G.8 – Quarterly Statement of Revenue, Expenses & Net Worth..........161
EXHIBIT G – Attachment 11 - Report G.8.1 – Net Worth Adjusted Medical Loss Ratio.................................163
EXHIBIT G – Attachment 12 - Report G.8.2 – OHP Medical Loss Ratios........................................................164
EXHIBIT G – Attachment 13 - Report G.9 – Cash Flow Analysis Corporate Activity/Indirect Method...........165
EXHIBIT G – Attachment 14 - Report G.10 – Corporate Relationships of Contractors....................................167
EXHIBIT G – Attachment 15 - Report G.11.......................................................................................................171
EXHIBIT G – Attachment 16 - Report G.12 – Physician Incentive Plan Disclosure Form – Contractor
Relationships........................................................................................................................................................172
EXHIBIT G – Attachment 17 – Report G.13 – Disclosure of Compensation.....................................................175
EXHIBIT H - Encounter Data Minimum Data Set Requirements and Corrective Action..................................176
EXHIBIT H – Attachment 1 - Data Certification and Validation.......................................................................190
EXHIBIT H – Attachment 2 - Form H.2 – Signature Authorization Form.........................................................191
EXHIBIT H – Attachment 3 - Form H.3 – Data Certification and Validation Report Form*............................192
EXHIBIT H – Attachment 4 - Form H.4 – Claim Count Verification Acknowledgement and Action Form.....193
EXHIBIT I – Third Party Resources and Personal Injury Liens.........................................................................194
EXHIBIT J - Prevention and Detection of Fraud and Abuse ..............................................................................198
EXHIBIT K – Provider Capacity Report.............................................................................................................205
EXHIBIT K – Attachment 1 - Form K.1 – Data Certification Form...................................................................211
EXHIBIT L – Member Grievances/Appeals Report ...........................................................................................212
EXHIBIT M – Physician Incentive Plan Regulation Guidance...........................................................................214
EXHIBIT N – Grievance System ........................................................................................................................220
EXHIBIT O – Enrollment Reconciliation...........................................................................................................235
EXHIBIT O – Attachment 1 - Enrollment Reconciliation Certification – Form 1 .............................................236
EXHIBIT O – Attachment 1 - Enrollment Reconciliation Certification – Form 2 .............................................237
SCHEDULE 1 – CDO – Performance Measure – Assessed Pregnant Women For CDO Services....................238
SCHEDULE 2 – Performance Improvement Projects.........................................................................................239
SCHEDULE 2 – Attachment 1 - Form 2.1 – The Collaborative PIP Instructions ..............................................240
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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
CHEMICAL DEPENDENCY ORGANIZATION
This Contract is between the State of Oregon, acting by and through its Department of Human
Services hereinafter referred to as “DHS”, and
Deschutes County
2577 NE Courtney Drive
Bend, OR 97701
hereinafter referred to as “Contractor”.
Work to be performed under this Contract relates principally to the DHS’
Division of Medical Assistance Programs (DMAP)
500 Summer Street NE
Salem, Oregon 97301
Contract Administrator: Katrina Gonzales, MCO Policy Analyst
Phone: 503-945-6919
Fax: 503-947-5221
katrina.m.gonzales@state.or.us
I. Effective Date and Duration
A. 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, 2009 whichever date is later. Unless extended or terminated earlier
in accordance with its terms, this Contract shall expire on December 31, 2009.
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.
B. Contractor shall give DMAP not less than 60 days notice of its intent to not proceed
with a renewal contract prior to December 31, 2009.
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 Data Minimum Data Set Requirements and Corrective Action
Exhibit I: Third Party Resources and Personal Injury Liens
Exhibit J: Prevention and Detection of Fraud and Abuse
Exhibit K: Provider Capacity Report
Exhibit L: Member Grievances Appeals Report
Exhibit M: Physician Incentive Plan Regulation Guidance
Exhibit N: Grievance System
Exhibit O: Enrollment Reconciliation
Schedule 1: CDO Performance Measure Submission Form
Schedule 2: Performance Improvement Projects (PIP)
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 or a non-profit
corporation organized under the laws of Oregon, which is serving as a Chemical
Dependency Organization (CDO ) under this Contract.
B. Contractor shall not provide prepaid health services on a capitated basis to any
persons other than DMAP Members, unless Contractor meets all statutory and
regulatory requirements as a Health Care Service Contractor under ORS Chapter
750.005(4).
C. Contractor designates:
Jeff Emrick, LCSW, CADC III
2577 NE Courtney Drive
Bend, Oregon 97701
Phone: 541-602-1663
Fax: 541-322-7565
Email: Jeff_Emrick@co.deschutes.or.us
as the point of contact pursuant to Exhibit D, Section 22 of this Contract. Contractor
shall notify DMAP in writing of any changes to the designated contact.
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IV. Service Area
The Service Area is the geographic area in which DMAP Members or Potential DMAP
Members reside and for whom the Contractor is authorized to provide Capitated Services
under this Contract. Contractor’s designated Service Area is listed in Part V, below.
V. Enrollment Limits
A. Contractor’s maximum enrollment limit by Service Area is:
12,000 for Deschutes County
The maximum enrollment limit established in this section is expressly subject to
such additional enrollment as may be authorized in Exhibit B, Part III, Section 4, of
this Contract; however, such additional authorized enrollment does not create a new
maximum enrollment limit.
B. Contractor’s total maximum enrollment limit for the entire Service Area is 12,000
under this Contract, subject to such additional enrollment as may be authorized in
Exhibit B, Part III, Section 4 of this Contract; however, such additional authorized
enrollment does not create a new total maximum enrollment limit.
VI. Interpretation and Administration of Contract
A. DMAP 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 DMAP needs to look outside of this Contract, including its exhibits,
schedules and attachments, for purposes of interpreting its terms, DMAP will
consider only the following sources in the order of precedence listed:
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 Demonstration Project), and the Health Insurance
Flexibility and Accountability (HIFA) demonstration, including all special
terms and conditions and waivers.
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2. The Federal Medicaid Act, Title XIX of the Social Security Act, and its
implementing regulations, except as waived by CMS for the OHP Medicaid
Demonstration Project, the HIFA demonstration and the State Children’s
Health Insurance Program (SCHIP), established by Title XXI of the Social
Security Act as amended and as administered in Oregon by DHS.
3. The Oregon Revised Statutes (ORS) concerning the OHP.
4. The Oregon Administrative Rules (OAR) promulgated by DMAP to
implement the Oregon Health Plan program.
5. Other applicable Oregon statutes and OARs concerning the Medical
Assistance Program.
C. If Contractor believes that any provision of this Contract or DMAP’s interpretation
thereof, is in conflict with federal or State statutes or regulations, Contractor shall
notify DMAP in writing immediately.
D. Except as otherwise expressly provided in this Contract, Contractor shall have a right
to a review of any DMAP actions or decisions concerning the Contractor’s
responsibilities under this Contract by requesting Administrative Review as provided
in OAR 410-120-1580(4)-(5).
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:
Federal Tax I.D.#
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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CONTRACTOR, BY EXECUTION OF THIS CONTRACT, HEREBY ACKNOWLEDGES
THAT CONTRACTOR HAS READ THIS CONTRACT, UNDERSTANDS IT, AND
AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS.
BY EXECUTION OF THIS CONTRACT, I, AN AUTHORIZED OFFICIAL OF
CONTRACTOR CERTIFY THAT ALL DATA, CLAIMS SUBMISSIONS OR OTHER
SUBMISSIONS THAT PROVIDE A BASIS FOR CAPITATION PAYMENTS ARE TRUE,
ACCURATE AND COMPLETE; AND ACKNOWLEDGE THAT PAYMENT OF CLAIMS
AND CAPITATION PAYMENTS WILL BE FROM FEDERAL AND STATE FUNDS, AND
THAT THEREFORE ANY FALSIFICATION, OR CONCEALMENT OF A MATERIAL
FACT WHEN SUBMITTING CLAIMS OR OTHER SUBMISSIONS TO OBTAIN
PAYMENTS, MAY BE PROSECUTED UNDER FEDERAL AND STATE LAWS.
CONTRACTOR: YOU WILL NOT BE PAID FOR SERVICES RENDERED PRIOR TO
NECESSARY STATE APPROVALS.
IX. Signatures
CONTRACTOR
By
Authorized Date
Title
DHS - DIVISION OF MEDICAL ASSISTANCE PROGRAMS
By
DMAP Deputy Director Date
Approved as to Legal Sufficiency:
Electronic approval by: Theodore C. Falk, Senior Assistant Attorney General, on
November 18, 2008, email in Contract file.
Reviewed by DHS - DMAP Contract Administrator:
By
Katrina Gonzales, MCO Policy Analyst Date
Reviewed by DHS-Office of Contracts & Procurement:
By
Tammy L. Hurst, Contract Specialist Date
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit A Page 12 of 242
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) 410-120-0000, 410-120-1160 and 410-141-0000. The order of
preference for interpreting conflicting definitions is this Contract, (following the order of precedence in
Section VII), Oregon Health Plan Rules of DHS and General Rules of DHS. The following terms shall
have the following meanings when capitalized:
1. “Action,” when capitalized, 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
DMAP Member who resides in a rural Service Area where Contractor is the only Chemical
Dependency Organization (CDO), 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.
2. “Administrative Hearing,” means a hearing related to an Action, including a denial,
reduction, or termination of benefits that is held when requested by the DMAP Member or it’s
Representative. An Administrative Hearing may also be held when requested by a DMAP
Member or it’s Representative who believes a Claim for services was not acted upon with
reasonable promptness or believes the payor took an Action erroneously.
3. “Appeal,” when capitalized, means a request by a DMAP Member or Representative, or by a
Provider acting on behalf of the DMAP Member with the Member’s written consent, for
Contractor to review an Action as defined in this section.
4. “Benefit Group” means the people listed on the OHP application form and determined to be
eligible to receive Covered Services available through the Funded Benefit Package.
5. “Business Day” means any day except Saturday, Sunday or a legal holiday. The word "day"
not qualified as Business Day means calendar day.
6. “Capitated Payment” or “Capitation Payment” means a monthly prepayment to Contractor
for the provision of Capitated Services provided on behalf of DMAP Members. Capitation
payment is made on a per DMAP Member, per month basis. Capitation Payment does not
include any payment made to a Fully Capitated Health Plan as a supplemental incentive
payment under a Physician Access Improvement Plan Demonstration Project.
7. “Capitated Services” means those Covered Services that Contractor agrees to provide in the
Statement of Work, Exhibit B, Part I through VI of this Contract, in exchange for a Capitation
Payment.
8. “Chemical Dependency Services” means assessment, treatment and rehabilitation on a
regularly scheduled basis, or in response to crisis for alcohol and/or other drug abusing or
dependent clients and their family members or significant others that are consistent with Level I
or Level II of ASAM PPC 2R patient placement criteria established in OAR 415-015-0005(2).
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9. “CFR” means Code of Federal Regulations.
10. “Claim” means (1) a bill for services, (2) a line item of a service, or (3) all services for one
recipient within a bill.
11. “CMS” means Centers for Medicare and Medicaid Services of the United States Department of
Health and Human Services.
12. “Contract Year” means this Contract term beginning on the Contract Effective Date and
ending on December 31, 2008. If this Contract is renewed or extended, separate Contract years
begin on January 1 and ends on the following December 31, unless this Contract expires or is
otherwise terminated.
13. “Contractor” means the entity identified on page 1 of this Contract as “Contractor” and
includes any officers, employees, agents and representatives of the Contractor.
14. “Corrective Action” or "Corrective Action Plan" means a DMAP initiated request for
Contractor to develop and implement a time specific plan, that is acceptable to DMAP, for the
correction of DMAP identified areas of noncompliance, as described in Exhibit H, Encounter
Data Minimum Data Set Requirements and Corrective Action, Schedule 4, Pharmacy Data
Requirements and Corrective Action, and in Exhibit B, Part VI, Section 2, Sanctions.
15. “Covered Services” are Medically Appropriate Chemical Dependency services that are funded
by the Legislature and described in: ORS 414.705 to 414.750; OAR 410-120-1210, Medical
Assistance Benefit Packages and Delivery System; 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 Plus and Standard Benefit
Package of Covered Services; except as excluded or limited under OAR 410-141-0500,
Excluded Services and Limitations for OHP Clients.
16. “Department of Human Services” or “DHS” means the Department of Human Services
established in ORS Chapter 409, including such divisions, programs and offices as may be
established therein. Where the former Seniors and People with Disabilities (SPD) is used in this
Contract or in rule, it shall mean the Seniors and People with Disabilities Division (SPD).
Where the former Children, Adults and Families (CAF) is used in this Contract or rule, it shall
mean the Children, Adults and Families Division (CAF). Where the former Health Division is
used in this Contract or rule, it shall mean the Public Health Division (PHD).
17. “DMAP Member” means an OHP Client who is currently enrolled with Contractor.
18. “Disenrollment” means the act of discharging a DMAP Member from Contractor’s
responsibility under this Contract. After the effective date of Disenrollment an OHP Client is
no longer required to obtain Capitated Services from Contractor, nor be referred by Contractor
for Medical Case Managed Services.
19. “Employer-Sponsored Insurance” (ESI) means an employer sponsored health benefit plan in
which the employer contribution is in accordance with ORS 735.724(5), and the health benefit
plan meets the applicable eligibility criteria of OAR 442-004-0050(2)(f).
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20. “Funded Benefit Package” means the condition/treatment pairs that are above the funding line
on the Prioritized List of Health Services as approved by the Oregon Legislature.
21. “Grievance” is a DMAP Member's or Representative's expression of dissatisfaction to
Contractor or to a Participating Provider about any matter other than an Action, as “Action” is
defined in this section.
22. “Grievance System” refers to the overall system that includes Grievances and Appeals
handled at the Contractor level and access to the Administrative 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 DMAP Member's rights.)
23. “Health Care Professionals” 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), dentists, osteopathic
physicians, psychologists, registered nurses, nurse practitioners, licensed practical nurses,
certified medical assistants, licensed physician assistants, qualified mental health professionals
(QMHPs), qualified mental health associates (QMHAs), dental hygienists, denturists, and
certified dental assistants. These professionals may conduct health, mental health or dental
assessments of DMAP Members and provide screening services to OHP Clients within their
scope of practice, licensure or certification.
24. “Health Information System” is an interconnected set of information resources under the
same direct management control that shares common functionality. The “system” may or may
not be computerized, but does include trained personnel to ensure Contract compliance.
25. “Material Change” for purposes of the reporting required in Exhibit K means any
circumstance in which Contractor experiences a change in operations that is reasonably likely
to affect Contractor’s Participating Provider capacity or reduce or expand the amount, scope or
duration of Covered Services being provided to DMAP Members including but not limited to:
a. Changes in Contractor’s service delivery system that may directly impact the provision
of services to Contractor’s DMAP Members or affect Provider participation;
b. Expansion or reduction of a Service Area requiring a Contract amendment, particularly
related to Provider capacity and service delivery in the affected Service Area;
c. Modifications of Provider payment processes or mechanisms that could affect Provider
participation levels;
d. Enrollment of a new population (e.g., roll over or new OHP benefit package recipients);
e. Loss of a Participating Provider, specialty Provider, clinic or hospital, previously
identified on the Provider Capacity Report that will impact Contractor’s DMAP
Members; or
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f. The addition of a Participating Provider, specialty Provider, clinic or hospital not
previously identified on the Provider Capacity Report that will impact Contractor’s
DMAP Members.
26. “Medically Appropriate” are services and medical supplies that are required for prevention,
diagnosis or treatment of a health condition that encompasses physical or mental conditions, or
injuries and which are:
a. Consistent with the symptoms of a health condition or treatment of a health condition;
b. Appropriate with regard to standards of good health practice and generally recognized
by the relevant scientific community and professional standards of care as effective;
c. Not solely for the convenience of a DMAP Member or a Provider of the service or
medical supplies; and
d. The most cost effective of the alternative levels of medical services or medical supplies
that can be safely provided to a DMAP Member in Contractor’s judgment.
27. “Medicare Advantage” is a capitated health plan that contracts with CMS to provide
Medicare benefits to Medicare enrollees.
28. National Provider Identifier (NPI): is a Health Insurance Portability and Accountability Act
(HIPAA) Administrative Simplification Standard. The NPI is a unique identification number
for covered health care providers. Covered health care providers and all health plans and health
care clearinghouses will use NPIs in the administrative and financial transactions adopted under
HIPAA. The NPI is a 10-position, intelligence-free number identifier (10-digit number). This
mean that the numbers do not carry other information about healthcare providers, such as the
state in which they live or their medical specialty. The NPI must be used in lieu of legacy
provider identifiers in the HIPAA standards transactions.
29. “Non-Participating Provider” means a Provider who does not have a subcontract with
Contractor. If a Non-Participating Provider is, or becomes enrolled with DMAP,
reimbursement of the Non-Participating Provider is governed by DMAP General Rules
(Division 120).
30. “Oregon Health Plan” (OHP) means the Medicaid Demonstration Project, which expands
Medicaid 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.
31. “OHP Client” means an individual found eligible by DHS to receive services under the OHP.
32. “OHP Plus Benefit Package” or “Plus Benefit Package” means a benefit package available
to eligible OHP Clients as described in OAR 410-120-1210 Medical Assistance Benefits:
Excluded Services and Limitations and in OAR 410-141-0520 Prioritized List of Health
Services and OAR 410-120-1230.
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33. “OHP Standard Benefit Package” or “Standard Benefit Package” means a benefit package
available to eligible OHP Clients (including families, adults and couples) who are not otherwise
eligible for the OHP Plus Benefit Package as described in OAR 410-120-1210, Medical
Assistance Benefit Packages and Delivery System and in OAR 410-141-0520, Prioritized List
of Health Services.
34. “Outpatient” means a hospital patient who:
a. Is treated and released the same day or is admitted to the hospital and discharged before
midnight and is not listed on the following day's census, excluding a patient who:
(1) Is admitted and transferred to another acute care hospital on the same day;
(2) Expires on the day of admission; or
(3) Is born in the hospital;
b. Is admitted for ambulatory surgery, to a birthing center, a treatment or observation
room, or a short-term stay bed;
c. Receives observation services provided by a hospital, including the use of a bed and
periodic monitoring by hospital nursing or other staff for the purpose of evaluation of a
patient's medical condition for a maximum of 48 hours; or
d. Receives routine preparation services and recovery for diagnostic services provided in a
hospital Outpatient department.
35. “Outpatient Hospital Services” means services that are furnished in a hospital for the care
and treatment of an Outpatient.
36. “Participating Provider” means an individual, facility, corporate entity, or other organization
that supplies medical, dental, or mental health services or medical and dental items and that has
agreed to provide those services or items to DMAP Members under a subcontract with
Contractor and to bill in accordance with the subcontract with Contractor.
37. “Payment” means a Capitation Payment plus any supplemental payment described herein.
38. “Potential DMAP Member” is 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.
39. “Prepaid Health Plan” or “PHP” means a managed health, dental, chemical dependency, or
mental health care organization that contracts with DMAP and/or AMH on a case managed,
prepaid, capitated basis under the OHP. PHPs may be Dental Care Organizations (DCOs),
Fully Capitated Health Plans (FCHPs), Mental Health Organizations (MHOs), Physician Care
Organizations (PCOs), or Chemical Dependency Organizations (CDOs).
40. “Provider” means a Participating Provider or a Non-Participating Provider.
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41. Provider Taxonomy Codes: is 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.
42. “Representative” means a person who can make OHP related decisions for OHP Clients who
are not able to make such decisions themselves. A Representative may be, in the following
order of priority, a person who is the OHP Client's health care Representative under ORS
127.505(12), a court-appointed guardian, a spouse, or other family member as designated by
the OHP Client, the Individual Service Plan Team (for developmentally disabled clients), a
DHS case manager or other DHS designee.
43. “State” means the State of Oregon.
44. “Subcontractor” means any Participating Provider or any other individual, entity, facility, or
organization that has entered into a subcontract with the Contractor or any Subcontractor for
any portion of the Work under this Contract.
45. “Valid Claim” means a Claim received by the Contractor for payment of Covered Services
rendered to a DMAP Client which: (1) Can be processed without obtaining additional
information from the Provider of the service or from a third party; and (2) Has been received
within the time limitations prescribed in OHP Rules. A “Valid Claim” does not include a
Claim from a Provider who is under investigation for fraud or abuse, or a Claim under review
for Medical Appropriateness. A “Valid Claim” is a “clean claim” as defined in 42 CFR 447.45
(b).
46. “Work” means all components of Contractor’s obligations under this Contract, including the
administration of Capitated Services, all information, data, reports, and all other materials.
“Work” includes all related legal rights and obligations, as more specifically described in the
Statement of Work and elsewhere in this Contract.
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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. Capitated Services
a. Contractor shall provide Chemical Dependency Services, in exchange for a Capitation
Payment.
b. Contractor shall have no responsibility under this Contract to provide Medical Assistance
Services for DMAP Members unless such services are Capitated Services that are Covered
Services.
c. Medical Assistance Services that are not Capitated Services are authorized and paid
outside of this Contract according to procedures provided in the General Rules and DMAP
Provider Guides, or by separate Contract, and are not included in the Capitation Payment.
This includes services for:
(1) Physician assisted suicide under the Oregon Death with Dignity Act, ORS 127.800-
127.897;
(2) Therapeutic abortions;
(3) Non-emergency medical transportation, which is transportation other than those
classified as ambulance service(s);
(4) Mental Health Services under a Mental Health Organization Agreement that are not
Chemical Dependency Services;
(5) Medical assistance services that are Covered Services under the Fully Capitated
Health Plan;
(6) Dental services that are Covered Services under the Dental Care Organization
Contract; and
(7) Standard therapeutic Class 7 & 11 Prescription drugs, Depakote, Lamictal and their
generic equivalents dispensed through a licensed pharmacy. These medications are
paid through DMAP’s Fee For Service system.
2. Plus and Standard Benefit Packages of Covered Services
a. Subject to the provisions of this Contract, Contractor shall pay for Covered Chemical
Dependency Services to DMAP Members eligible for the OHP Plus Benefit Package.
(1) Contractor shall provide Chemical Dependency Services for the OHP Benefit
Package of Covered Services, OAR 410-120-1210 (3) (a), OAR 410-141-0480,
including diagnostic services that are necessary and reasonable to diagnose the
presenting condition, regardless of whether or not the final diagnosis is covered.
(2) Contractor shall provide treatment, including ancillary services, which is included
in or supports the condition/treatment pairs that are above the funding line on the
Prioritized List of Health Services, OAR 410-141-0520.
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Contract #126667 Exhibit B Page 20 of 242
(3) Except as otherwise provided in OAR 410-141-0480(7), Contractor is not
responsible for excluded or limited services as defined in OAR 410-141-0500.
(4) Before denying treatment for a condition that is below the funding line on the
Prioritized List for any DMAP Member, especially a DMAP Member with a
disability or co-morbid condition, Contractor must determine whether the DMAP
Member has a funded condition and paired treatment that would entitle the DMAP
Member to treatment under OAR 410-141-0480(7).
b. Subject to the provisions of this Contract, Contractor shall pay for Covered Services to
DMAP Members eligible for the OHP Standard Benefit Package. Contractor shall provide
Outpatient Chemical Dependency Services for the OHP Benefit Package of Covered
Services, OAR 410-141-0480 and Medical Assistance Benefit Packages and Delivery
System, OAR 410-120-1210.
c. Pursuant to ORS 414.720 and 414.735, the Prioritized List of condition-treatment pairs
developed by the Health Services Commission may be expanded, limited or otherwise
changed, or the funding line for the services on the Prioritized List may be changed by the
Legislature.
(1) In the event that insufficient resources are available during this Contract Year, ORS
414.735 provides that reimbursement shall be adjusted by eliminating services in
the order of priority recommended by the Health Services Commission, starting
with the least important and progressing toward the most important.
(2) Before instituting reductions, DHS is required to obtain the approval of the
Legislative Assembly or the Emergency Board if the Legislative Assembly is not in
session. In addition, the DHS will notify Contractor at least two weeks prior to any
legislative consideration of such reductions.
(3) Any reductions made under ORS 414.735 shall take effect no sooner than 60 days
following final legislative action approving the reductions. Any reductions shall be
made by amendment to this Contract.
d. Contractor’s utilization management activities must not be structured so as to provide
incentives for the individual or entity to deny, limit, or discontinue Medically Appropriate
services to a DMAP Member.
3. Authorization of Covered Services
a. Contractor may require DMAP Members and Subcontractors to obtain authorization for
Covered Services from Contractor, except to the extent prior authorization is not required
in OAR 410-141-0420 or elsewhere in this Statement of Work. Contractor shall have
written procedures that Contractor follows, and shall require its Participating Providers and
Subcontractors to follow, for processing initial and continuing pre-authorization requests
received from any Provider, pursuant to OAR 410-141-0420 and in accordance with 42
CFR 438.210(d). Contractor shall have in effect mechanisms to ensure consistent
application of review criteria for authorization decisions, taking into account applicable
clinical practice guidelines, and shall consult with the requesting Provider when
appropriate.
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b. When the DMAP Member is out of Contractor’s Service Area, Contractor may refuse to
pay for Covered Services that have not been authorized by Contractor, except for
Emergency Services, described in Exhibit B, Part I, Section 5.
c. Contractor shall be responsible for payment of Covered Services provided by a Non-
Participating Provider under the following circumstances:
(1) Contractor pre-authorized the services pursuant to OAR 410-141-0420(6)(a);
(2) Contractor is responsible for payment pursuant to OAR 410-141-0420(6)(e); or
(3) Services are Emergency Services.
d. Contractor shall coordinate preauthorization and related services with FCHPs to ensure the
provision of health care with mutual DMAP Members that is required to be performed in
an Outpatient hospital or ambulatory surgical setting due to the age, disability, or medical
condition of the DMAP Member.
(1) Except as provided in Paragraph (2) of this Subsection f, Contractor may not
prohibit or otherwise limit or restrict Health Care Professionals who are its
employees or Subcontractors acting within the lawful scope of practice, from
advising or advocating on behalf of a DMAP Member, who is a patient of the
professional, for the following:
(a) For the DMAP Member’s health status, medical care, or treatment options,
including any alternative treatment that may be self-administered, that is
Medically Appropriate even if such care or treatment is not covered under
this Contract or is subject to co-payment;
(b) Any information the DMAP Member needs in order to decide among
relevant treatment options;
(c) The risks, benefits, and consequences of treatment or non-treatment; and
(d) The DMAP Member’s right to participate in decisions regarding his or her
health care, including the right to refuse treatment, and to express
preferences about future treatment decisions.
(2) Contractor is not required to provide, reimburse for, or provide coverage of a
counseling or referral service because of the requirement in Paragraph (1) of this
Subsection f. if Contractor objects to the service on moral or religious grounds. If
Contractor elects not to provide, reimburse for, or provide coverage of, a
counseling or referral service because of an objection on moral or religious grounds
under this paragraph, Contractor shall adopt a written policy consistent with the
provisions of 42 CFR 438.10 for such election and furnish information about the
services Contractor does not cover as follows:
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(a) To DMAP:
(i) With Contractor’s application for a Medicaid contract; and
(ii) Whenever Contractor adopts the policy during the term of this
Contract, at least 30 days prior to Contractor’s formal adoption of
the policy, and
(b) Following DMAP prior approval:
(i) To Potential DMAP Members before and during Enrollment; and
(ii) To DMAP Members within 90 days after adopting the policy with
respect to any particular service.
e. Contractor must provide to DMAP Members, at a minimum, those Covered Services that
are Medically Appropriate and as described as funded condition-treatment pairs on the
Prioritized List of Health Services contained in OAR 410-141-0520 and as identified,
defined and specified in the OHP Administrative Rules. Contractor must ensure all
Medically Appropriate Covered Services are furnished in an amount, duration and scope
that is no less than the amount, duration and scope for the same services furnished to OHP
Clients under fee-for-service and as set forth in 42 CFR 438.210. Contractor must also
ensure the Covered Services are sufficient in amount, duration and scope to reasonably be
expected to achieve the purpose for which the services are furnished.
f. Contractor must notify the requesting Provider, in writing or orally, when Contractor
denies a request to authorize a Covered Service or when the authorization is in an amount,
duration, or scope that is less than requested. Contractor must notify the DMAP Member
in writing of any decision to deny a service authorization request, or to authorize a service
in an amount, duration or scope that is less than requested pursuant to the requirements of
Exhibit N.
g. Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a Covered
Service solely because of the diagnosis, type of illness, or condition, subject to the
Prioritized List.
h. Contractor must define service authorization in a manner that at least includes an enrolled
DMAP Member's request for the provision of a service.
i. Contractor shall have written procedures that Contractor follows, and shall require
Participating Providers to follow, for the initial and continuing authorizations of services
requiring that any decision to deny a service authorization request or to
authorize a service in an amount, duration or scope that is less than requested, be made by
a Health Care Professional who has appropriate clinical expertise in treating the DMAP
Member’s condition or disease.
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4. Covered Service Detail
a. Without limiting the generality of Contractor’s obligation to provide Covered Services,
when providing Covered Services Contractor shall comply with the specific requirements
described in more detail below.
b. Contractor may cover, for DMAP Members, services that are in addition to Covered
Services.
c. Contractor must provide Medically Appropriate Covered Services for any DMAP Member
using a Non-Participating Provider when the same services are not available by
Contractor’s Participating Provider. Contractor must adequately and timely provide these
services out of network for the DMAP Member for as long as Contractor is unable to
provide them with a Participating Provider. Contractor must ensure that the cost to the
DMAP Member is no greater than it would be if a Participating Provider furnished the
services. Non-Participating Providers must coordinate with Contractor with respect to
payment, pursuant to OAR 410-120-1295.
d. Contractor must meet and require Contractor’s Participating Providers to meet OHP
standards for timely access to care and services, taking into account the urgency of the
need for services as specified in OAR 410-141-0220. This requirement includes the
Participating Providers offering hours of operation that are not less than the hours of
operation offered to Contractor’s commercial members (as applicable).
5. Emergency and Urgent Care Services
a. Contractor shall have written policies and procedures and monitoring systems that provide
for Emergency and Urgent Services for all DMAP Members on a 24-hour, 7-day-a-week
basis consistent with OAR 410-141-0140, OHP Prepaid Health Plan Emergency and
Urgent Care Medical Services.
(1) “Emergency Services” are defined as the Covered Services furnished by a
Provider that is qualified to furnish these services and that are needed to evaluate or
stabilize an Emergency Medical Condition. “Emergency Services” include all
inpatient and Outpatient treatment that may be necessary to assure within
reasonable medical probability that no material deterioration of the patient’s
condition is likely to result from, or occur during, discharge of the DMAP Member
or transfer of the DMAP Member to another facility.
(2) “Emergency Medical Condition” means a medical condition manifesting itself by
acute symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in placing
the health of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy, serious impairment to bodily
functions or 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
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Contract #126667 Exhibit B Page 24 of 242
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.
(3) “Urgent Care Services” are defined as Covered Chemical Dependency Services
that are Medically Appropriate and immediately required in order to prevent a
serious deterioration of a DMAP Member’s health that results from an unforeseen
illness or an injury. Services that can be foreseen by the individual are not
considered Urgent Services.
(4) “Stabilize” means that no material deterioration of the Emergency Medical
Condition is likely, within reasonable medical probability, to result from or occur
during the transfer of the individual from a facility.
(5) “Post Stabilization Services” means Covered Chemical Dependency Services
related to an Emergency Medical Condition that are provided after a DMAP
Member is Stabilized in order to maintain the Stabilized condition or that are
provided under the circumstances described in Exhibit B, Part I, Section 5,
Subsection h. Paragraph (3) to improve or resolve the DMAP Member’s condition.
b. Contractor shall not require prior authorization for Emergency Services. Contractor shall
provide an after-hours call-in system adequate to triage Urgent Care and Emergency
Service calls, consistent with OAR 410-141-0140.
c. Contractor must cover and pay for Emergency Services regardless of whether the Provider
that furnishes the services has a contract with Contractor and may not deny payment for
treatment obtained under either of the following circumstances:
(1) A DMAP Member had an Emergency Medical Condition; or
(2) A representative of the Contractor instructed the DMAP Member to seek
Emergency Services.
d. If the Emergency Services Provider does not have a contract with Contractor, Contractor
shall pay the Non-Participating Provider pursuant to the Non-Participating Provider rule,
410-120-1295 and General Rules OAR 410-120-1280, Billing, and OAR 410-120-1300,
Timely Submission of Claims.
e. Contractor shall not:
(1) Limit what constitutes an Emergency Medical Condition on the basis of lists of
diagnoses or symptoms; or
(2) Refuse to cover Emergency Services based on the emergency room Provider,
hospital, or fiscal agent not notifying the DMAP Member’s PCP or the Contractor
of the DMAP Member’s screening and treatment within 10 days of presentation for
Emergency Services.
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f. A DMAP Member who has an Emergency Medical Condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific condition
or stabilize the patient.
g. The attending emergency physician, or the Provider actually treating the DMAP Member,
is responsible for determining when the DMAP Member is sufficiently stabilized for
transfer or discharge, and that determination is binding on Contractor for payment
purposes.
h. Contractor is financially responsible for Post-Stabilization Services obtained by DMAP
Members within or outside the Contractor’s network under the following circumstances:
(1) Post Stabilization Services have been pre-approved by Contractor’s authorized
representative; or
(2) Post Stabilization Services have not been pre-approved by Contractor’s authorized
representative, but are administered to maintain the DMAP Member’s stabilized
condition within 1 hour of a request to the Contractor’s authorized representative
for approval of further Post Stabilization Services; or
(3) Post Stabilization Services have not been pre-approved by Contractor’s authorized
representative, but are administered to maintain, improve, or resolve the DMAP
Member’s stabilized condition if:
(a) The Contractor’s authorized representative does not respond to a request for
authorization within 1 hour;
(b) The Contractor’s authorized representative cannot be contacted; or
(c) The Contractor’s authorized representative and the treating physician cannot
reach an agreement concerning the DMAP Member’s care and the
Participating Provider is not available for consultation. In this situation, the
Contractor must give the treating physician the opportunity to consult with
the Participating Provider and the treating physician may continue with care
of the DMAP Member until the Participating Provider is reached or one of
the criteria in Subsection i below, have been met; or
(4) Contractor shall limit charges to DMAP Members, for post stabilization services, to
an amount no greater than what the Contractor would charge for in network
services.
i. Contractor’s financial responsibility for Post-Stabilization Services it has not pre-approved
ends when:
(1) The Participating Provider with privileges at the treating hospital assumes
responsibilities for the DMAP Member’s care;
(2) The Participating Provider assumes responsibility for the DMAP Member’s care
through transfer;
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(3) A Contractor representative and the treating physician reach an agreement
concerning the DMAP Member’s care; or
(4) The DMAP Member is discharged.
6. Chemical Dependency
a. Contractor shall provide Chemical Dependency Services to eligible DMAP Members,
which include Outpatient treatment services, Opiate Substitution Services, and Intensive
Outpatient treatment services. For purposes of this Contract, DHS’ AMH rules and criteria
applicable to Outpatient treatment services are located in OAR 415-051-0000, and the
AMH rules and criteria applicable to synthetic opiate treatment services located in OAR
415-020-0000. For purposes of this Contract, the AMH contact shall be the OHP
Addiction Services Specialist, 500 Summer Street, NE, Salem, Oregon 97301, 503-945-
5962 (voice), 503-378-8467 (fax).
(1) Contractor shall make decisions about access to Chemical Dependency Services,
continued stay, discharges, and referrals based upon AMH approved criteria, which
are deemed to be Medically Appropriate. Contractor shall ensure that employees or
Subcontractors who evaluate DMAP Members for access to and length of stay in
Chemical Dependency Services have the training and background in Chemical
Dependency Services and working knowledge of ASAM PPC-2R. Contractor shall
participate with AMH in a review of AMH provided data about the impact of these
criteria on service quality, cost, outcome and access.
(2) Contractor shall consider each eligible DMAP Member’s needs and, to the extent
appropriate and possible, provide specialized Chemical Dependency Services
designed specifically for the following groups as set forth in AMH Administrative
Rules: (a) adolescents, taking into consideration adolescent development; (b)
women and women’s specific issues; (c) ethnic and racial diversity and
environments that are culturally relevant; (d) intravenous drug users; (e) people
involved with the criminal justice system; and (f) individuals with co-occurring
disorders.
(3) Contractor must implement mechanisms to identify DMAP Members with special
health care needs.
(a) Contractor must implement mechanisms to assess each DMAP Member
with special health care needs in order to identify any ongoing special
conditions of the DMAP Member that require a course of chemical
dependency treatment or regular care monitoring within the scope of
services under this Contract. The assessment mechanism must use
appropriate Health Care Professionals.
(b) The chemical dependency treatment plan for DMAP Members with special
health care needs must be (i) developed by the DMAP Member’s chemical
dependency Provider with DMAP Member participation and in consultation
with any specialists caring for the DMAP Member (within confidentiality
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Contract #126667 Exhibit B Page 27 of 242
requirements); (ii) approved by the CDO in a timely manner if approval of
the treatment plan is required by the CDO; and (iii) in accord with any
applicable State quality assurance and utilization review standards.
(c) For enrollees with special health care needs determined through assessment
by appropriate Health Care Professionals (consistent with section (a) of this
paragraph) to need a course of chemical dependency treatment or regular
care monitoring, Contractor must have a mechanism in place to allow
DMAP Members to directly access a specialist (for example, through a
standing referral or an approved number of visits) as appropriate for the
DMAP Member’s condition and identified needs, and within the scope of
services covered under this Contract.
(4) Consistent with Exhibit B, Part II, Section 1, Subsection d, of this Contract,
Services Coordination for Non-Capitated Services, Contractor shall coordinate
referral and follow-up of DMAP Members to Non-Capitated Services such as
residential treatment services, and community detoxification. Contractor’s
employees or Subcontractors providing Chemical Dependency Services shall
provide to DMAP Member, to the extent of available community resources and as
clinically indicated, information and referral to community services which may
include, but are not limited to; child care; elder care; housing; transportation;
employment; vocational training; educational services; mental health services;
financial; and legal services.
(5) Contractor shall authorize and pay for at least Outpatient Chemical Dependency
Services to eligible DMAP Members who meet AMH criteria for residential
treatment services community detoxification, or opiate substitution maintenance,
when services are not immediately available.
(6) Contractor shall require employees or Subcontractors providing Chemical
Dependency Services to provide AMH, within 30 days of admission or discharge,
with all information required by AMH’ most current publication “Client Process
Monitoring System”.
(7) Contractor shall utilize AMH approved chemical dependency screening
instruments to determine whether a diagnostic assessment for chemical dependency
problems is indicated for a DMAP Member. Contractor may submit alternative
screening instruments to AMH for review and possible approval.
(8) Contractor shall make a good faith effort to screen all eligible DMAP Members
who are in any of the following circumstances, for chemical dependency problems:
(a) at an initial contact or routine physical exam; (b) at an initial prenatal exam; (c)
when the DMAP Member shows evidence of trigger conditions (as noted on the
screening tool); or (d) when the DMAP Member shows inappropriate over-
utilization of Capitated Services.
(9) Contractor shall ensure that Chemical Dependency Services are provided only by
individuals or programs that have a letter of approval or license from AMH for the
services they provide and meet all other applicable requirements of this Contract.
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(10) Contractor shall refer at least 50% of eligible DMAP Members needing chemical
dependency diagnostic and/or treatment to Essential Community Providers (ECP),
unless Contractor can document non-feasibility due to cost or quality of care. A list
of ECPs is available from AMH upon request.
(11) Contractor shall inform all eligible DMAP Members that chemical dependency
Outpatient, intensive Outpatient, and opiate substitution treatment services are
included in the Plus Benefit package, consistent with OAR 410-141-0300 Oregon
Health Plan Prepaid Health Plan Member Education.
(12) Contractor shall provide covered chemical dependency treatment services for any
eligible DMAP Member who meets admission criteria for Outpatient, intensive
Outpatient and opiate substitution treatment, regardless of prior alcohol/other drug
treatment or education.
(13) Contractor shall comply with the following access requirements; eligible DMAP
Members shall be seen the same day for emergency Chemical Dependency
Treatment care. Eligible DMAP Members, including pregnant women, shall be
seen within 48 hours for urgent Chemical Dependency treatment care. Eligible
DMAP Members, including intravenous drug users, shall be seen within 10 days or
the community standard for routine Chemical Dependency Treatment care.
(14) In addition to any other confidentiality requirements described in this Contract,
Contractor shall follow the federal (42 CFR Part 2 and state ORS 179.505, 430.397,
430.399) confidentiality laws and regulations governing the identity and medical
client records of DMAP Members who receive Chemical Dependency Services.
(15) Contractor shall identify specialized programs in each Service Area in the
following categories that are to be used as exclusive Chemical Dependency
Services Providers for: Drug Court referrals, Children, Adult and Families (CAF)
referrals, Job Opportunities and Basic Skills (JOBS) referrals, and referrals for
persons with co-occurring disorders.
(16) Contractor shall provide DMAP Members with alcohol, tobacco, and other drug
abuse prevention/education that reduces the risk for those DMAP Members who
recently use those substances, and for those who do not. Contractor’s prevention
program shall meet or model national quality assurance standards. Contractor
should have mechanisms to monitor the use of its preventive programs and assess
their effectiveness on its DMAP Members.
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EXHIBIT B –Statement of Work – Part II – Providers and Delivery System
1. Delivery System Configuration
a. Provider Capacity
Contractor shall maintain and monitor a panel of Participating Providers that is
supported with written agreements (as specified in Exhibit D, Section 16) and has
sufficient capacity to provide adequate, timely and Medically Appropriate Covered
Services for Contractor’s DMAP Members as required by this Contract and under OAR
410-141-0120, OHP Prepaid Health Plan Provision of Health Care services. Contractor
shall comply with the requirements specified in 438.214, which includes selection and
retention of Providers, credentialing and re-credentialing requirements, and
nondiscrimination. In establishing and maintaining the network, Contractor shall:
(1) Offer an appropriate range of services and access to preventive and primary care
services for the population enrolled or expected to be enrolled in the Service
Area covered by this Contract;
(2) Utilize sufficient numbers and types (in terms of training, experience and
specialization) of Providers of services consistent with the Plus Benefit Package
of Covered Services;
(3) Consider the geographical location of Participating Providers and DMAP
Members considering distance, travel time, the means of transportation
ordinarily used by DMAP Members and whether the location provides physical
access for DMAP Members with disabilities;
(4) Complete the Provider Capacity Report in Exhibit K as specified in Exhibit B,
Part IV, Section 1, Subsection (4) and submit to the DHS an update of this
Provider Capacity Report at any time there has been a Material Change in
Contractor’s operations that would affect adequate capacity and services;
(5) Utilize Provider selection policies and procedures, in accordance with 42 CFR
438.12 and 42 CFR 438.214, that do not discriminate against particular
Providers that serve high-risk populations or specialize in conditions that require
costly treatment. If Contractor declines to include individual or groups of
Providers in its network, it must give the affected Providers written notice of the
reason for its decision;
(6) Consider the expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented; and
(7) Consider the number of Participating Providers who are not accepting new
DMAP Members.
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b. Accessibility
(1) Contractor shall provide Medical Case Management Services for Covered
Services and provide DMAP Members access to Covered Services. Contractor
shall not discriminate between DMAP Members and non-DMAP Members, as
provided in OAR 410-141-0220, OHP Prepaid Health Plan Accessibility.
(a) Contractor shall require that Participating Providers offer office hours of
operation that are no less that the hours of operation offered to
commercial members or comparable to Medicaid fee-for-service, if the
Provider serves only Medicaid members.
(b) Contractor shall require that Participating Providers establish
mechanisms to comply with the timely access requirements, monitor
regularly to determine compliance and take corrective action if there is a
failure to comply.
(2) Contractor shall comply with the requirements of Title II of the Americans with
Disabilities Act and Title VI of the Civil Rights Act by assuring communication
and delivery of Covered Services to DMAP Members who have difficulty
communicating due to a disability, or limited English proficiency or diverse
cultural and ethnic backgrounds, and shall maintain written policies, procedures
and plans in accordance with the requirements of OAR 410-141-0220.
Contractor shall ensure that its employees, Subcontractors and facilities are
prepared to meet the special needs of DMAP Members who require
accommodations because of a disability or limited English proficiency.
Contractor’s Grievance and Appeal procedures, described in Exhibit B, Part III,
Section 3 and in Exhibit N, shall include a process for Grievances and Appeals
concerning communication or access to Covered Services or facilities.
(3) Contractor shall ensure that continuity of care is provided as required under
OAR 410-141-0160, Oregon Health Plan Prepaid Health Plan Continuity of
Care.
(4) Contractor is encouraged to establish agreements with hospitals in Contractor’s
Service Area for payment of emergency screening examinations consistent with
ORS 441.094(5).
(5) Contractor shall ensure each DMAP Member has an ongoing source of primary
care appropriate to the DMAP Member's needs and a person or entity formally
designated as primarily responsible for coordinating the health care services
furnished as described in OAR 410-141-0120 and required by 42 CFR 438.208
(b)(1).
(6) Contractor shall implement procedures to ensure that in the process of
coordinating care, each DMAP Member’s privacy is protected consistent with
the confidentiality requirements in 42 CFR parts 160 and 164.
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(7) Contractor shall provide for a second opinion from a qualified Participating
Provider. If a qualified Participating Provider cannot be arranged then
Contractor shall arrange for the DMAP Member to obtain the second opinion
from a Non-Participating Provider, at no cost to the DMAP Member.
c. Agreements with Public Health Organizations
Consistent with ORS 414.153 and OAR 410-141-0120(2), Contractor shall execute
Subcontracts with county health departments and other publicly supported programs
and provide access to public health services. Contractor shall report to DMAP on the
status in executing Subcontracts with publicly funded Providers and on the involvement
of publicly supported health care and service programs on an annual basis with it's
reporting under Exhibit K of this Contract.
d. Services Coordination for Non-Capitated Services
(1) Contractor shall coordinate services for each DMAP Member who requires
medical assistance services not covered under the Capitation Payment.
Contractor shall arrange, coordinate, and monitor Non-Capitated Services for
chemical dependency, mental health or medical health care for that DMAP
Member on an ongoing basis, except as provided for in Paragraph (3) of this
Subsection d.
(2) Contractor shall document its professional relationships with Local or Regional
Allied Agencies, as defined in OAR 410-141-0000; community Emergency
Service agencies; residential Chemical Dependency Services Providers; and
local Non-Participating Providers which may offer services that are not Covered
Services under the Capitation Payment.
(3) Contractor shall not require DMAP Members to obtain the approval of a
Primary Care Physician in order to gain access to mental health or alcohol and
drug assessment and evaluation services. DMAP Members may refer themselves
to MHO services.
e. Cooperation with Mental Health Organizations (MHOs)
(1) Contractors shall cooperate with MHOs as follows:
(a) Consult and communicate with the DMAP Member’s mental health
Providers as Medically Appropriate and within the laws governing
confidentiality as specified in OAR 410-141-0180, Prepaid Health Plan
Record Keeping; and
(b) Develop and implement methods of coordinating with MHOs in order to
assure appropriate coordination of services delivered to mutual DMAP
Members, particularly DMAP Members with exceptional service needs.
In additional to any other confidentiality requirements described in this
Contract, such coordination shall be in accordance within laws governing
confidentiality.
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f. Cooperation with Residential, Nursing Facilities, Foster Care & Group Homes
(1) Contractor shall coordinate the provision of Covered Services for DMAP
Members, as appropriate, with residential, nursing facilities, foster care and
group homes serving Contractor’s DMAP Members.
(2) Contractor shall arrange to provide medication that is part of Capitated Services
to nursing or residential facility and group or foster home residents in a format
that is consistent with the individual facility’s delivery, dosage and packaging
requirements and Oregon law.
g. Contractor shall not discriminate with respect to participation, reimbursement or
indemnification as to any Provider who is acting within the scope of the Provider’s
license or certification under applicable State law, solely on the basis of such 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 DMAP 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.
h. Medicare Payers and Providers
(1) Contractor shall coordinate with Medicare payers and Providers as Medically
Appropriate to coordinate the care and benefits of DMAP Members who are
eligible for both Medicaid and Medicare.
(2) 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 DMAP 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.
i. Health Information Systems
Contractor shall maintain a Health Information System that meets the requirements of
this Contract and that will:
(1) Collect, analyze, integrate and report data that includes, but is not limited to:
(a) Appeals;
(b) Claims data;
(c) Grievances;
(d) Enrollment;
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(e) Utilization of services; and
(f) Disenrollment for other than loss of Medicaid eligibility.
(2) Collect data at a minimum on:
(a) Provider characteristics as required in Exhibit K;
(b) DMAP Member characteristics;
(c) DMAP Member enrollment; and
(d) Services provided to DMAP Members for Encounter Data reporting.
(3) Ensure Claims data received from Providers, either directly or through a third
party submitter, is accurate, truthful and complete by:
(a) Verifying accuracy and timeliness of reported data;
(b) Screening data for completeness, logic and consistency;
(c) Submitting the certification contained in Exhibit H; and
(d) Collecting service information in standardized formats to the extent
feasible and appropriate, if HIPAA standard Contractor must utilize the
HIPAA standard including DHS Electronic Data Transmission (EDT)
procedures.
(4) Make all collected and reported data available upon request to DMAP and CMS
(as specified in 42 CFR 438.242).
j. Evidenced-Based Clinical Practice Guidelines
Contractor shall adopt evidenced-based clinical practice guidelines that are based on
valid and reliable clinical evidence or a consensus of Health Care Professionals, in
consultation with Contractor’s Participating Providers, in the particular field. These
evidenced-based clinical practice guidelines must consider the needs of Contractor’s
DMAP Members and be reviewed and updated periodically as appropriate. Contractor
shall disseminate the evidenced-based clinical practice guidelines to all affected
Participating Providers and, upon request, to DMAP, Contractor’s DMAP Members,
Potential DMAP Members or Representatives. Decisions for utilization management,
coverage of services, or other areas, to which the guidelines apply, should be consistent
with the adopted evidenced-based clinical practice guidelines. Contractor shall describe
in their annual written evaluation of the Quality Performance Improvement Program
their process for adoption and dissemination of the evidenced-based clinical practice
guidelines and identify those that have been adopted.
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2. Adjustments in Service Area or Enrollment
a. If Contractor experiences a Material Change, or is engaged in the termination or loss of
a medical Provider or 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 DMAP Members to other Providers employed or subcontracted with Contractor,
Contractor shall provide DMAP with a written plan for transferring the DMAP
Members and an updated Provider Capacity Report, Exhibit K, at least ninety (90) days
prior to the date of such action, notwithstanding the Contract renewal date. Contractor
remains responsible for maintaining sufficient capacity and solvency, and providing all
Capitated Services through the end of the 90-day period.
(1) If Contractor must terminate a medical Provider or group due to circumstances
that could compromise DMAP Member care, less than the required notice to
DMAP may be provided with the approval of DMAP.
(2) If a medical Provider or 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 DMAP may be provided with the
approval of DMAP.
(3) If Contractor cannot demonstrate sufficient Provider capacity, DMAP reserves
the right to seek other avenues to provide services to DMAP Members. If
DMAP determines that some or all of the affected DMAP Members must be
Disenrolled from Contractor, the applicable provisions of this Section shall
apply.
b. If Contractor experiences a Material Change, or is engaged in the termination or loss of
a medical Provider or group or affected by other factors which has significant impact on
access in that Service Area and which may result in reducing Contractor’s Service Area
and/or Disenrolling a substantial number of DMAP Members from Contractor,
Contractor shall provide DMAP with a written notice and a plan for implementation
(which may include an intent to transfer its DMAP Members in the Service Area to a
designated Contractor) at least 90 days prior to the date of such action, notwithstanding
the Contract renewal date. Contractor remains responsible for providing all Capitated
Services through the end of the 90-day period, without limitation, for all DMAP
Members for which the Contractor received a Capitation Payment.
(1) If Contractor must terminate a medical Provider or group due to circumstances
that could compromise DMAP Member care, less than the required notice to
DMAP may be provided with the approval of DMAP.
(2) If a medical Provider or group terminates their Subcontract or employment with
Contractor or Contractor is affected by other circumstances beyond Contractor’s
control and the Contractor cannot reasonably provide the required 90 days
notice, less than the required notice to DMAP may be provided with the
approval of DMAP.
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(3) If Contractor provides DMAP with the required 90-day notice but provides no
Letter of Intent to transfer its DMAP Members to a designated Contractor within
30 days of the 90-day notice, DMAP Members enrolled with Contractor in the
affected Service Area will be Disenrolled from Contractor and will be assigned
to existing Contractors providing services in the affected Service Area(s) who
can demonstrate Provider capacity.
(4) If Contractor provides DMAP with the required 90-day notice and also provides
a Letter of Intent to transfer its DMAP Members to a designated Contractor, and
DMAP determines that the designated Contractor(s) will have sufficient
Provider capacity as of the date of the proposed transfer, DMAP may approve
the Disenrollment and transfer of DMAP Members and develop such Contract
amendment(s) as may be necessary to effect the transfer.
(5) DMAP reserves the right to seek other avenues to provide services to the DMAP
Members in the affected area(s).
c. If DMAP Members are required to Disenroll from Contractor pursuant to this section,
Contractor remains responsible for all Capitated Services, without limitation, for each
DMAP Member until the effective date of Disenrollment. Unless specified otherwise by
DMAP, Disenrollments shall be effective the end of the month in which the
Disenrollment occurs. Contractor shall cooperate in notifying the affected DMAP
Members and coordinating care and transferring records during the transition to the
designated contractor or to the contractor that has been assigned to the DMAP Member
or to such other PCP as may be designated. If DMAP must notify affected DMAP
Members of the change, Contractor shall provide DMAP with the name, prime number,
and at least one address label for each of the affected DMAP Members not less than
forty-five (45) days prior to the effective Disenrollment date.
d. Contractor is responsible for completing submission and corrections to Encounter Data
for services received by DMAP Members; and for assuring payment of Valid Claims by
employees and Subcontractors, and for Non-Participating Providers providing Covered
Services to DMAP Members; and for compliance with such other terms of this Contract
applicable to the dates of service before Disenrollment of DMAP Members pursuant to
this section. DMAP may, in its discretion, withhold 20% of Contractor’s Capitation
Payment until all contractual obligations have been met to DMAP’s satisfaction. Failure
to complete or ensure completion of said contractual obligations within a reasonable
period of time shall result in a forfeiture of the amount withheld.
e. If Contractor is assigned or transferred OHP Clients pursuant to Subsections b. or c. of
this section, Contractor shall accept all assigned or transferred OHP Clients without
regard to the enrollment exemptions in OAR 410-141-0060.
f. If this Contract is amended to reduce the Service Area and/or to reduce the enrollment
limit, the Capitation Payment rates may be recalculated using the methodology
described in Exhibit C, Attachment I, as follows:
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If the calculation based on the reduced Service Area and/or enrollment limit would
result in a rate decrease, this Contract will be amended to reduce the amount of the
Capitation Payment rates in Exhibit C, Attachment II, effective the date of the reduction
of the Service Area and/or enrollment limit.
g. If this Contract is amended to expand the Service Area and/or the enrollment limit, the
Capitation Payment rates may be recalculated using the methodology described in
Exhibit C, Attachment I, as follows:
(1) If the calculation based on the expanded Service Area and/or enrollment limit
would result in a rate increase, this Contract will be amended to increase the
amount of the Capitation Payment rates in Exhibit C, Attachment II, effective
the date of the expansion of the Service Area and/or enrollment limit.
(2) If the calculation based on the expanded Service Area and/or enrollment limit
would result in a rate decrease, Contractor’s rates will be amended to adjust the
rates when the next OHP-wide rate adjustment occurs.
3. Quality and Performance Improvement Requirements
Contractor shall maintain an internal Quality and Performance Improvement Program based on
written policies, standards and procedures that are designed to achieve through ongoing
measurements and intervention, significant improvement, sustained over time, in clinical care
and non-clinical care areas and that are expected to have a favorable effect on health outcomes
and DMAP Member satisfaction. (See Subsection e.(1) of this section, for examples of non-
clinical areas). The Quality and Performance Improvement Program shall be in accordance
with accepted professional standards consistent with OAR 410-141-0200, OHP Managed Care
Organization Quality Improvement System, and consistent with 42 CFR 438.200 Subpart D,
Quality Assessment and Performance Improvement.
a. Contractor shall submit performance measures to DMAP, in conformance with 42 CFR
438.240(c), Performance Improvement measurements, which include:
(1) Chemical Dependency Services performance measurements::
(a) The performance measurement period is the calendar year 2008;
(b) DMAP will provide each Contractor with the denominator number of the
DMAP Member population eligible for performance measure; and
(c) Performance measures shall be reported using a data submission form
supplied by DMAP, see Schedule 1, for model, and submitted to the
designated DMAP Performance Measure Coordinator by August 1 of the
Contract Year.
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(2) DMAP may modify, replace or eliminate reporting requirements or time frames
of the performance measures specified in Subsection a.(1) based on consultation
with the Quality and Performance Improvement Workgroup or an assessment by
DMAP in consultation with Contractor of the Contractor’s capabilities for
reporting;
(3) DMAP reserves the right to publish the reported performance measures with
notations on methodology and statistical significance;
(4) The performance measures reporting requirements measure the quantity of
chemical dependency care and services during a time period in which Contractor
was providing OHP Capitated Services. The performance measures reporting
requirements expressly survive the expiration, termination or amendment of this
Contract, even if contract expiration, termination or amendment results in a
termination, modification or reduction of the Contractor’s services area, since
performance measures services are rendered when the Contractor is providing
Capitated Services under this Contract; and
(5) Organizations which are governed by ORS 743.814 (3) shall report Health
Promotion and Disease Prevention Activities, national accreditation organization
results and HEDIS® measures as required by the Department of Consumer and
Business Services (DCBS) in OAR 836-053-1000. A copy of the reports shall be
provided to the DMAP Quality Improvement Coordinator concurrent with
submission to DCBS.
b. External Quality Review and Improvement
(1) 42 CFR 438.204 (d) and 42 CFR 438.310-438.370 require DMAP to arrange for
an annual External Quality Review (EQR) to review quality outcomes and
timeliness of, and access to the services provided by Contractor. The EQR is an
analysis and evaluation of performance improvement projects and measures, and
structure and operations of the Contractor or its Subcontractors. The External
Quality Review Organization (EQRO) is an organization that meets the
independence and competency requirements in 42 CFR 438.354 and performs
EQR activities outlined in 42 CFR 438.358 or both. DMAP implements this
external review requirement by contracting with an EQRO and authorizing the
EQRO to contact Contractor to obtain information for the purpose of the EQR.
CMS may also contract with an EQRO or Quality Improvement Organization to
conduct EQR of the services provided under this Contract. Contractor shall
cooperate with CMS’ external review process
(2) Contractor shall cooperate with the EQRO and shall provide whatever records
and information is requested by the EQRO for purposes of the EQR. Contractor
may direct EQRO to obtain the requested information from DMAP if Contractor
already has submitted the requested information to DMAP. Contractor shall
require, through written agreements with Contractor’s Subcontractors, a
requirement that the Subcontractors shall cooperate with and provide all the
records and information the EQRO may request.
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(3) If the EQRO identifies an adverse health situation, the EQRO shall immediately
report the findings to DMAP and Contractor. Upon receipt of such report
Contractor shall assign a staff person(s) to follow-up with Participating
Providers, assure that necessary care is provided, and report on the results to
DMAP and the EQRO. If determined by DMAP, at the recommendation of the
EQRO, Contractor shall develop and comply with a Corrective Action Plan as
specified by DMAP.
(4) EQRO will provide the results of the EQR to the Contractor, to DMAP and upon
request to CMS, Office of Inspector General, and the United States Comptroller
General.
c. DMAP Quality Improvement Evaluation (QIE)
42 CFR 438.202 requires DMAP to have a strategy for assessing and improving the
quality of Capitated Services offered, ensuring compliance with standards established
by DMAP, and to conduct periodic reviews to evaluate the effectiveness of the
strategies. The QIE is one form of periodic review of Contractor’s Quality and
Performance Improvement Program (QPI) and the State quality improvement strategy.
Contractor shall cooperate with DMAP and supply those records and information
required by Contract and described in OAR 410-141-0200, OHP Prepaid Health Plan
Quality Improvement System, that are requested by the QI Team for the purposes of the
QIE review. The QI Team will review all requested and reported materials to determine
Contractor’s compliance with rules and Contract; to assess Contractor’s quality
improvement program, and to establish standards in determining the need for additional
review of appropriate medical management practices and utilization levels.
d. Contractor’s Quality and Performance Improvement Program must have ongoing
performance improvement projects for the Covered Services it provides to Contractor’s
DMAP Members. Contractor’s performance improvement projects must be designed to
achieve through ongoing measurements and intervention, significant improvement
sustained over time that are expected to have a favorable effect on DMAP Member
health outcomes and satisfaction. The provision to submit the status and results of
performance improvement projects shall survive for one year following the date of
Contract expiration or termination.
(1) Contractor must measure and report to DMAP the results of performance
improvement projects for the designated calendar year. Contractor must use
either the performance improvement projects identified in Paragraph (2) of this
subsection below and as specified in Schedule 2, or no less than one
performance improvement projects Contractor has initiated.
If Contractor chooses not to use the performance improvement projects
described in Schedule 2, Contractor-initiated performance improvement projects
must be reviewed by and have prior approval of DMAP and must focus on
clinical and non-clinical areas and involve the following:
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(a) Measurement of performance using objective quality indicators;
(b) Implementation of system interventions to achieve improvement in
quality;
(c) Evaluation of the effectiveness of the interventions;
(d) Planning and initiation of activities for increasing or sustaining
improvements; and
(e) Contractor must report the status and results of each Contractor-initiated
performance improvement project to DMAP annually in the Quality and
Performance Improvement (QPI) annual report described in this Exhibit
B, Part II, Section 3, Subsection e. Contractor‘s annual QPI Report will
consist of information supplied by Contractor during DMAP onsite visits
to Contractor’s organization or through Contractor’s written submission
of self-evaluation of Contractor’s QPI program. The onsite visits and/or
the written submission of self-evaluation for the current calendar year
will be due on a mutually agreed upon date specified by DMAP and
Contractor. This Paragraph (1) of this subsection shall survive Contract
termination or expiration.
(2) If Contractor does not initiate performance improvement projects meeting the
standards identified above, Contractor must use performance improvement
projects as outlined in Performance Improvement Projects (PIP) Schedule 2. The
current performance improvement projects include tobacco cessation and the
mental health/ physical health Collaborative PIP.
Written reports and re-measurement, as specified in Schedule 2, for tobacco
cessation shall be submitted by Contractor annually no later than August 1, 2009
(or on a date mutually agreed to by DMAP and Contractor) for the previous
calendar year. Additionally, Contractor shall submit the tobacco cessation
baseline by March 15, 2009. DMAP will complete Activity 1 for tobacco
cessation.
Written reports and re-measurement, as specified in Schedule 2 for the
Collaborative PIP shall be submitted by Contractor annually no later than
August 1, 2009 (or on a date mutually agreed to by DMAP and Contractor) for
the previous calendar year. Additionally, Contractor shall submit the
Collaborative PIP baseline by March 15, 2009. The Collaborative baseline
minimum requirement is Activity 1, 2 and 3. DMAP will complete Activity 1
for the mental health/ physical health Collaborative.
The results of reports and re-measurements will be made available by DMAP
annually for Contractor.
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(3) A Quality and Performance Improvement Workgroup will meet regularly
throughout each Contract Year. Contractor shall designate a liaison to
participate in the Quality and Performance Improvement Workgroup with
DMAP oversight to provide a review and approval of revised or newly
developed performance improvement projects to be specified in Schedule 2.
(4) The performance improvement project revisions to Schedule 2 shall be mutually
agreed to by DMAP and Contractor and incorporated either by amendment, as
designated in Exhibit D, Section 19 of this Contract, if additional or revised
performance projects are developed, or at Contract renewal. Requested changes
must meet the time lines for amendments or Contract renewal as stipulated by
DMAP. Revisions to performance projects and Schedule 2 that do not meet
DMAP’s time lines for revision will be incorporated at DMAP’s discretion.
(5) Contractor shall demonstrate sustainability of previous PIP topics.
Documentation of sustainability must be submitted as an inclusion of the QI
Annual Report.
(6) Notwithstanding the requirements in this section, in conformance with 42 CFR
438.240(a)(2), Contractor will comply with performance improvement projects
required by CMS, which will be coordinated by DMAP..
e. In conformance with 42 CFR 438.240, Contractor shall annually report the status of
Contractor’s QPI Program. Contractor’s annual QPI Program report will consist of
information supplied by Contractor during DMAP onsite visits to Contractor’s
organization and/or through Contractor’s written submission of self-evaluation of
Contractor’s QPI Program. The onsite visits and/or the written submission of self-
evaluation for the current calendar year will be due on mutually agreed upon dates
specified by DMAP and Contractor. The evaluation of the QPI program and DMAP
Member care shall include a description of completed and ongoing QI activities in
clinical and non-clinical areas, and an evaluation of the QPI program’s overall
effectiveness. Contractor may submit reports, materials or information that are relevant
to this Subsection e, Paragraphs (1), (2), (3), or (4) that Contractor had already
submitted to DMAP for QIE or to the EQRO. This evaluation shall include, but is not
limited to:
(1) Assessment of Contractor initiated performance improvement projects in clinical
and/or non-clinical areas. This includes projects to address access to, timeliness,
quality and appropriateness of care. Such projects may include review of:
clinical records, utilization reviews, referrals, co-morbitities, prior
authorizations, emergency services, out of Contractor’s network utilization,
medication review; Contractor initiated Disenrollments, encounter data
management, and access to care and services;
(2) Assessment of access to, timeliness, quality and appropriateness of care for
DMAP Members who are aged, blind, disabled or children receiving Child
Welfare or Oregon Youth Authority services (or DMAP Members with special
health care needs), including Contractor review of the Exceptional Needs Care
Coordination program, and any adverse events for the DMAP Members;
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(3) Results of review of Contractor’s utilization review mechanisms to detect both
under-utilization and over-utilization of services;
(4) A report on the process for adoption and dissemination of Contractor’s
evidenced-based clinical practice guidelines; and the identification of specific
adopted guidelines; and
(5) Contractor’s annual QPI report shall be submitted as designated in Exhibit B,
Part II, Section 3, Subsection e.
4. Credentialing
a. Contractor shall have written policies and procedures for collecting evidence of
credentials, screening the credentials, reporting credential information, as specified in
Exhibit K, and requiring recredentialing of Participating Providers, programs and
facilities used to deliver Covered Services, consistent with OAR 410-141-0120, Oregon
Health Plan Prepaid Health Plan Provision of Health Care Services, except as provided
in Subsection b, of this Section. These procedures shall also include collecting proof of
professional liability insurance.
b. If Participating Providers (whether employees or Subcontractors) are not required to be
licensed or certified by a State of Oregon board or licensing agency, Contractor shall
document, certify and report on Exhibit K the date that the person’s education,
experience, competence, and supervision are adequate to permit the person to perform
his or her specific assigned duties.
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EXHIBIT B –Statement of Work – Part III – Members
1. Informational Materials and Education of DMAP Members and Potential DMAP Members
a. Contractor shall provide all of Contractor’s enrollment notices, informational materials and
instructional materials relating to DMAP Members and Potential DMAP Members in a
manner and format that may be easily understood.
b. Contractor shall have in place a mechanism to help DMAP Members and Potential DMAP
Members understand the requirements and benefits of Contractor’s plan, consistent with the
requirements of OAR 410-141-0300, Oregon Health Plan Prepaid Health Plan Member
Education, and OAR 410-141-0280, Oregon Health Plan Prepaid Health Plan Informational
Requirements.
c. Contractor shall make written information available in the prevalent non-English languages in
its particular Service Area(s), using the criteria in OAR 410-141-0280(2).
d. Contractor shall make oral interpretation services available free of charge to each Potential
DMAP Member and DMAP Member. This applies to all non-English languages, not just
those that the DHS has identified as a prevalent language.
e. Contractor shall make its written material available in alternative formats and in an
appropriate manner that takes into account the special needs of those who, for example, are
visually limited or have limited reading proficiency. All DMAP Members and Potential
DMAP Members must be informed that Contractor’s written information is available in
alternative formats and how to access those formats.
f. Contractor shall develop informational materials for Potential DMAP Members. Contractor
shall also provide that information to DMAP as required by OAR 410-141-0280.
(1) Contractor shall provide DMAP with informational materials sufficient for the
Potential DMAP Member to make an informed decision about Contractor selection
and enrollment. A summary of the following information is sufficient, but Contractor
must provide more detailed information to the DMAP Member upon request:
(a) Names, locations, telephone numbers of, and non-English language spoken by
current Participating Providers, and including identification of Participating
Providers that are not accepting new patients. This information must include,
at a minimum, information on primary care physicians, specialists and
hospitals; and
(b) Identify any counseling or referral service that the Contractor does not cover
because of moral or religious objection.
(2) Contractor shall ensure that all Contractor’s staff who have contact with Potential
DMAP Members are fully informed of Contractor policies, including enrollment,
Disenrollment, Grievance and Appeal policies and the provision of interpreter services
including the Participating Providers’ offices that have bilingual capacity.
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g. Contractor must furnish to each of its DMAP Members the information specified in 42 CFR
438.10(f)(6) and 42 CFR 438.10(g), if applicable, within a reasonable time after the
Contractor receives notice of the recipient’s enrollment from the State. Contractor shall
notify all DMAP Members of their right to request and obtain the information described in
this paragraph at least once a year.
h. Contractor shall provide written notice to affected DMAP Members of any Material Change
in the information described in Subsection g, of this section, that is reasonably likely to
impact the affected DMAP Members’ ability to access care or services from Contractor’s
Participating Providers. Such notice shall be provided at least 30 days prior to the effective
date of those changes, or as soon as possible if the Participating Providers(s) has not given the
Contractor sufficient notification to meet the 30 days notice requirement. DMAP will review
and approve such materials within two (2) Business Days.
2. DMAP Member Rights
a. Contractor shall require, and cause its Participating Providers to require, that DMAP
Members are treated with respect, due consideration for his or her dignity and privacy, and the
same as non-DMAP Members or other patients who receive services equivalent to Covered
Services consistent with the requirements of this Contract and OAR 410-141-0320, OHP
Member Rights and Responsibilities.
b. Contractor shall comply with, and require its staff, Subcontractors and Participating Providers
to comply with, any applicable federal and State laws that pertain to DMAP Member rights,
and shall take those rights into account when furnishing services to DMAP Members.
c. Contractor shall provide equal access for both males and females under 18 years of age to
appropriate facilities, services and treatment under this Contract, consistent with DMAP’s
obligations under ORS 417.270.
d. Contractor shall allow each DMAP Member to choose his or her health professional from
available Participating Providers and facilities to the extent possible and appropriate. For a
DMAP Member in a Service Area serviced by only one PHP, any limitation the Contractor
imposes on his or her freedom to change between PCPs may be no more restrictive than the
limitation on Disenrollment under Exhibit B, Part III, Section 4, Subsection b, of this
Contract.
e. Contractor shall require, and cause its Participating Providers to require, that DMAP
Members receive information on available treatment options and alternatives, presented in a
manner appropriate to the DMAP Member’s condition and ability to understand.
f. Contractor shall require, and cause its Participating Providers to require, that DMAP
Members be allowed to participate in decisions regarding their health care, including the right
to refuse treatment and to express preferences about future treatment decisions.
g. Contractor shall ensure DMAP Members are free from any form of restraint or seclusion used
as a means of coercion, discipline, convenience or retaliations specified in federal regulations
on the use of restraints and seclusion.
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h. Contractor shall make oral interpretation services available free of charge to each Potential
DMAP Member and DMAP Member. This applies to all non-English languages not just those
that DHS identifies as prevalent.
i. Contractor shall notify its DMAP Members and Potential DMAP Members that oral
interpretation is available for any language and that written information is available in
prevalent non-English languages in Contractor’s particular Service Area(s).
j. Contractor shall notify its DMAP Members how to access oral and written interpretation
services.
k. Contractor shall make a good faith effort to provide its DMAP Members written notice of
termination of a Participating Provider. Notice must be issued within 15 days after receipt or
issuance of the termination notice, to each enrolled DMAP Member who received his or her
primary care from, or was seen on a regular basis by, the terminated Participating Provider.
l. Contractor shall ensure, and cause its Participating Providers to ensure, that DMAP Members
may request and receive a copy of his or her medical records and request that they be
amended or corrected as specified in 45 CFR Part 164.
m. Contractor shall ensure, and shall cause its Participating Providers to ensure, that each DMAP
Member is free to exercise his or her rights, and that the exercise of those rights does not
adversely affect the way the Contractor, its staff, Subcontractors or Participating Providers,
treat the DMAP Member. Contractor shall not discriminate in any way against Contractor’s
DMAP Members when those DMAP Members exercise their rights under the OHP.
n. At a DMAP Member’s request, Contractor shall provide information on the structure and
operation of the Contractor’s organization and any physician incentive plan. Contractor shall
provide information on advance directives as required in Exhibit E, Section 15, of this
Contract.
o. Any cost sharing authorized under this Contract for DMAP Members must be in accordance
with 42 CFR 447.50 through 42 CFR 447.60 and with the General Rules.
3. Grievance System
a. Each time a Covered Service or benefit will be 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 Intended Action (NOA) to the affected DMAP Member at least 10
Business Days before the date of the Action unless there is documentation that the DMAP
Member 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.
b. Contractor shall have written procedures approved in writing by DHS for accepting,
processing and responding to all Grievances and Appeals from DMAP 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 DMAP Members with a disability or limited English proficiency.
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DHS reviews the Contractor’s procedures for compliance with the requirements of Exhibit N
and OAR 410-141-0260 through OAR 410-141-0266, as well as any applicable federal
requirements, including 42 CFR 438.
c. In the event a DMAP Member or their Representative requests an Administrative Hearing
from DMAP, Contractor shall comply with the requirements of Exhibit N and OAR 410-141-
0264, Administrative Hearings.
d. Contractor shall maintain a log of all DMAP Member Grievances and Appeals. The log shall
identify the DMAP Member, the date of the Grievance, the resolution and the date of
resolution. Contractor shall retain Grievance and Appeal logs for 7 years. This provision shall
survive expiration or termination of this Contract.
e. Contractor shall provide to DMAP a quarterly report summarizing DMAP Member
Grievances, using the report format in Exhibit L.
f. Contractor and its Subcontractors shall cooperate with DHS’ ombudsman and DHS’ hearing
representatives in all of DHS’ activities related to DMAP Member Grievances, Appeals, and
Administrative Hearings.
g. Contractor shall inform DMAP Members about the Contractor’s Grievance and Appeal
procedures and timeframes, the availability of assistance in the filing process, the toll-free
numbers that a DMAP Member can use to file a Grievance or Appeal by phone, how to
request continuation of benefits (and DMAP 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 DMAP Member), and how to access a DMAP Administrative Hearing at the
time of the DMAP Member’s enrollment.
4. Enrollment and Disenrollment
a. Enrollment
(1) “Enrollment” is the process by which DHS signs on with a particular Contractor those
OHP Clients who have been determined to be eligible for services under the OHP
Medicaid Demonstration Project and/or the Children's’ Health Insurance Program.
Enrollment is voluntary on the part of the DMAP Member, except in the case of
mandatory Enrollment, pursuant to OAR 410-141-0060. DHS will sign on such OHP
Clients with the contractor selected by the OHP Client unless, pursuant to OAR 410-
141-0060, DHS assigns the OHP Client to a contractor because the OHP Client failed
to select a contractor. Automatic reenrollment” of a DMAP Member with the same
contractor occurs if the DMAP Member is disenrolled solely because he or she loses
Medicaid eligibility for a period of 2 months or less.
Except as otherwise provided in this Section 4, 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
by DHS, unless DMAP and/or Contractor have closed Enrollment with Contractor as
described in Paragraph (3) Item (a) of this subsection. Contractor shall not
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discriminate against individuals eligible to enroll on the basis of race, color, or
national origin, and shall not use any policy or practice that has the effect of
discriminating on the basis of race, color, or national origin.
(2) Contractor may be assigned OHP Clients during periods of open Enrollment, during
which periods Contractor shall accept, without restriction, all eligible OHP Clients in
the order in which they apply and are signed on by DHS.
(a) A period of open Enrollment shall commence on the first day of the month
after the month in which DMAP determines that the Contractor’s Enrollment is
20% or more below their Enrollment limit, established in Part V, Section 2 of
this Contract.
(b) Enrollment shall remain continuously open until the first day of the month
after the month in which DMAP determines that the Contractor’s Enrollment is
20% or less above their Enrollment limit established in Part V, Section 2 of
this Contract.
(c) Contractor shall have not less than 30 continuous days of open Enrollment
every Contract Year. The open Enrollment periods for consecutive Contract
Years may not be more than 14 months apart. If these requirements could
cause Contractor to exceed the ceiling established in Paragraph (2), Item (b) of
this subsection, Contractor shall consult with DMAP about whether an
amendment of this Contract should be authorized.
(3) Enrollment may be closed by DMAP, or by Contractor notifying the designated
DMAP PHP Coordinator, because Contractor’s maximum Enrollment has been
reached or for any other reason mutually agreed to by DMAP and Contractor, or as
otherwise authorized under this Contract.
(a) Notification by Contractor to the DMAP PHP Coordinator shall be no less than
15 days prior to the anticipated closure date or a specified time period mutually
agreed to by DMAP and Contractor. The date DMAP receives notification
does not qualify as one of the 15 notification days.
(b) Notification by DMAP to Contractor shall be no less than 15 days prior to the
anticipated closure date or a specified time period mutually agreed to by
Contractor and DMAP. The date Contractor receives notification does not
qualify as one of the 15 notification days.
(4) If Contractor is assigned or transferred OHP Clients pursuant to Exhibit B, Part II,
Section 2 of this Contract, Contractor shall accept all assigned or transferred OHP
Clients without regard to the Enrollment exemptions in OAR 410-141-0060. This
provision does not apply to a Medicare Advantage plan’s fully dual eligible members.
Contractor will not, on the basis of health status or need for health services,
discriminate against Potential DMAP Members.
(5) Enrollment of OHP Clients with Contractor shall occur on a weekly and monthly
basis. For weekly Enrollment, a week shall begin on Monday and end the following
Sunday. If Enrollment is initiated by a DHS employee on or before Wednesday, the
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date of Enrollment shall be the following Monday. If Enrollment is initiated by a DHS
employee after Wednesday, the date of Enrollment shall be one week from the
following Monday. For monthly Enrollment, the date of Enrollment with Contractor
shall be the first of the month following the month-end cutoff (four (4) Business Days
before the end of the month). These dates of Enrollment shall apply in all cases
except:
(a) For newborns, whose mother was enrolled with Contractor at the time of birth,
the date of Enrollment with Contractor shall be the newborn’s date of birth;
(b) For persons who are enrolled with Contractor on the same day as they are
admitted to the hospital, Contractor shall be responsible for said
hospitalization. If the person is enrolled after the first day of the Inpatient stay,
the person shall be Disenrolled, and the date of Enrollment shall be the next
available Enrollment date following discharge from Inpatient hospital services;
(c) For persons who are re-enrolled within 30 days of Disenrollment, the date of
Enrollment shall be the date specified by DMAP, which may be retroactive to
the date of Disenrollment;
(d) For persons who are automatically re-enrolled with Contractor, the date of
Enrollment shall be the date specified by DMAP; and
(e) For adopted children or children placed in an adoptive placement, the date of
Enrollment shall be the date specified by DMAP.
(6) If DMAP enrolls an OHP Client with Contractor in error, and the erroneously enrolled
OHP Client has not received services from Contractor, DMAP may retroactively
Disenroll the DMAP Member from Contractor and enroll the OHP Client with the
originally intended contractor up to sixty (60) days from the date of the erroneous
Enrollment, and the Capitation Payment to Contractor shall be adjusted accordingly.
(7) Contractor shall provide Enrollment validation as described in Exhibit O of the
Contract.
b. Disenrollment
The requirements and limitations governing Disenrollments contained in 42 CFR 438.56,
Disenrollment Requirements, apply to all managed care arrangements whether Enrollment is
mandatory or voluntary, except to the extent that 42 CFR 438.56(c)(2)(i) is expressly waived
by CMS. If Contractor receives a request for Disenrollment from a DMAP Member or their
Representative, Contractor shall submit the request to DMAP within 10 business days.
(1) An individual is no longer a DMAP Member for purposes of this Contract as of the
effective date of the individual’s Disenrollment from Contractor, and as of that date,
Contractor is no longer required to provide services to such individual by the terms of
this Contract, unless the DMAP Member is hospitalized at the time of Disenrollment.
In such an event, Contractor is responsible for Inpatient hospital services until
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discharge or until the DMAP Member’s PCP determines that care in the hospital is no
longer Medically Appropriate. DMAP will assume responsibility for other services not
included in the Diagnostic Related Group (DRG).
(2) A DMAP Member may be Disenrolled from Contractor as follows:
(a) If requested orally or in writing by the DMAP Member or the Representative,
DHS may Disenroll the DMAP Member in accordance with OAR 410-141-
0000 and 410-141-0080(1)(b), OHP Disenrollment from PHPs, for the
following reasons:
(i) Without cause:
(A) After six months of DMAP Member’s Enrollment; or
(B) Upon automatic reenrollment (e.g., a recipient who is
automatically reenrolled after being disenrolled, solely because
he or she loses Medicaid eligibility for a period of 2 months or
less), if the temporary loss of Medicaid eligibility has caused
the DMAP Member to miss the annual disenrollment
opportunity; or
(C) Whenever the DMAP Member’s eligibility is re-determined by
DHS.
(ii) With cause:
(A) At any time;
(B) The DMAP Member has Disenrolled from a Medicare
Advantage plan;
(C) The DMAP Member receiving Medicare requests
Disenrollment from Contractor who is the corresponding
Medicare Advantage plan;
(D) The Contractor does not, because of moral or religious
objections, cover the service the DMAP Member seeks;
(E) The DMAP Member needs related services to be performed at
the same time, not all related services are available within the
network, and the DMAP Member’s PCP or another Provider
determines that receiving the services separately would subject
the DMAP Member to unnecessary risk; or
(F) 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 DMAP Member’s health care needs. Examples of sufficient
cause include but are not limited to:
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(I) The DMAP Member moves out of the Contractor’s
Service Area;
(II) It would be detrimental to the DMAP Member’s health
to continue Enrollment;
(III) The DMAP Member is a Native American or Alaskan
Native; or
(IV) For continuity of care.
The effective date of Disenrollment when requested by a DMAP Member shall
be the first of the month following DHS’ approval of Disenrollment. The
effective date of Disenrollment for DMAP Members who Disenroll from
Contractor’s Medicare Advantage plan shall be the first of the month that their
MedicareAdvantage Disenrollment is effective. If the DHS fails to make a
Disenrollment determination by the first day of the second month following the
month in which the DMAP Member files a request for Disenrollment, the
Disenrollment is considered approved.
(b) DHS may Disenroll a DMAP Member upon request by Contractor because the
DMAP Member:
(i) Is unruly or abusive to others (except as excluded in Paragraph (2),
Item (d), (iv) or (v) of this subsection;
(ii) Threatens or commits an act of physical violence pursuant to OAR 410-
141-0080;
(iii) Committed fraudulent or illegal acts such as permitting the use of his or
her DMAP Medical Care Identification by another person pursuant to
OAR 410-141-0080;
(iv) Is suspected of altering a prescription;
(v) Is suspected of theft or other criminal acts committed in any Provider’s
or Contractor’s premises;
(vi) Otherwise misused the Medical Assistance Program; or
(vii) Satisfies any of the other reasons specified in OAR 410-141-0080(2),
except non-payment of co-payments under OAR 410-141-0080
(2)(A)(vi).
Contractor must submit requests for Disenrollment in writing, detailing the
specific reason as required in OAR 410-141-0080(2)(a)(C) and this Contract,
to their PHP Coordinator for prior approval except where otherwise specified
in OAR 410-141-0080.
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(c) DHS may Disenroll the DMAP Member and other individuals in the DMAP
Member’s Benefit Group in accordance with OAR 410-141-0080, OHP
Disenrollment from PHPs. The effective date of Disenrollment when requested
by Contractor shall be the date of Contractor’s request for Disenrollment,
subject to any Administrative Hearing by the DMAP Member.
(d) Contractor shall not request Disenrollment of a DMAP Member for reasons
related to:
(i) An adverse change in the DMAP Member’s health status;
(ii) A need for health services;
(iii) Diminished mental capacity;
(iv) Uncooperative or disruptive behavior resulting from the DMAP
Member’s special needs (except when the continued Enrollment
seriously impairs Contractor’s ability to furnish services to either this
DMAP Member or other DMAP Members);
(v) A disability or any condition that is a direct result of their disability,
unless otherwise specified in OHP Administrative Rule; or
(vi) Other reasons specified in OAR 410-141-0080(2)(B).
(e) If DMAP determines that the DMAP Member has sufficient Third Party
Resources such that health care and services should be provided on a fee-for-
service basis instead of on a prepaid capitated basis, DHS may Disenroll the
DMAP Member. The effective date of Disenrollment shall be specified by
DMAP. If the DMAP Member or Representative Appeals the Disenrollment,
all DMAP Members of the enrolled Benefit Group will remain enrolled with
Contractor until the Administrative Hearing has been adjudicated.
(f) If DMAP determines that Contractor’s DMAP Member has enrolled with their
Employer Sponsored Insurance (ESI) through FHIAP, the effective date of the
Disenrollment shall be the DMAP Member’s effective date of coverage with
FHIAP.
(3) Contractor shall inform DMAP immediately upon receiving notice that a DMAP
Member has requested Disenrollment from or has been Disenrolled from Contractor’s
Medicare Advantage plan.
(4) If Contractor has knowledge of a DMAP Member’s change of address, or death,
Contractor shall notify DHS by using the toll-free number (800) 699-9075.
(a) If the DMAP Member moves out of Contractor’s Service Area(s), the effective
date of Disenrollment shall be the date specified by DMAP, which may be
retroactive.
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(b) If the DMAP Member dies, the effective date of Disenrollment shall be the end
of the month during which the death occurred. DMAP will recoup from
Contractor any Capitation Payments made after the date of Disenrollment.
(5) If the DMAP Member is no longer eligible under the Medical Assistance Program, the
effective date of Disenrollment shall be the date specified by DMAP.
(6) If DHS Disenrolls a DMAP Member retroactively, any Capitation Payments received
by Contractor after the effective date of Disenrollment shall be recouped by DMAP. If
the Disenrolled DMAP Member was otherwise eligible for the OHP, services they
received during the period of the retroactive Disenrollment may be eligible for fee-for-
service payment under DMAP rules.
(7) If DHS Disenrolls a DMAP Member due to a DHS administrative error and the
DMAP Member has not received services from another contractor, the DMAP
Member may be retroactively re-enrolled with Contractor up to sixty (60) days from
the date of Disenrollment.
(8) Disenrollment required by adjustments in Service Area or Enrollment shall be
governed by Exhibit B, Part II, Section 2 of this Contract.
c. Benefit Package Changes
The Weekly and Monthly Enrollment file (as described in Exhibit C, Section 4 of this
Contract) will identify Contractor’s DMAP Member eligibility status for either the Plus or the
Standard Benefit Package. The file does not include any historical data on DMAP Member’s
eligibility status. A benefit package change due to a DMAP Member's eligibility status may
constitute Disenrollment.
5. Identification Cards
Contractor shall issue identification cards to DMAP Members, unless waived by DMAP. Such
identification cards shall be for DMAP Members’ and Providers’ convenience only and shall confer
no rights to services or other benefits under this Contract. To be entitled to such services or benefits,
the holder of the identification card must, in fact, be a current DMAP Member with Contractor.
6. Marketing
a. Contractor shall not and cause its agents, Subcontractors, and Subcontractor’s agents to not
initiate contact nor market (as defined in OAR 410-141-0000) independently to potential OHP
Clients, directly or through any agent or independent contractor, in an attempt to influence an
OHP Client’s enrollment with Contractor, without the express written consent of DMAP.
Contractor may not conduct, directly or indirectly, door-to-door, telephonic, mail, electronic,
or other Cold Call Marketing practices (as defined in OAR 410-141-0000) to entice DMAP
OHP Client to enroll with Contractor, or to not enroll with another Contractor. Contractor or
Subcontractors or their agents shall not seek to influence an OHP Client’s enrollment with the
Contractor in conjunction with the sale of any other insurance.
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b. Subject to Subsection d, of this section, Contractor may engage in activities under Exhibit B,
Parts I through VI, or activities intended to provide outreach to Contractor’s existing DMAP
Members for the purpose of enhancing health promotion or education within Contractor’s
Service Area(s). Activities may include, but are not limited to, creation and distribution of
brochures, pamphlets, newsletters, posters, fliers, web sites, health fairs or sponsorship of
health-related events. Contractor may communicate with or involve Providers, caseworkers,
community agencies or other interested parties in such activities.
c. In determining whether or not Contractor has attempted to influence a DMAP Member’s
enrollment as prohibited in Subsection a, of this Section, the method of communication, by
itself, shall not constitute a violation. The message and/or content of the communication shall
be evidence of the Contractor’s intent.
d. Contractor shall provide to DMAP, for approval prior to use, the form and content of all
materials that reference benefits and/or coverage and Marketing Materials (as defined in OAR
410-141-0000). In the process of reviewing and approving Marketing Material, DMAP will
provide for consultation with a medical care advisory committee. Any Contractor
representative or agent serving on the advisory committee shall be excused from review of
Contractor’s materials. Messages strictly for the purpose of health promotion, health
education or outreach distributed to Contractor’s existing DMAP Members do not require
prior approval from DMAP.
e. Contractor shall ensure that DMAP Members are not intentionally misled about their options
by Contractor’s staff, activities or materials. Materials may not contain false, confusing or
misleading information. Contractor shall make available copies of all written Marketing
Materials to all DHS offices within Contractor’s Service Area(s). Statements that will be
considered inaccurate, false, or misleading include, but are not limited to, any assertion or
statement (whether written or oral) that:
(1) The Potential DMAP Member and DMAP Member must enroll with Contractor in
order to obtain benefits or in order to not lose benefits; or
(2) The Contractor is endorsed by CMS, the federal or State government, or similar entity.
f. Contractor shall comply with the information requirements of 42 CFR 438.10 to ensure that,
before enrolling, the Potential DMAP Member receives, from the Contractor or the DHS, the
accurate oral and written information he or she needs to make an informed decision on
whether to enroll with the Contractor.
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EXHIBIT B –Statement of Work – Part IV – Financial Matters
1. Financial Risk, Management and Solvency
a. Contractor shall demonstrate to DMAP through proof of financial responsibility that it is able to
perform the Work required under this Contract efficiently, effectively and economically and is
able to comply with the requirements of this Contract. As part of the proof of financial
responsibility, Contractor shall provide assurances satisfactory to DMAP that Contractor’s
provision(s) against the risk of insolvency are adequate to ensure that DMAP Members will not
be liable for Contractor’s debts if Contractor becomes insolvent. Contractor shall also provide
risk protection against catastrophic or unexpected DMAP Member expenses related to Capitated
Services for DMAP Members.
b. Contractor shall submit to DMAP the following documentation for purposes of determining
Contractor’s financial responsibility:
(1) An annual audit performed by an independent certified public accountant or accounting
firm, containing but not limited to the information required in Exhibit G. Contractor shall
submit the annual audit to DMAP not later than June 30 following the last day of each
calendar year that this Contract is in effect. This provision shall survive for one year
following the date of Contract expiration or termination;
(2) Quarterly Financial Reports required in Exhibit G. Contractor shall submit the Quarterly
Financial Reports to DMAP no later than March 31, May 15, August 15 and November
15 of each year during which this Contract is in effect. This provision shall survive for
one year following the date of Contract expiration or termination;
(3) Net Worth Reports required to be submitted with Quarterly Financial Reports in Exhibit
G. The Net Worth Reports, shall demonstrate that Contractor has maintained a level of
net worth that will provide for a minimum adequate operating capital for each quarter
consistent with the calculations in Exhibit G. If Contractor fails to meet the required
premium to surplus ratio of 20:1, Contractor will be required to retain additional amounts
until Contractor has a premium to surplus ratio of 20:1;
(4) Provider Capacity Reports shall be submitted no later than March 31 of each year that
this Contract is in effect (identifying Contractor Provider panels in place as of January 1
of the Contract Year), as required in Exhibit K. This provision shall survive expiration or
termination of this Contract;
(5) Utilization reports shall be submitted at the same time as the Quarterly Financial Reports,
according to the instructions found in Exhibit G, Report G.4;
(6) Evidence of professional and general liability insurance coverage, required under Exhibit
F, of this Contract shall be submitted within 30 days of the Contract Effective Date and
within 10 days of any change in coverage;
(7) Contractor shall notify DMAP of its intent to update or change its data transaction
systems that interface with DHS’ data systems or transactions not later than 30 days
before making such update or change in order to allow appropriate compatibility testing
of any data interfaces with the DHS, if necessary; and
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(8) Contractor may submit any of the requested documentation electronically, in a format
acceptable to DMAP. If any of the information Contractor submits to DMAP that forms
the basis for determining the Contractor’s financial responsibility is eliminated, changed,
or modified in any manner, Contractor shall immediately notify DMAP. Failure to
comply with financial responsibility documentation requirements, including solvency
protection specified pursuant to the requirements of this Contract, shall be grounds for
termination or sanction under this Contract, at DMAP’s sole discretion.
c. Contractor shall provide solvency protection through maintenance of a restricted reserve account,
or other means approved by DMAP, in a manner and amount determined pursuant to the
calculation in Exhibit G. The restricted reserve account depository agreement or similar
instrument shall be submitted to DMAP, on the Effective Date of this Contract if it has not been
submitted prior to the Effective Date, and shall remain in effect throughout the period this
Contract is in effect without interruption, except on the written instruction of DMAP.
(1) Funds held in the restricted reserves shall be made available to DMAP for the purpose of
making payments to Providers in the event of Contractor’s insolvency. Insolvency occurs
when Contractor is unable to pay debts when due, even if assets exceed liabilities.
(2) If any of the information that forms the basis for determining the manner or amount of a
restricted reserve account is eliminated, changed, or modified in any manner, Contractor
shall immediately notify DMAP.
(3) Failure to maintain adequate financial solvency, including solvency protections specified
pursuant to the requirements of this Contract, shall be grounds for termination, reduction
in Service Area or enrollment, or sanction under this Contract, at DMAP's sole discretion.
(4) Contractor shall submit to DMAP the following documentation of protections against
insolvency:
(a) Quarterly calculation of restricted reserve amount(s);
(b) Restricted reserve Model Depository Agreement(s), surety bond(s) or evidence of
a unique Certificate of Authority number issued by DCBS, whichever is required
pursuant to Exhibit G of this Contract; and
(c) Contractor shall have procedures and policies to assure that DMAP Members will
not be liable for any debts or payment of Claims in the event a Subcontractor
becomes insolvent. All Subcontracts will include a clause that the Subcontractor
will look only to the Contractor, and under no circumstances to the DMAP
Member, for full payment of Claims, and shall further require that this clause
survives the termination of this Contract or Subcontract, including breach of
Contract or Subcontract due to insolvency.
(5) In the event that insolvency occurs, Contractor remains responsible for providing
Covered Services for DMAP Members through the end of the period for which it has
been paid and for its hospitalized DMAP Members until discharge.
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Contract #126667 Exhibit B Page 55 of 242
(6) Contractor understands and agrees that in no circumstances will a DMAP Member be
held liable for any payments for any of the following:
(a) The Contractor’s or Subcontractors’ debt due to Contractor’s or Subcontractors’
insolvency;
(b) Capitated Services authorized or required to be provided under this Contract to
the DMAP Member, for which:
(i) The State does not pay the Contractor; or
(ii) The Contractor does not pay a Provider or Subcontractor that furnishes the
services under a contractual, referral, or other arrangement; or
(c) Payments for Covered Services furnished under a contract, referral or other
arrangement with Contractors, to the extent that those payments are in excess of
the amount that the DMAP Member would owe if the Contractor provided the
services directly.
Nothing in this Paragraph (6) Item (c), limits Contractor, DHS, a Provider or
Subcontractor from pursuing other legal remedies that will not result in DMAP
Member personal liability for such payments.
d. Contractor assumes the risk of providing the Capitated Services required under this Contract;
except that Contractor shall obtain risk protection against catastrophic and unexpected expenses
related to Capitated Services for DMAP Members. Contractor is not required to obtain
catastrophic stop-loss protection.
e. Contractor may operate a physician incentive plan only if no specific payment is made directly
or indirectly under the plan to a physician or physician group as an inducement to reduce or limit
Medically Appropriate Covered Services furnished to an individual DMAP Member. Contractor
shall disclose to DMAP information about Physician Incentive Plans (PIP), which is defined to
mean “any compensation to pay a physician or physician group that may directly or indirectly
have the effect of reducing or limiting services furnished to a DMAP Member.” These Contract
requirements implement federal law and regulations to protect DMAP Members against
improper clinical decisions made under the influence of strong financial incentives.
(1) Contractor shall demonstrate compliance with PIP requirements by reporting to DMAP
the information required in Exhibit M. If the calculations required in Exhibit M
demonstrate that the Contractor’s PIP places physicians or physician groups at substantial
risk, as defined in Exhibit M, Contractor shall (1) establish and maintain the level of PIP
stop-loss protection required in Exhibit M, and (2) conduct the customer survey.
(2) Contractor shall provide to DMAP the information in Exhibit M not later than August 31
of each year this Contract is in effect. If any of the information that forms the basis for
determining substantial risk or the amount of stop-loss protection as defined in Exhibit
M, is eliminated, changed, or modified in any manner, Contractor shall immediately
notify DMAP.
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Contract #126667 Exhibit B Page 56 of 242
(3) At a DMAP Member’s request, Contractor shall provide information indicating whether
Contractor or any of its Subcontractors use a PIP that may affect the use of referral
services, the type of incentive arrangement(s) used, and whether PIP stop-loss protection
is provided. If Contractor is required to conduct a customer survey, it must also provide
DMAP Member requestors with a summary of survey results.
(4) Failure to maintain adequate stop-loss protection or to comply with survey or information
requirements in this Contract, including Exhibit M, shall be grounds for termination or
sanction under this Contract, at DMAP’s sole discretion.
f. DMAP may evaluate the adequacy of information provided and the sufficiency, in DMAP’s
discretion, of the evidence of financial responsibility, solvency and catastrophic protections, and
Physician Incentive Plan stop-loss protections obtained by Contractor for purposes of Subsection
e of this section. Contractor agrees to cooperate to make records and knowledgeable personnel
available to support or supplement documentation provided for purposes of this section.
g. If at any time DMAP believes that Contractor has incorrectly computed the amounts related to
these requirements, or that the coverage or protection amounts obtained by Contractor are
insufficient to meet these requirements, DMAP may notify Contractor of changes it requires.
Within 30 days of any notice by DMAP under this section, Contractor shall either make the
required changes or request an Administrative Review as defined in OAR 410-120-1580(4)-(5).
In the event an Administrative Review is requested and pending disposition of that review,
DMAP may require that Contractor take such actions as will assure financial responsibility and
solvency or PIP stop-loss protections as may be determined necessary.
2. Dual Payment
Except as specifically permitted by this Contract including Third Party Resources recovery, Contractor
and its Subcontractors may not be compensated for Work performed under this Contract from any other
department of the State, nor from any other source including the federal government.
Certain federal laws governing reimbursement of Federally Qualified Health Centers and Rural Health
Centers may require DMAP to provide supplemental payments to those entities, even though those
entities have subcontracted with Contractor to provide Covered Services. These supplemental payments
are outside the scope of this Contract and do not violate the prohibition on dual payment contained
herein. Contractor is required to maintain encounter data records and such additional Subcontract
information documenting Contractor’s reimbursement to Federally Qualified Health Centers and Rural
Health Centers, and to provide such information to DMAP upon request.
3. Claims Payment
a. Contractor may require Participating Providers to submit all billings for DMAP Members to
Contractor within four (4) months of the date of service, except under the following
circumstances:
(1) Billing is delayed due to eligibility issues;
(2) Medicare is the primary payer;
(3) Cases involving Third Party Resources;
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Contract #126667 Exhibit B Page 57 of 242
(4) Covered Services provided by Non-Participating Providers that are enrolled with DMAP;
or
(5) Other circumstances in which there are reasonable grounds for delay (which does not
include a Subcontractor’s failure to verify DMAP Member eligibility).
b. Contractor shall have written procedures for processing Claims submitted for payment from any
source. The procedures shall specify time frames for and include:
(1) Date stamping Claims when received;
(2) Determining within a specific number of days from receipt whether a Claim is valid or
non-valid;
(3) The specific number of days allowed for follow up of pended Claims to obtain additional
information;
(4) The specific number of days following receipt of additional information that a
determination must be made;
(5) Sending notice of the decision with Appeal rights to the DMAP Member when the
determination is made to deny the Claim;
(6) Making Appeal rights available upon request to a DMAP Member’s authorized
Representative who may be either a Participating Provider or a Non-participating
Provider when the determination is made to deny a Claim for payment; and
(7) The date of payment, which is the date of the check or date of other form of payment.
c. Contractor shall pay or deny at least 90% of Valid Claims within forty-five (45) days of receipt
and at least 99% of Valid Claims within sixty (60) days of receipt. Contractors shall make an
initial determination on 99% of all Claims submitted within sixty (60) days of receipt.
d. Claims that are subject to payment under this Contract by Contractor from Non-Participating
Providers who are enrolled with DMAP will be billed to Contractor consistent with the
requirements of OAR 410-120-1280, Billing, and OAR 410-120-1300, Timely Submission of
Claims. If a Provider is not enrolled with DMAP on the date of service, but the Provider
becomes enrolled pursuant to OAR 410-120-1260(6), Provider Enrollment, the Claim shall be
processed by Contractor as a Claim from a Non-Participating Provider. Payment of Non-
Participating Providers shall be consistent with the provisions of OAR 410-120-1340, Payment.
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Contract #126667 Exhibit B Page 58 of 242
EXHIBIT B –Statement of Work – Part V – Operations
1. Record Keeping
a. Clinical Records
Contractor shall maintain a Chemical Dependency Services record keeping system
adequate to fully disclose and document the condition of the DMAP Member and the
extent of Capitated Services received by DMAP Members
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 sound financial management and generate periodic financial
reports and make them available to DMAP consistent with requirements of OAR 410-
141-0340, OHP Prepaid Health Plan Financial Solvency, and the requirements of
Exhibit G (Solvency Plan Financial Reporting), Exhibit K (Provider Capacity Report),
and Exhibit M (Physician Incentive Plan Regulation Guidance).
Financial records, supporting documents, statistical records, and all other records
pertinent to this Contract shall be retained by Contractor for a period of five (5) years
from the date of submission of the final Claims for payment. If any litigation, Claim,
financial management review or audit is started before the expiration of the five (5) year
period, the records shall be retained until all litigation, Claims or audit findings
involving the records have been resolved and final action taken.
c. Client Process Monitoring System (CPMS) Data
The Client Process Monitoring System is a vital monitoring tool used by AMH to
provide documentation that DMAP Members received Chemical Dependency Services
and to provide data on access and service delivery of Chemical Dependency Services
under Exhibit B, Part I, Section 14. Contractor shall provide, and shall include a
provision in its contracts with Subcontractors for Chemical Dependency Services that
the Subcontractors shall provide, to AMH within 30 days of DMAP Member admission
or discharge all the information required by AMH's most current publication of “Client
Process Monitoring System”.
d. HIPAA Security, Data Transactions Systems and Privacy Compliance
For the provision of Capitated Services under this Contract, Contractor is a “Covered
Entity” for purposes of the Health Insurance Portability and Accountability Act, 42
USC § 1320-d et seq., and the federal regulations implementing the Act (collectively
referred to as “HIPAA”). 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 required to comply with this Contract and with HIPAA.
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Contract #126667 Exhibit B Page 59 of 242
(1) Data transactions systems: Contractor shall comply with the HIPAA standards
for electronic transactions published in 45 CFR Part 162 and the DHS EDT
Rules, OAR 410-001-0000 through 410-001-0200.
(2) Privacy: Contractor, its agents, employees and Subcontractors shall ensure that
Individually Identifiable Health Information (IIHI) of DMAP Members is
protected from unauthorized use or disclosure consistent with the requirements
of the HIPAA Privacy Rules in 45 CFR Parts 160 and 164 and as defined in
Exhibit D, Section 13, Access to Records and Facilities, Subsections a. and b.
(3) HIPAA Information Security. All information in any format about a DMAP
Member obtained by Contractor or its officers, employees, Subcontractors or
agents in the performance of the Work under this Contract, including
information obtained in the course of providing services, shall be defined as
“DMAP Member Information”. Contractor shall adopt and employ reasonable
administrative and physical safeguards consistent with the Security Rules in 45
CFR Part 164 to ensure that DMAP Member Information shall be used by or
disclosed only to the extent necessary for the permitted use or disclosure and
consistent with applicable State and federal laws and the terms and conditions of
this Contract. Security incidents involving DMAP Member Information must be
immediately reported to DHS’ Privacy Officer.
(4) Contractor shall require each Physician to have a unique provider identification
number that complies with 42 USC 1320d-2(b).
2. [Reserved]
3. Encounter Data
Encounter Data collection is a method that DMAP has established to provide verification that
services were actually provided to Contractor’s DMAP Members.
a. Encounter Data are records of health care services that have been provided to DMAP
Members in exchange for Capitation Payments. An “Encounter” is a service or bundle
of services provided to one DMAP Member by one Chemical Dependency Services
Provider (whether a Contractor employee or Subcontractor or Non-Participating
Provider for which Contractor is responsible for payment) in one time period.
b. Contractor shall submit Encounter Data to DMAP on a monthly basis pursuant to the
requirements of Exhibit H, Encounter Data Minimum Data Set Requirements and
Corrective Action.
c. Accuracy, completeness and timeliness of data submissions and resubmissions, as well
as availability of supporting medical records required in Exhibit H, are material
requirements of this Contract. Failure to comply with these requirements may result in
Corrective Action and/or such other Sanctions as DMAP may impose under Exhibit B,
Part VI, Section 2 of this Contract.
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Contract #126667 Exhibit B Page 60 of 242
d. The Encounter Data reporting requirements measure the provision of chemical
dependency care and services during a time period in which Contractor was providing
OHP Capitated Services. The Encounter Data reporting requirements expressly survive
the expiration or termination of this Contract. Termination of this Contract,
modification or reduction of the Contractor’s Service Area does not relieve Contractor
of its obligation to submit all required Encounter Data for dates of service applicable to
Contractor’s Service Areas while they were paid a Capitation Payment under this
Contract, nor does it relieve Contractor of the obligation to complete Corrective Action
plans or pay recovery costs related to Encounter Data obligations under Exhibit B, Part
VI, Section 2 of this Contract.
e. Data Certification and Validation.
Contractor shall comply with the requirements described in Exhibit H, Data
Certification and Validation. The requirements include, but are not limited to:
(1) Completion and required updates of the H.2 Signature Authorization Form;
(2) Concurrent submission of the H.3 Data Certification and Validation Report
Form with each Encounter Data submission; and
(3) Completion of the H.4 Claim Count Validation Acknowledgement and Action
Form as indicated pursuant to the instructions in Exhibit H.
An H.3 Data Certification and Validation Report Form submitted to DMAP that omits
required information will not meet the requirements of Certified and Validated Data and
will not be accepted by DMAP.
Failure by Contractor to comply with the requirements in Exhibit H will result in
Corrective Action and/or such other remedies or sanctions as DMAP may impose under
Exhibit B, Part II, Section 2, of this Contract.
When Corrective Action has been initiated by DMAP, Contractor may submit
documentation to DMAP citing specific circumstances which delay Contractor’s timely
submittal of the Data Certification and Validation Forms or Claim Count Verification
Acknowledgment and Action Forms. DMAP will review the documentation and make a
determination within ten (10) Business Days on whether the circumstances cited are
Acceptable.
4. (Reserved)
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Contract #126667 Exhibit B Page 61 of 242
EXHIBIT B –Statement of Work – Part VI – Relationship of Parties
1. DMAP Compliance Review
DMAP is authorized to monitor compliance with the requirements in the Statement of Work. Methods of
monitoring compliance may include review of documentation submitted by Contractor, Contract
performance review, Grievances, on-site review of documentation or any other source of relevant
information. Contractor agrees to cooperate to make records and facilities available for compliance
review, consistent with Exhibit D, Section 13 of this Contract. If compliance cannot be determined, or if
DMAP determines that Contractor is non-compliant with the requirements of the Contract, DMAP may
find Contractor has breached Contract requirements and may impose Sanctions under Exhibit B, Part VI,
Section 2, of this Contract, and pursue other remedies available under this Contract.
2. Sanctions
a. DMAP may impose sanctions, as specified in Subsection b. of this section, if it determines that
Contractor has acted or failed to act as described in this Subsection a. DMAP’s determination
may be based on findings from an onsite survey, DMAP Member or other complaints, financial
status or any other source. Conditions that may result in a Sanction under this section may
include when Contractor acts or fails to act as follows:
(1) Fails substantially to provide Medically Appropriate services that the Contractor is
required to provide, under law or under its Contract with DMAP, to a DMAP Member
covered under this Contract;
(2) Imposes on DMAP Members premiums or charges that are in excess of the premiums or
charges permitted under the Oregon Medical Assistance Program;
(3) Acts to discriminate among DMAP Members on the basis of their health status or need
for Chemical Dependency Services. This includes, but is not limited to, termination of
enrollment or refusal to reenroll a DMAP Member, except as permitted under the Oregon
Medical Assistance Program, or any practice that would reasonably be expected to
discourage enrollment by individuals whose condition or history indicates probable need
for substantial future Chemical Dependency Services;
(4) Misrepresents or falsifies any information that it furnishes to CMS or to the State, or its
designees, including but not limited to the assurances submitted with its application or
enrollment, any certification, any report required to be submitted under this Contract,
encounter data or other information relating to care or services provided to a DMAP
Member;
(5) Misrepresents or falsifies information that it furnishes to a DMAP Member, Potential
DMAP Member, or health care Provider;
(6) Fails to comply with the requirements for Physician Incentive Plans, as set forth in 42
CFR 422.208 and 422.210, and this Contract;
(7) Fails to maintain a Participating Provider Panel sufficient to ensure adequate capacity to
provide Covered Services under this Contract;
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Contract #126667 Exhibit B Page 62 of 242
(8) Fails to maintain an internal quality improvement program, or fraud and abuse prevention
program, or to provide timely reports and data required under Exhibit B, Part I through
Part VI, of this Contract;
(9) Fails to comply with Grievance and Appeal requirements, including required notices,
continuation or reinstatement of benefits, expedited procedures, compliance with
requirements for processing and disposition of Grievances and Appeals, and record
keeping and reporting requirements;
(10) Fails to pay for Emergency Services and post-emergency stabilization services or Urgent
Care Services required under this Contract;
(11) Fails to follow accounting principles or accounting standards or cost principles required
by federal or State laws, rule or regulation, or this Contract;
(12) Fails to make timely Claims payment to Providers or fails to provide timely approval of
authorization requests;
(13) Fails to disclose required ownership information or fails to supply requested information
to DMAP on Subcontractors and suppliers of goods and services;
(14) Fails to submit accurate, complete, and truthful Encounter Data in the time and manner
required by Exhibit H, “Encounter Data Minimum Data Set Requirements and Corrective
Action”, Schedule 4, “Pharmacy Data Requirements and Corrective Action”and Exhibit
H, Form H.3 “Data Certification and Validation;”
(15) Contractor distributes directly or indirectly through any agent or independent contractor,
marketing materials that have not been approved by the State or that contain false or
materially misleading information;
(16) Contractor fails to comply with a term or condition of this Contract, whether by default or
breach of this Contract. Imposition of a sanction for default or breach of this Contract
does not limit DMAP’s other available remedies; or
(17) Contractor violates any of the other applicable requirements of 42 USC §1396b(m) or
1396u-2 and any implementing regulations.
b. Sanctions that may be imposed include but are not limited to the following sanctions. The use of
one sanction by DMAP does not preclude the imposition of any other sanction or combination of
sanctions or any other remedy authorized under this Contract for the same deficiencies. DMAP
may:
(1) Assess a Recovery Amount in the amounts authorized in 42 USC 1396u-2(e)(2);
(2) Assess a Recovery Amount equal to one percent (1%) of Contractor’s last monthly
Capitation Payment immediately prior to imposition of the sanction, to be deducted from
Contractor’s next monthly Capitation Payment after imposition of sanction, except when
a Recovery Amount has been assessed under Paragraph (1) of this subsection;
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Contract #126667 Exhibit B Page 63 of 242
(3) Grant DMAP Members the right to Disenroll without cause (DMAP may notify the
affected DMAP Members of their right to Disenroll);
(4) Suspend all new enrollment, including default enrollment, or reduce the enrollment level
and/or the number of Contractor’s current DMAP Members after the effective date of the
sanction;
(5) Suspend payment for DMAP Members enrolled after the effective date of the sanction
until DMAP is satisfied that the reasons for imposition of the sanction no longer exists
and is not likely to recur;
(6) Require Contractor to develop and implement a plan that is acceptable to DMAP for
correcting the problem.
(a) At a minimum, the Corrective Action Plan must include:
(i) A written standard of conduct to be implemented by the Contractor that
corrects the specific areas of non-compliance and how that standard of
conduct will be established and maintained within Contractor’s and
Subcontractor’s (as applicable) organization; and
(ii) Designation of the person with authority within Contractor’s organization
charged with the responsibility of accomplishing and monitoring
compliance.
(b) If Contractor has not submitted a Corrective Action Plan that is acceptable to
DMAP within the specified time period or does not implement or complete the
Corrective Action within the specified time period, DMAP will proceed with
other sanctions or with termination of this Contract.
(7) If DMAP determines that there is continued egregious behavior that is described in
Exhibit B, Part II, Section 2, Subsection a., of this Contract; or that there is substantial
risk to DMAP Members’ health; or that action is necessary to ensure the health of DMAP
Members while improvements are made to remedy violations or until there is an orderly
termination or reorganization by Contractor:
(a) DMAP must require Contractor to implement temporary management
mechanisms, such as employment of consultants or other individuals or entities
approved by DMAP for the purpose, at Contractor’s expense;
(b) DMAP must grant DMAP Members the right to Disenroll without cause and
notify DMAP Members of the right to disenroll without cause;
(c) DMAP must not delay the imposition of temporary management mechanisms to
provide for Administrative Review before imposing this sanction; and
(d) DMAP must not terminate temporary management mechanisms until it
determines that Contractor can ensure that the sanctioned behavior will not recur.
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Contract #126667 Exhibit B Page 64 of 242
(8) Deny payments under this Contract for new DMAP Members when, and for so long as,
payment for those DMAP Members is denied by CMS in accordance with 42 CFR
438.730; or
(9) Any other sanctions reasonably designed to remedy and/or compel future compliance
with this Contract.
c. DMAP will notify the Contractor in writing of its intent to impose a sanction. The notification
shall explain the factual basis for the sanction, reference to the section(s) of this Contract or
federal or State law or regulation that has been violated, explain the actions expected of
Contractor, and state the Contractor’s right to file a request for Administrative Review with the
Director of DMAP in writing within 30 days of the date of the sanction notice. Notwithstanding
the preceding provision of this Subsection c., in cases in which DMAP determines that
conditions could compromise a DMAP Member’s health or safety or when DMAP acts pursuant
to Subsection b, Paragraph (7) of this section, DMAP may provisionally impose the sanction
before such Administrative Review opportunity is provided.
(1) Contractor shall make Recovery Amount payments in full to DMAP within 30 days of
the date of the sanction notice, unless Contractor has made a timely request for
Administrative Review pursuant to this Subsection c. above in which case Contractor
may withhold payment of a disputed amount pending the issuance of the Administrative
Review decision. Absent a timely request for Administrative Review, if Contractor fails
to make payment within 30 days of the sanction notice, DMAP will recoup the recovery
payment from Contractor’s future Capitation Payment(s) or as otherwise provided under
this Contract, until the Recovery Amount payment is satisfied.
(2) The Administrative Review process described in Subsections b, Paragraph (7) of this
section and this Subsection c, will be conducted in the same manner described in OAR
410-120-1580(4)-(6). Contractor understands and agrees that Administrative Review is
the sole avenue for review of sanction decisions under this Exhibit B, Part II, Section 2,
of this Contract.
d. Notice to CMS of Contractor Sanction
DMAP will give CMS’ Regional Office written notice whenever Contractor has a sanction
imposed or lifted by DMAP for one of the violations listed in this Section 2, Subsection a,
Paragraphs (1) through (6) or Paragraph (15). DMAP may, at DMAP’s discretion, give CMS’
Regional Office written notice whenever Contractor has a sanction imposed or lifted by DMAP
for any breach or violation of this Contract requirement excluding those specifically noted above.
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Contract #126667 Exhibit C Page 65 of 242
EXHIBIT C – Consideration
1. Payment Types and Rates
In consideration of all the Work to be performed under this Contract, DHS will pay Contractor
a monthly Capitation Payment for each DMAP Member, beginning with the date of enrollment
and ending with the date of Disenrollment, for those DMAP Members who are enrolled with
Contractor according to DHS records. The monthly Capitation Payment rate authorized for
each DMAP Member in the Rate Group identified in this Exhibit, Attachment 2, Capitation
Rates, is that amount indicated in this Exhibit, Attachment 2, for that particular Eligibility
Category as “Capitation Rate with Admin.” Where the date of a DMAP Member’s enrollment
or Disenrollment is during mid-month, the Capitation Payment for that DMAP Member shall
be prorated.
a. The general description of the actuarial basis for calculating Capitation Payments is
described in Exhibit C, Attachment 1, Calculation of Capitation Payment Rates.
The Covered Services described in Exhibit B, Part I, Section 2 have been divided into
categories of services. Categories of service describe but do not replace or supercede the
scope of Covered Services described in Exhibit B, Part I through Part VI; categories of
services are used to develop Capitation Payment rates as described in Exhibit C,
Attachment 2.
(1) Mandatory Categories of Services.
(a) For purposes of developing Capitation Rates, the following service
categories constitute the mandatory categories of Covered Services for
DMAP Members eligible for the Plus Benefit Package:
Chemical Dependency Services
(b) For purposes of developing Capitation Rates, the following service
categories constitute the categories of Covered Services for DMAP
Members eligible for the Standard Benefit Package:
Chemical Dependency Services
The Standard Benefit Package may exclude or limit some benefits in the
above listed service categories as described in OAR 410-120-1210,
Medical Assistance Benefit Packages and Delivery System.
(2) The Capitation Payments calculations result in a specific capitation rate schedule
applicable to this Contract, attached hereto and incorporated herein as Exhibit C,
Attachment 2, Capitation Rates.
(3) If Contractor has a contractual relationship with a designated Type A, Type B,
or rural critical access hospital, the Contractor and each said hospital shall
provide representations and warranties to DMAP:
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Contract #126667 Exhibit C Page 66 of 242
(a) That said contract establishes the total reimbursement for the services
provided to persons whose medical assistance benefits are administered
by the Contractor; and
(b) That hospital reimbursed under the terms of said contract is not entitled
to any additional reimbursement from DMAP for services provided to
persons whose medical assistance benefits are administered by
Contractor.
2. Payment in Full
The Capitation Payment rate indicated in Attachment 2, to this Exhibit, for each Eligibility
Category as “Capitation Rate with Admin.” is the rate authorized to be payable to the
Contractor from DHS per DMAP Member in the applicable Eligibility Category for all Work
provided under this Contract.
3. Changes in Payment Rates
The Capitation Payment rate established in Attachment 2, to this Exhibit may be changed only
by amendment to this Contract pursuant to Exhibit D, Section 19 of this Contract.
a. Changes in the Capitation Payment rate as a result of adjustments to the Service Area
and/or to the enrollment limit may be required pursuant to Exhibit B, Part II, Section 2
of this Contract.
b. The Capitation Payments authorized to be paid under this Contract are based on the
funded condition-treatment pairs on the Prioritized List of Health Services contained in
OAR 410-141-0520 in effect on the date this Contract is executed, subject to the terms
of this Contract.
(1) Pursuant to ORS 414.720, the Prioritized List of condition-treatment pairs
developed by the Health Services Commission may be expanded, limited or
otherwise changed. Pursuant to ORS 414.715 and 414.735, the funding line for
the services on the Prioritized List may be changed by the Legislature.
(2) In the event that insufficient resources are available during this Contract period,
ORS 414.735 provides that reimbursement shall be adjusted by eliminating
services in the order of priority recommended by the Health Services
Commission, starting with the least important and progressing toward the most
important.
(3) Before instituting reductions in Covered Services pursuant to ORS 414.735,
DHS is required to obtain the approval of the Legislative Assembly or the
Emergency Board if the Legislative Assembly is not in session.
(4) In addition, DHS will notify Contractor at least two weeks prior to any
legislative consideration of such reductions.
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Contract #126667 Exhibit C Page 67 of 242
(5) Adjustments made to the Covered Services pursuant to ORS 414.735 during this
Contract Year will be referred to the actuary who is under Contract with DMAP
for the determination of capitation rates. The actuary will determine any rate
modifications required as the result of cumulative adjustments to the funded list
of Covered Services based on the totality of the OHP rates for all Contractors
(total OHP rates).
(a) For changes made during the first year of the two year per capita cost
period since the list was last approved by the Legislative Assembly or
the Emergency Board, the actuary will consider whether changes are
covered by the trend rate included in the existing total OHP capitation
rate(s) and, thus, not subject to adjustment or are services moved from a
non-covered service to a Covered Service.
(b) If the net result under Paragraph (5) or (5)(a) above for services subject
to the adjustment is less than 1% of the total OHP rates, no adjustment to
the Capitation Payment rate(s) in Attachment 2, to this Exhibit will be
made.
(c) If the net result under Paragraph (5) or (5)(a) above is 1% or greater of
the total OHP rates, the Capitation Payment rate(s) in Attachment 2, to
this Exhibit will be amended pursuant to Exhibit D, Section 19 of this
Contract.
(d) The assumptions and methodologies used by the actuary to determine
whether the net result is more or less than 1% shall be made available to
Contractor.
(6) Any reductions made in Covered Services under ORS 414.735 shall take effect
no sooner than 60 days following final legislative action approving the
reductions. Any reductions in Covered Services or Capitation Payment rates
shall be made by amendment to this Contract.
(7) Contractor shall be responsible for all federal and State taxes applicable to
compensation or payment paid to Contractor under this Contract and, unless
Contractor is subject to backup withholdings, DHS will not withhold from such
compensation or payments any amount(s) to cover Contractor’s federal or State
tax obligations.
(8) Contractor is not eligible for any Social Security unemployment insurance,
workers’ compensation, or Public Employees’ Retirement System, benefits from
compensation or payments paid to Contractor under this Contract.
4. Timing of Capitation Payments
a. The date on which DHS will process Capitation Payments for Contractor’s DMAP
Members depends on whether the DMAP enrollment occurred during a weekly or
monthly enrollment cycle. DMAP/DSU will provide a schedule of enrollment end of
month deadlines for each month of the Contract period. On months where the first of
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Contract #126667 Exhibit C Page 68 of 242
the month falls on a Friday, Saturday or Sunday, Capitation Payments will be made
available to the Contractor no later than the 11th day of the month to which such
payments are applicable.
(1) Weekly Enrollment: For DMAP Members enrolled with Contractor during a
weekly enrollment cycle, Capitation Payments will be made available to
Contractor no later than two weeks following the date of enrollment, except for
those occurrences each year when the weekly and monthly enrollment start date
are the same day.
(2) Monthly Enrollment: For DMAP Members enrolled with Contractor during a
monthly enrollment cycle, Capitation Payments shall be made available to
Contractor by the 10th day of the month to which such payments are applicable,
except for those occurrences each year when the weekly and monthly Capitation
Payments coincide with each other.
b. Both sets of payments described in Subsection a, of this section shall appear on the
monthly Payment/Remittance Advice. To assist Contractor with enrollment and
Capitation Payment/Remittance Advice reconciliation, DHS will include in the
enrollment transaction the original adjustment amount and the Capitation/Premium paid
amount for each of Contractor's enrolled DMAP Members. The inclusion of this
information does not ensure or suggest that the two transaction files will balance. If
Contractor believes that there are any errors in the enrollment information, Contractor
shall notify DMAP by contacting their designated DMAP PHP Coordinator. Contractor
may request an adjustment to the Remittance Advice no later than 18 months from the
affected enrollment period.
c. DMAP will make retroactive Capitation Premium/Payments to Contractor for any
DMAP Member(s) erroneously omitted from the enrollment transaction files. Such
payments will be made to Contractor once DMAP manually processes the correction(s).
d. DMAP will make retroactive Capitation Premium/Payments to Contractor for newborn
DMAP Members enrolled with Contractor. Such payments will be made to Contractor
by the 10th day of the month after DMAP adds the newborn(s).
e. Services that are not Capitated Services provided to a DMAP Member or for any health
care services provided to OHP Clients who are not enrolled with Contractor are not
entitled to be paid as Capitated Premium/Payments. Fee-for-service Claims for payment
must be billed directly to DMAP by Contractor, its Subcontractors, or its Participating
Providers, all of which must be enrolled with DMAP in order to receive payment.
Billing and payment of all fee-for-service Claims shall be pursuant to and under DMAP
General Rules (Division 120).
5. Settlement of Accounts
a. If a DMAP Member is Disenrolled, any Capitation Payments received by Contractor
after the effective date of Disenrollment will be considered an overpayment and will be
recouped by DMAP from future Capitation Payments.
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Contract #126667 Exhibit C Page 69 of 242
b. DMAP will have no obligation to make any payments to Contractor for any period(s)
during which Contractor fails to carry out any of the terms of this Contract.
c. If Contractor requests, or is required by DMAP, to adjust the Service Area or
enrollment limit or to transfer or reassign DMAP Members due to loss of Provider
capacity or for other reasons, any delay in executing amendments or completing other
Contract obligations pursuant to Exhibit B, Part II, Section 2, Adjustments in Service
Area or enrollment, may result in recovery of Capitation Payments to which Contractor
was not entitled under the terms of this Contract.
d. Any payments received by Contractor from DMAP or DHS under this Contract, and
any other payments received by Contractor from DMAP or DHS, or any other source to
which Contractor is not entitled under the terms of this Contract shall be considered an
overpayment and shall be recovered from Contractor.
e. Sanctions imposed that result in Recovery Amounts pursuant to Exhibit B, Part VI,
Section 2 of this Contract are subject to recovery and shall be recovered from
Contractor.
f. Any overpayment and/or Recovery Amount under Exhibit B, Part II, Section 2 of this
Contract may be recovered by recoupment from any future payments to which
Contractor would be entitled from DMAP or the DHS, or pursuant to the terms of a
written agreement with DMAP, or by civil action to recover the amount. DMAP may
withhold payments to Contractor for amounts disputed in good faith and shall not be
charged interest on any payments so withheld.
g. The requirements of this section expressly survive the termination of this Contract, and
shall not be affected by any amendment to this Contract, even if amendment results in
modification or reduction of Contractor’s Service Area or enrollment. Termination,
modification, or reduction of Contractor’s Service Area does not relieve Contractor of
its obligation to submit documentation for dates of service applicable to Service Areas
while they were paid a Capitation Payment under this Contract, nor does it relieve
Contractor of the obligation to repay overpayment amounts or Recovery Amounts under
this section.
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Contract #126667 Exhibit C Page 70 of 242
EXHIBIT C – Consideration - Attachment 1 – Calculation of Capitation Payments
Capitation Rate Methodology
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 Analysis of
Federal Fiscal Years 2008-2009 Average Costs, dated September 22, 2006, 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 PwC
document Oregon Health Plan Medicaid Demonstration Capitation Rate Development, January
2009-December 2009, dated November 2008, which is by this reference incorporated herein.
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Contract #126667 Exhibit C Page 71 of 242
EXHIBIT C – Consideration - Attachment 2 – Capitation Rates
Oregon Health Plan Medicaid Demonstration
CDO Capitation Rates for January 2009 through December 2009
With Adjustments for Funding Through Line 503 of the 2008-2009 Prioritized List
Plan:Deschutes County CDO
Region:Other
Eligibility Category
Statewide
Capitation
Rate
Risk
Adjustment
Factor
Adjusted
Capitation
Rate
Capitation
Rate
with Admin,
MCO Tax
Capitation
Rate
with Admin
Temporary Assistance to Needy Families (Adults Only) $11.05 1.015 $11.21 $12.90 $12.19
Poverty Level Medical Adults $5.62 1.000 $5.62 $6.47 $6.11
PLM, TANF, and CHIP Children < 1 $0.01 1.000 $0.01 $0.01 $0.01
PLM, TANF, and CHIP Children 1 - 5 $0.00 1.019 $0.00 $0.00 $0.00
PLM, TANF, and CHIP Children 6 - 18 $1.11 1.030 $1.14 $1.31 $1.24
Aid to the Blind/Aid to the Disabled with Medicare $4.89 0.989 $4.83 $5.56 $5.25
Aid to the Blind/Aid to the Disabled without Medicare $8.12 0.991 $8.04 $9.25 $8.74
Old Age Assistance with Medicare $0.41 1.000 $0.41 $0.47 $0.44
Old Age Assistance without Medicare $0.04 1.000 $0.04 $0.05 $0.04
SCF Children $5.85 1.000 $5.85 $6.73 $6.36
OHP Families $3.60 1.109 $3.99 $4.59 $4.34
OHP Adults & Couples $19.37 1.147 $22.20 $25.54 $24.13
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Contract #126667 Exhibit D Page 72 of 242
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. Any
action or suit involving this Contract shall be filed and tried in Marion County, Oregon; provided,
however, that if a claim must be brought in a federal forum, then it shall be conducted solely and
exclusively within the United States District Court for the District of Oregon. In no event shall this
provision be construed as a waiver of the State’s sovereign immunity. Contractor, by execution of this
Contract, hereby consents to the in personam jurisdiction of said courts.
2. Compliance with Applicable Laws and Rules
a. Contractor shall comply and cause all Subcontractors to comply with all State and local laws,
rules, and regulations applicable to the 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 provision of prepaid capitated
health care and services, OAR Chapter 410, Division 141; and (iv) all other DHS Rules in OAR
Chapter 410. 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, any written material that is generated
and provided by Contractor under this Contract to DHS clients, including Medicaid-Eligible
Individuals, 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.
3. Independent Contractor
Contractor is not an officer, employee, or agent of the State of Oregon as those terms are used in ORS
30.265 or otherwise.
a. 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
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Contract #126667 Exhibit D Page 73 of 242
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.
b. 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.
c. 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.
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. DMAP certifies at the time this Contract is signed that sufficient funds are available and
authorized for expenditure to finance costs of this Contract within DMAP’s current appropriation
or limitation. However, continuation of this Contract, or any extension, after the end of the
biennium in which this Contract is signed, is contingent upon DMAP receiving sufficient
appropriations, limitations, or other expenditure authority to make payments as required under
this Contract. In the event the Oregon Legislative Assembly fails to approve sufficient
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Contract #126667 Exhibit D Page 74 of 242
appropriations, limitations, or other expenditure authority for the succeeding biennium, DMAP
may terminate this Contract effective upon written notice to Contractor with no further liability
to Contractor.
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 Medicaid services
6. Changes/Ownership
a. Contractor shall notify DMAP of any changes in the ownership of Contractor and provide
DMAP 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,
consistent with 42 CFR 455.100 through 42 CFR 455.104. If Contractor changes address,
licensure status as a health plan with DCBS or as a Medicare Advantage plan, or Federal Tax
Identification Number (TIN), Contractor shall notify DMAP within 30 days of the changes.
Failure to notify DMAP of a change, particularly a change in Federal Tax Identification Number,
may result in the imposition of a sanction from DMAP and may require Corrective Action to
correct payment records, as well as any other action required to correctly identify payments to
the appropriate TIN.
b. Contractor understands and agrees that DMAP through this Contract, Contractor is the “Entity”
that DMAP is engaging the expertise, experience, judgment, representations and warranties, and
certifications of the Contractor designated in this Contract. Contractor shall not transfer,
Subcontract, reassign or sell its contractual or ownership interests, such that Contractor is no
longer available to provide DMAP with its expertise, experience, judgment and representations
and certifications, without first obtaining DMAP’s prior written approval 60 days before such
transfer, subcontract, reassignment or sale occurs, except as otherwise provided in Exhibit B,
Part II, Section 2 of this Contract governing Adjustments in Service Area or enrollment, and
Exhibit D, Section 17, Subcontracting.
c. As a condition precedent to obtaining DMAP’s approval, not later than 60 days before the
transfer, subcontract, reassignment or sale occurs, Contractor shall provide to DMAP:
(1) The name(s) and address(es) of all directors, officers, partners, owners, or persons or
entities with beneficial ownership interest of more than 5% of the proposed new Entity’s
equity;
(2) Representation and warranty signed and dated by the proposed new Entity and by
Contractor that warrants and represents that the policies, procedures and processes issued
by the current Contractor will be those policies, procedures, or processes provided to
DMAP by the current Contractor or by an existing Contractor within the past two years,
and that those policies, procedures and processes still accurately describe those used at
the time of the ownership change and will continue to be used once DMAP has approved
the ownership change request, except as modified by ongoing Contract and
Administrative Rule requirements. If Contractor and the proposed new Entity cannot
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Contract #126667 Exhibit D Page 75 of 242
provide representations and warranties required under this subsection, DMAP shall be
provided with the new policies, procedures and processes proposed by the proposed new
Entity for review consistent with the requirements of this Contract;
(3) The financial responsibility and solvency information for the proposed new Entity for
DMAP review consistent with the requirements of this Contract;
(4) Contractor’s assignment/assumption agreement or such other form of agreement,
assigning, transferring, subcontracting or selling its rights and responsibilities under this
Contract to the proposed new Entity, including responsibility for all records and
reporting, provision of services to DMAP Members, payment of Valid Claims incurred
for dates of services in which Contractor has received a Capitation Payment, and such
other tasks associated with termination of Contractor’s contractual obligations under this
Contract. DMAP reserves the right to require Contractor to provide such additional
information and/or take such actions as may reasonably be required to assure full
compliance with Contract terms as a condition precedent to DMAP’s agreement to accept
the assignment/assumption or other agreement; and
(5) DMAP will review the information to determine that the proposed new Entity is qualified
to perform the Statement of Work and to assume rights and responsibilities of the
Contractor under this Contract. DMAP’s review will be based upon the requirements of
this Contract. DMAP reserves the right to require such additional information and/or
measures it deems appropriate as a condition precedent to DMAP’s agreement to accept
the assignment/assumption or other agreement.
d. Contractor shall disclose to DMAP within the notes of the Annual Audited Financial Reports any
sale, exchange or lease of any property, any lending of money or other extension of credit and
any furnishing for consideration of goods, services or facilities between the Contractor and any
party of interest, excluding regular business operation administrative expenses, such as
compensation and bonuses made to personnel. Party of interest is defined as 1) any director,
officer, partner, affiliate, or employee responsible for management or administration of the
Contractor, 2) any person who is directly or indirectly the beneficial owner of more than 5% of
the net worth of the Contractor, 3) any person who is the beneficial owner of a mortgage, deed of
trust, note, or other interest secured by, and valuing more than 5% of the Contractor, or 4) in the
case of a Contractor organized as a nonprofit corporation, an incorporator or member of such
corporation under applicable State corporation law.
7. Indemnification
CONTRACTOR SHALL DEFEND, SAVE, HOLD HARMLESS AND INDEMNIFY THE STATE OF
OREGON, AND ITS AGENCIES, SUBDIVISIONS, OFFICERS, EMPLOYEES, AND AGENTS FROM
AND AGAINST ALL CLAIMS, SUITS, ACTIONS, LOSSES, DAMAGES, LIABILITIES, COSTS AND
EXPENSES OF ANY NATURE WHATSOEVER RESULTING FROM, ARISING OUT OF, OR
RELATING TO THE ACTIVITIES OF CONTRACTOR OR ITS OFFICERS, EMPLOYEES,
SUBCONTRACTORS, OR AGENTS UNDER THIS CONTRACT; PROVIDED, THAT DMAP
SHALL PROVIDE CONTRACTOR WITH PROMPT WRITTEN NOTICE OF ANY SUCH CLAIM,
SUIT, ACTION OR PROCEEDING AND REASONABLE ASSISTANCE, AT CONTRACTOR’S
EXPENSE, IN THE DEFENSE THEREOF.
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Contract #126667 Exhibit D Page 76 of 242
CONTRACTOR SHALL HAVE CONTROL OF THE DEFENSE AND SETTLEMENT THEREOF, BUT
NEITHER CONTRACTOR NOR ANY ATTORNEY ENGAGED BY CONTRACTOR, SHALL
DEFEND THE CLAIM IN THE NAME OF THE STATE OF OREGON OR ANY AGENCY OF THE
STATE OF OREGON, NOT PURPORT TO ACT AS LEGAL REPRESENTATIVE OF THE STATE
OF OREGON OR ANY OF ITS AGENCIES, WITHOUT THE PRIOR WRITTEN CONSENT OF THE
OREGON ATTORNEY GENERAL. THE STATE OF OREGON MAY, AT ITS ELECTION AND
EXPENSE, ASSUME ITS OWN DEFENSE AND SETTLEMENT IN THE EVENT THAT THE STATE
OF OREGON DETERMINES THAT CONTRACTOR IS PROHIBITED FROM DEFENDING THE
STATE OF OREGON, IS NOT ADEQUATELY DEFENDING ITS INTERESTS, AN IMPORTANT
GOVERNMENTAL PRINCIPLE IS AT ISSUE, OR IT IS IN THE BEST INTEREST OF THE STATE
OF OREGON TO DO SO.
TO THE EXTENT PERMITTED BY ARTICLE XI, SECTION 7 OF THE OREGON
CONSTITUTION AND BY OREGON TORT CLAIMS ACT, THE STATE OF OREGON SHALL
INDEMNIFY, WITHIN THE LIMITS OF THE TORT CLAIMS ACT, CONTRACTOR AGAINST
LIABILITY FOR DAMAGE TO LIFE OR PROPERTY ARISING FROM THE STATE’S ACTIVITY
UNDER THIS CONTRACT, PROVIDED THE STATE SHALL NOT BE REQUIRED TO INDEMNIFY
CONTRACTOR FOR ANY SUCH LIABILITY ARISING OUT OF THE WRONGFUL ACTS OF
EMPLOYEES, SUBCONTRACTORS OR AGENTS 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 DMAP’s notice or such longer period as DMAP 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
DMAP’s notice or such longer period as DMAP 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:
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Contract #126667 Exhibit D Page 77 of 242
(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;
(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; or
(d) 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 DMAP determines that health or welfare of DMAP Members is in jeopardy if this
Contract continues; or
(6) If DMAP 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;
(b) That failure to amend this Contract to execute those changes in the time and
manner proposed in the amendment may place DMAP 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 the Contract within the time
allowed.
b. Default by DMAP
DMAP shall be in default under this Contract if:
(1) DMAP fails to pay Contractor any amount pursuant to the terms of this Contract, and
DMAP 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) DMAP 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 DMAP 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.
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Contract #126667 Exhibit D Page 78 of 242
9. Remedies for Default
a. DMAP’s Remedies
In the event Contractor is in default under Exhibit D, Section 8, of this Contract, DMAP 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 does not have a required DMAP
approval or has not met the service levels set forth in this Contract;
(3) Sanctions under Exhibit B, Part VI, Section 2 of this Contract;
(4) Initiation of an action or proceeding for damages, specific performance, declaratory or
injunctive relief; and
(5) Exercise of its right of setoff.
These remedies are cumulative to the extent the remedies are not inconsistent, and DMAP 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 of this
Contract, 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 DMAP terminates this Contract for convenience under Exhibit D, Section 10, or in
the event DMAP 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 DMAP 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 DMAP 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 ninety (90) days written notice by certified mail. If Contractor initiates termination,
DMAP has a right to full disclosure of Contractor’s records pertinent to Contractor’s
decision to terminate. Contractor shall promptly provide such disclosure to DMAP upon
demand;
(2) DMAP may terminate this Contract effective upon delivery of written notice to
Contractor, or at such later date as may be established by DMAP, under any of the
following conditions:
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(a) If DMAP funding from federal, State or other sources is not obtained, or is
withdrawn, reduced or limited, or if DMAP expenditures are greater than
anticipated, such that funds are insufficient to allow for the purchase of services
as required by this Contract; or
(b) If federal or State regulations or guidelines or CMS waiver terms are modified,
changed or interpreted in such a way that DMAP determines that 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.
(3) DMAP may by written notice of default or breach of Contract for circumstances
described in Exhibit D, Section 9, terminate the whole or any part of this Contract.
(4) Before terminating this Contract under Paragraph (3) of this subsection, DMAP shall:
(a) Provide Contractor with a written notice of its intent to terminate, the reason for
termination, and the opportunity to Provider appeal pursuant to OAR 410-120-
1560. Where termination is based on failure to comply with Corrective Action
under Exhibit B, Part II, Section 2 and Contractor has had an Administrative
Review on issues substantially similar to the basis for the termination decision,
such Administrative Review is deemed to satisfy the requirement for a pre-
termination hearing;
(b) After the hearing or Administrative Review, give Contractor written notice of the
decision affirming or reversing the proposed termination of this Contract and, for
an affirming decision, the effective date of the termination;
(c) After a decision affirming termination, give DMAP Members notice of the
termination and information on their options for receiving Medicaid services
following the effective date of the termination; and
(d) After DMAP notifies Contractor that it intends to terminate its Contract under
Paragraph (3) of this subsection, DMAP must give the affected DMAP Members
written notice of DMAP’s intent to terminate this Contract and allow affected
DMAP Members to Disenroll immediately without cause.
b. In the event of termination of this Contract or at the end of the term of this Contract if Contractor
does not execute a new Contract with DMAP, the following provisions shall apply to ensure
continuity of the Work by Contractor. Contractor shall ensure:
(1) Continuation of services to DMAP Members for the period in which a Capitation
Payment has been made, including Inpatient admissions up until discharge;
(2) Orderly and reasonable transfer of DMAP Member care in progress, whether or not those
DMAP Members are hospitalized;
(3) Timely submission of information, reports and records, including Encounter Data,
required to be provided to DMAP during the term of this Contract;
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(4) Timely payment of Valid Claims for services to DMAP Members for dates of service
included in the Contract Year; and
(5) If Contractor continues to provide services to a DMAP Member after the date of
termination, DMAP is only authorized to pay for services subject to DMAP rules on a
fee-for-service basis if the former DMAP Member is DMAP eligible and not covered
under any other DMAP Contractor. If Contractor chooses to provide services to a former
DMAP Member who is no longer DMAP eligible, DMAP shall have no responsibility to
pay for such services.
c. Upon termination, DMAP shall conduct an accounting of Capitation Payments paid or payable
and DMAP Members enrolled during the month in which termination is effective and shall be
accomplished as follows:
(1) Mid-Month Termination: For a 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 DMAP shall be entitled to a refund for the balance of the month.
(2) Responsibility for Capitated Payment/Claims: Contractor is responsible for any and all
Claims from Subcontractors or other Providers, including Emergency Service Providers,
for Capitated Services provided prior to the termination date.
(3) Notification of Outstanding DMAP Claims: Contractor shall promptly notify DMAP of
any outstanding Claims for which DMAP may owe, or be liable for, or a fee-for-service
payment(s), which are known to Contractor at the time of termination or when such new
Claims incurred prior to termination are received. Contractor shall supply DMAP with all
information necessary for reimbursement of such Claims.
(4) Responsibility to Complete Contractual Obligations: Contractor is responsible for
completing submission and corrections to encounter data for services received by DMAP
Members during the period of this Contract. Contractor is responsible for submitting
financial and other reports required during the period of this Contract.
(5) Withholding: Pending Completion of Contractual Obligations: DMAP shall withhold
20% of the Contractor’s last Capitation Payment until Contractor has complied with all
contractual obligations. DMAP’s determination of completion of Contractor’s contractual
obligations shall be no sooner than 6 months from the date of termination. Failure to
complete said contractual obligations within a reasonable time period shall result in a
forfeiture of the 20% withhold.
d. If this Contract expires as provided under Part I, Term and Approval, Subsection A., Contractor
shall comply with the requirements applicable to Contractor that are set forth in Subsection b.
and c of this section as if this Contract terminated.
11. Limitation of Liabilities.
a. 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.
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b. Contractor shall ensure that the DHS is not held liable for any of the following:
(1) Payment for Contractor’s or any Subcontractor’s debts or liabilities in the event of
insolvency; or
(2) Capitated Services authorized or required to be provided under this Contract.
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) DMAP;
(2) The Oregon Department of Human Services;
(3) The U. S. Centers for Medicare and Medicaid Services;
(4) The Comptroller General of the United States;
(5) The Oregon Secretary of State;
(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., of this section, Contractor and its agents, employees and
Subcontractors shall maintain all DMAP 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 of this Contract.
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(1) For the protection of DMAP 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 DMAP Member, his or her attorney, Representative, or except as
permitted by ORS 179.505 or by 2007 Senate Bill 163 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 DMAP 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 DMAP 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 DMAP Member information and records shall assure accuracy, backup for
retention, and safeguards against tampering, backdating, or alteration.
c. Contractor understands and agrees that information prepared, owned, used or retained by the
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
a. Neither Contractor nor DMAP shall be held responsible for delay or default caused by fire, riot,
war, and/or acts of God when they affect Contractor’s ability to perform the Work, which is
beyond either Contractor’s or DMAP’s reasonable control. Contractor or DMAP shall, however,
make all reasonable efforts to remove or eliminate such a cause of delay or default and shall,
upon the cessation of the cause, diligently pursue performance of its obligations under this
Contract.
b. If the rendering of services or benefits under this Contract is delayed or made impractical due to
a major disaster, epidemic, or labor dispute involving Contractor, care may be deferred until after
resolution of the labor dispute except in the following situations:
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(1) Care is needed for Emergency Services;
(2) Care is needed for Urgent Care Services; or
(3) Care is needed where there is a potential for a serious adverse medical consequence if
treatment or diagnosis is delayed more than sixty (60) days.
c. If a major disaster, epidemic, or labor dispute disrupts normal execution of Contractor duties
under this Contract, Contractor shall notify DMAP Members in writing of the situation and
direct DMAP 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 DMAP. 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 DMAP 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
(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 DMAP 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 shall ensure that all subcontracts meet the requirement described below and shall incorporate
portions of this Contract, as applicable, based on the scope of Work to be subcontracted.
a. Contractor is responsible for the quality of care and services and the timely and effective
performance of Work provided under the terms and requirements of this Contract. Subject to the
provisions of this section, Contractor may subcontract any or all of the Work to be performed
under this Contract. No Subcontract shall terminate or limit Contractor’s legal responsibility to
the DHS for the timely and effective performance of Contractor’s duties and responsibilities
under this Contract. Any and all Corrective Action, sanctions, recovery amounts and/or
enforcement actions are solely the responsibility of the Contractor.
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b. Before subcontracting of any Work, Contractor shall evaluate the prospective Subcontractor’s
ability to perform the Work under a subcontract.
c. Contractor shall have a written agreement (subcontract) that specifies the subcontracted Work
and reporting responsibilities of the Subcontractor. Contractor shall notify the DHS in writing of
Work to be subcontracted.
d. The following requirements of this Contract may not be subcontracted:
(1) Oversight and monitoring of quality improvement activities;
(2) Adjudication of final Appeals in a DMAP Member Grievance and Appeal process; and
(3) Financial responsibility, risk and solvency requirements of Exhibit B, Part IV, Section 1,
of this Contract.
e. Contractor’s agreement with the Subcontractor shall provide for the termination of the
Subcontract or imposition of other sanctions by Contractor if the Subcontractor’s performance is
inadequate to meet the requirements of this Contract.
f. Contractor shall monitor the Subcontractor’s performance on an ongoing basis and perform at
least once a year a formal review of compliance with delegated responsibilities and
Subcontractor performance, deficiencies or areas for improvement. Upon identification of
deficiencies or areas for improvement, the Contractor shall and shall cause Subcontractor to take
Corrective Action.
g. In addition to any other provisions that DMAP may require, Contractor shall include a provision
in all subcontracts that to the extent any provision in this Contract applies to Contractor with
respect to the Work Contractor is providing to DMAP under a subcontract, that provision shall
be incorporated by reference into the Subcontract and shall apply equally to Subcontractor.
h. Contractor shall ensure that all subcontracts meet the requirements described below and shall
incorporate portions of this Contract, as applicable, based on the scope of Work to be
subcontracted:
(1) Be in writing and incorporate each applicable requirement of this Contract, including the
following: Exhibit B, Part V, Section 1, Record keeping; Exhibit D, Section 19
Amendments, Exhibit D, Section 10 Terminations, Exhibit D, Section 7, Indemnification;
Exhibit D, Section 26, Tort Claims; Exhibit F, Insurance Requirements; Exhibit D,
Section 2, Compliance with Applicable Laws and Rules; Exhibit E, Required Federal
Provisions; and every other provision in this Contract that sets requirements for any of
the activities being subcontracted.
Contractor shall negotiate a rate of reimbursement with Fully Qualified Health Centers
(FQHCs) and Rural Health Centers (RHCs) 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 a FQHC or RHC consistent with the requirements of 42 USC
§1396b (m)(2)(A)(ix) and BBA 4712(b)(2);
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(2) Clearly identify the Work to be performed by the Subcontractor and what of that Work, if
any, the Subcontractor may further subcontract;
(3) Contain a provision requiring Subcontractor to comply with the requirements of 42 CFR
438.6 that are applicable to the Work required under the subcontract;
(4) Contain a provision that the Subcontractor shall not bill, charge, seek compensation,
remuneration or reimbursement from, or have recourse against the DHS or any DMAP
Member for Covered Services provided during the period for which Capitation Payments
were made by the DHS through DMAP to Contractor with respect to said DMAP
Member, even if Contractor becomes insolvent. Subcontractors and referral Providers
may not bill DMAP Members any amount greater than would be owed by the DMAP
Member if the Contractor provided the services directly (i.e., no balance billing by
Providers);
(5) 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;
(6) Contain a provision requiring the Subcontractor to comply with OAR 410-141-0420,
Billing and Payment under the OHP, when submitting Fee-for-Service Claims for OHP
services provided to DMAP Members that are not Covered Services under this Contract;
(7) 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; and by providing
Physician Incentive Plan stop-loss protection as required by Exhibit M;
(8) Contain a provision that health care Providers shall advise a DMAP Member who is the
patient of the Provider about the health status of the DMAP Member, or any service,
treatment or test that is Medically Appropriate but not authorized under the Plus or
Standard Benefit Package of Covered Services, Exhibit B, Part I, Section 2, of this
Contract or is subject to co-payments, if the Provider is acting within the lawful scope of
practice, and an ordinarily careful practitioner in the same or similar community would
do so under the same or similar circumstances;
(9) Contain a provision requiring the Subcontractor to provide notices of denials, reductions,
discontinuation or termination of services or service coverage consistent with the
requirements of OAR 410-141-0263, Notice of Action by a PHP, including but not
limited to:
(a) the DMAP Member’s right to an Administrative Hearing, how to obtain a hearing,
and representation rules at a hearing;
(b) the DMAP Member’s right to file grievances and Appeals and their requirements
and timeframes for filing;
(c) the availability of assistance in filing;
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(d) the toll-free numbers to file oral grievances and Appeals;
(e) the DMAP Member’s right to request continuation of benefits during an appeal or
Administrative Hearing filing and, if the Contractor’s action is upheld in a
hearing, the DMAP Member may be liable for the cost of any continued benefits;
and
(f) any State-determined provider appeal rights to challenge the failure of the
Contractor to cover a service.;
(10) If Contractor chooses to delegate the Grievance and Appeal process, except the
adjudication of final Appeals, Contractor shall require the Subcontractor to have written
policies and procedures for accepting, processing and responding to all Grievances and
Appeals from family members, and DMAP Members consistent with Exhibit B, Part III,
Section 3;
(11) Contain a provision that data used for analysis of delivery system capacity, consumer
satisfaction, financial solvency, encounter, utilization and quality improvement, and other
reporting requirements under this Contract must be provided to Contractor within time
frames sufficient to allow Contractor to meet its reporting requirements under this
Contract;
(12) Contain a provision that requires the Subcontractor to participate in internal or external
quality improvement activities of Contract, or those of the DHS, if requested to do so;
(13) 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
Record Keeping; Exhibit B, Part V, Section 1, Record Keeping;
(14) Contain a provision requiring the Subcontractor to maintain the confidentiality of DMAP
Member records and information as described in Exhibit D, Section 13, Access to
Records and Facilities;
(15) Contain a provision that requires the Subcontractor to cooperate with all processes and
procedures of child, elder, nursing home, developmentally disabled or mentally ill abuse
reporting, investigations, and protective services;
(16) Contain a provision that requires Subcontractor to comply with Contractor’s Fraud and
Abuse policies under Exhibit E, Section 2, and Exhibit J, Fraud and Abuse Reporting
Requirements, and to cooperate with all processes and procedures of fraud and abuse
investigations, reporting requirements, service verification and related activities by
Contractor, the DHS, or the Department of Justice Medicaid Fraud Control Unit; and
(17) Contain a requirement that the Subcontractor shall certify that all Claims submissions
and/or information received from the Subcontractor are true, accurate, and complete; and
that payment of the Claims by the Contractor will be from federal and State funds, and
therefore any falsification, or concealment of material fact by the Subcontractor when
submitting Claims may be prosecuted under federal and State laws.
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i. Contractor shall have written policies and procedures for selection and retention of Participating
Providers.
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
a. Except as specifically permitted by this Contract, the terms of this Contract shall not be waived,
altered, modified, supplemented or amended in any manner whatsoever without a duly executed
written amendment to this Contract. Any amendments to this Contract shall be effective only
when produced in writing and signed by all parties, and approved for legal sufficiency by the
Department of Justice, when required.
b. DMAP shall provide Contractor with an amendment if DMAP is required to amend this Contract
due to changes in federal or State statute or regulations, or due to changes in Covered Services
and Capitation Payments under ORS 414.735, and if failure to amend this Contract to execute
those changes in the time and manner proposed in the amendment may place DMAP at risk of
non-compliance with federal or State statute or regulations or the requirements of the Legislature
or Legislative Emergency Board. DMAP may provide Contractor with an amendment if the
DMAP actuary recalculates Standard population Capitation Payment rates under Exhibit C,
Section 3. DMAP will send to Contractor the necessary Contract amendment(s) no later than
fifteen (15) days before the proposed effective date of the amendment; and thirty (30) days for
review of a rate sheet before the proposed effective date of the amendment of the Capitation
Payment rates.
Any changes in the Capitation Payment rates under ORS 414.735 shall take effect on the date
approved by the Legislative Assembly or the Legislative Emergency Board. Any changes
required by federal or State law or regulation shall take effect not later than the effective date of
the federal or State law or regulation.
(1) If Contractor intends to accept the amendment(s), Contractor shall execute the
amendment in sufficient time to comply with the proposed effective date.
(2) If Contractor does not accept the amendment(s) in sufficient time to comply with the
proposed effective date, and if DMAP determines that the failure to implement the
amendment to this Contract would place DMAP at risk of non-compliance with federal or
State law or rules, DMAP shall provide written notice of its intent to terminate this
Contract pursuant to Exhibit D, Section 10 of this Contract and/or pursue other remedies
available to DMAP under this Contract.
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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 this 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
a. Except as otherwise expressly provided in this Contract, any communications between the
parties hereto or notices to be given hereunder shall be given in writing by personal delivery,
facsimile or mailing the same, postage prepaid, to Contractor or DMAP at the addresses or
facsimile numbers set forth in this section, or to such other addresses or facsimile numbers as
either party may hereinafter indicate pursuant to this section. Any communication or notice so
addressed and mailed shall be deemed to be given five (5) days after mailing. Any
communication or notice delivered by facsimile shall be deemed to be given when the
transmitting machine generates receipt of the transmission. To be effective against DMAP, such
facsimile transmission must be confirmed by telephone notice to DMAP’s Contract
Administrator. Any communication or notice by personal delivery shall be deemed to be given
when actually delivered.
(1) If to Contractor:
To the person designated as point of contact in the Part III, Section C of this Contract
captioned Status of Contractor at the address of the Contractor.
(2) If to a DMAP Member:
To the latest address provided for the DMAP Member on an address list, enrollment or
change of address form actually delivered to Contractor.
(3) If to DMAP:
DMAP Contract Administrator
Dept. of Human Services
500 Summer St. N.E.
Salem, Oregon 97301
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 this Contract to the extent possible.
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24. Headings/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 Contract 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 and
all necessary State of Oregon approvals have been obtained. 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 the signature below of its authorized representative, hereby acknowledges that
he or she has 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.
27. Counterparts
This Contract and any subsequent amendments, may be executed in several counterparts, all of which
when taken together shall constitute one Contract 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, 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 community mental health programs,
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, Fraud and
Abuse policies and procedures shall be reviewed annually. Contactor shall submit to DHS for
review and approval written Fraud 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
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Facilities. Violations shall be reported to DHS, DHHS and the appropriate Regional Office of the
Environmental Protection 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.
d. 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. HIPAA Compliance
If the Work funded in whole or in part with financial assistance provided under this Contract are
covered by the Health Insurance Portability and Accountability Act or the federal regulations
implementing the Act (collectively referred to as HIPAA), Contractor agrees to deliver the Work
in compliance with HIPAA. Without limiting the generality of the foregoing, Work funded in
whole or in part with financial assistance provided under this Contract are covered by HIPAA.
Contractor shall comply and cause all Subcontractors to comply with the following:
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a. Privacy and Security Of Individually Identifiable Health Information Individually
Identifiable Health Information about specific individuals is confidential. Individually
Identifiable Health Information relating to specific individuals may be exchanged between
Contractor and DHS for purposes directly related to the provision of services to Clients
which are funded in whole or in part under this Contract. However, Contractor shall not
use or disclose any Individually Identifiable Health Information about specific individuals
in a manner that would violate DHS Privacy Rules, OAR 410-014-0000 et. seq., or DHS
Notice of Privacy Practices, if done by DHS. A copy of the most recent DHS Notice of
Privacy Practices is posted on the DHS web site at
http://www.dhs.state.or.us/policy/admin/infosecuritylist.htm, or may be obtained from
DHS.
b. Data Transactions Systems If Contractor intends to exchange electronic data transactions
with DHS in connection with Claims or encounter data, eligibility or enrollment
information, authorizations or other electronic transaction, Contractor shall execute an
EDT Trading Partner Agreement with DHS and shall comply with the DHS EDT Rules.
c. Consultation and Testing If Contractor reasonably believes that the Contractor's or DHS'
data transactions system or other application of HIPAA privacy or security compliance
policy may result in a violation of HIPAA requirements, Contractor shall promptly consult
the DHS HIPAA officer. Contractor or DHS may initiate a request for testing of HIPAA
transaction requirements, subject to available resources and DHS testing schedule.
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 and Suspension
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.
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11. Drug-Free Workplace
Contractor shall comply and cause all Subcontractors to comply with the following provisions to
maintain a drug-free workplace:
a. 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;
b. 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;
c. Provide each employee to be engaged in the performance of services under this contract a
copy of the statement mentioned in Paragraph 11 a above;
d. Notify each employee in the statement required by Paragraph 11 a 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;
e. Notify DHS within ten (10) days after receiving notice under Subparagraph 11d from an
employee or otherwise receiving actual notice of such conviction;
f. 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;
g. Make a good-faith effort to continue a drug-free workplace through implementation of
Subparagraphs 11 a through 11 f;
h. Require any Subcontractor to comply with Subparagraphs 11 a through 11 g;
i. 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;
j. Violation of any provision of this subsection may result in termination of this Contract.
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12. Pro-Children Act
Contractor shall comply and cause all sub-contractors to comply with the Pro-Children Act of
1994 (codified at 20 USC Section 6081 et. seq.).
13. Medicaid Services
Contractor shall comply with all applicable federal and State laws and regulations pertaining to the
provision of Medicaid Services under the Medicaid Act, Title XIX, 42 USC Section 1396 et. seq.,
including without limitation:
a. Keep such records as are necessary to fully disclose the extent of the services provided to
individuals receiving Medicaid assistance and shall furnish such information to any State
or federal agency responsible for administering the Medicaid program regarding any
payments claimed by such person or institution for providing Medicaid 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).
b. Comply with all disclosure requirements of 42 CFR 1002.3(a) and 42 CFR 455 Subpart
(B).
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 Medicaid 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 Medicaid
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
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 to applicants for
services.
15. Clinical Laboratory Improvements
Contractor shall and shall ensure that any laboratories used by Contractor shall comply with the
Clinical Laboratory Improvement Amendments (CLIA 1988), 42 CFR Part 493 Laboratory
Requirements and ORS 438 (Clinical Laboratories, 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 a CLIA
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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 DMAP
Members receiving medical care by Contractor. Contractor shall provide adult DMAP 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 DMAP Members with respect to the
following:
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 DMAP 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 (PIP)
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 a DMAP Member. Contractor shall comply with all requirements of
Exhibit M, Practitioner Incentive Plan Regulation Guidance, to ensure compliance with Sections
4204 (a) and 4731 of the Omnibus Budget Reconciliation Act of 1990 that concern physician
incentive plans.
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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.
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:
(a) promptly report any contact with an applicant, bidder or offeror in writing
to DHS; and
(b) 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.
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(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
Americans with Disabilities Act (ADA) 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. OASIS
To the extent applicable, Contractor shall comply with, and shall require Subcontractors to comply
with, the OASIS reporting requirements and patient notice requirements for skilled services
provided by Home Health Agencies, pursuant to CMS requirements published in 64 FR3764, 64
FR 3748, 64 FR 23846, and 64 FR 32984, and such subsequent regulations as CMS may issue in
relation to the OASIS program.
23. Patient Rights Condition of Participation
To the extent applicable, Contractor shall comply with, and shall require Subcontractors to comply
with, the Patient Rights Condition of Participation (COP) that hospitals must meet to continue
participation in the Medicaid program, pursuant to 42 CFR Part 482. For purposes of this
Contract, hospitals include short-term, psychiatric, rehabilitation, long-term, and children’s
hospitals.
24. Federal Grant Requirements
The federal Medicaid rules establish that the 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 the DHS requires Contractor to supply information or
comply with procedures to permit the 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);
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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 OHP.
25. Provider’s Opinion
DMAP 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 OHP.
Contractor shall not prohibit or otherwise restrict a Health Care Professional from advising a
DMAP Member who is a patient of that professional about the health status of the DMAP Member
or treatment for the DMAP 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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EXHIBIT F – Insurance Requirements
During the term of this Contract, Contractor shall maintain in force at its own expense, each
insurance noted below:
1. Workers’ Compensation Coverage
All employers, including Contractor, that employ subject workers, as defined in ORS
656.027, shall provide workers’ compensation insurance coverage for those workers, and
must comply with ORS 656.017, unless they meet the requirements for an exemption
under ORS 656.126(2). Contractor shall require and ensure that each of its
Subcontractors complies with these requirements.
2. Professional Liability Insurance
Contractor shall maintain, and shall require that all persons and entities performing
services under this Contract (except Oregon Licensed Direct Entry Midwives, of whom
professional liability insurance is not required) obtain and keep in effect during the term
of this Contract, professional liability insurance which provides coverage of 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. Contractor shall
maintain and shall require coverage of not less than the amount of $1,000,000 per person
per incident and $1,000,000 in the aggregate;
3. General Liability Insurance
Contractor shall obtain and maintain 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. The policy shall be endorsed to also include contractual liability
coverage for the Indemnity provided under this Contract. The policy shall provide that
the State of Oregon, Department of Human Services, Division of Medical Assistance
Programs, and its officers and employees are Additional Insureds but only with respect to
Contractor’s services to be provided under this Contract.
4. Catastrophic coverage through stop-loss or re-insurance shall be maintained pursuant to
the requirements of the Statement of Work, Financial Solvency.
5. Physician Incentive Plan (PIP) stop-loss coverage shall be maintained pursuant to the
requirements of the Statement of Work, Financial Solvency.
6. Proof of insurance shall be provided to DMAP upon request. As evidence of the
insurance coverages required by this Contract, Contractor shall maintain acceptable
insurance certificates. The certificate shall specify all of the parties who are Additional
Insureds. Insuring companies are subject to DMAP acceptance. If requested, complete
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Contract #126667 Exhibit F Page 100 of 242
copies of insurance policies, trust agreements, etc. shall be provided to DMAP. The
Contractor shall be financially responsible for all pertinent deductibles, self insured
retentions, or self insurance, as applicable
7. 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 DMAP.
8. 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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EXHIBIT G – Solvency Plan and Financial Reporting
1. Background/Authority:
Contractor shall demonstrate to DMAP through proof of financial responsibility that it is able to perform
the Work required under this Contract efficiently, effectively and economically and is able to comply
with the requirements of this Contract. As part of the proof of financial responsibility, Contractor shall
provide assurance satisfactory to DMAP that Contractor’s provision(s) against the risk of insolvency are
adequate to ensure the ability to comply with the requirements of this Contract. Contractor shall submit
to DMAP all Reports attached to this Exhibit G as instructed in this Exhibit G.
2. Audited Financial Statements:
Contractor shall submit Audited Financial Statements to DMAP no later than June 30th following the
last day of each calendar year that this Contract is in effect, except as otherwise specified herein.
Audited Financial Statements shall be prepared by an independent accounting firm and shall include, but
are not limited to, the following information:
a. A statement of opinion by the independent accounting firm about the financial statements based
on the results of their audit;
b. A statement of opinion by an independent actuarial firm about the assumptions and methods used
in determining loss reserve, actuarial liabilities and related items;
Contractors regulated by DCBS may submit the same forms submitted to DCBS, except as
otherwise specified herein.
c. Balance Sheet(s). The information specified in Report G.5 shall be included in the Audited
Yearly Balance Sheet of Corporate Activity or the accompanying notes or schedules to Financial
Statements. Amounts reported on Report G.5 shall equal the amounts previously reported to
DMAP on Reports G.7 for the 1st, 2nd, 3rd, and 4th quarters of the calendar year. Contractor
shall amend prior Quarterly Financial Reports for audit adjustments and submit to DMAP no
later then June 30th, following the last day of each calendar year that this Contract is in effect.
Contractors regulated by DCBS shall submit the same forms submitted to DCBS and are not
required to submit the information specified in Report G.5.
d. Statement of Revenue, Expenses and Changes in Fund Balance. The information specified in
Report G.6 shall be included in the Audited Yearly Statement of Revenue, Expenses and
Changes in Fund Balance or the accompanying Notes to Financial Statements. Amounts
reported on Report G.6 shall equal the amounts previously reported to DMAP on Reports G.8 for
the 1st, 2nd, 3rd, and 4th quarters of the calendar year. Contractor shall amend prior Quarterly
Financial Reports G.8 for audit adjustments and submit to DMAP no later then June 30th,
following the last day of each calendar year that this Contract is in effect. Contractors regulated
by DCBS shall submit the Statement of Revenue, Expenses and Changes in Fund Balance
submitted to DCBS. Contractors regulated by DCBS shall submit audited financial results in the
format required by DCBS and shall prepare amended prior Quarterly Financial Reports G.8 for
audit adjustments no later then June 30th, following the last day of each calendar year that this
Contract is in effect.
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e. Statement of Cash Flow. The information specified in Report G.9 shall be included in the
Audited Cash Flow Analysis for Corporate Activity or the accompanying Notes to Financial
Statements. Contractor shall allocate cash flow using the Indirect Method of Accounting, as
described by GAAP. Contractor regulated by DCBS shall submit the Cash Flow analysis
submitted to DCBS, as described by NAIC.
f. Notes to Financial Statements; and
g. Any supplemental information deemed necessary by the independent accounting firm, actuary or
DMAP.
h. Audited Financial Statements and the accompanying Notes to Financial Statements shall include
information specified in Reports G.5, G.6, and G.9, attached to this Exhibit G. Contractor shall
use Generally Accepted Accounting Principles (GAAP) to define the information requested.
Contractors regulated by DCBS shall use National Association of Insurance Commission Annual
Statement Instructions and Accounting Practices and Procedures.
3. Quarterly Financial Reports:
Contractor shall report results of financial operations to DMAP quarterly unless annotated as an annual
requirement only. The reports identified below are included in this Exhibit G, and are incorporated
herein by this reference and shall be referred to collectively as the Quarterly Financial Reports.
Definitions and instructions for completing each report identified below have been included in this
Exhibit G.
a. Quarterly Financial Reports include, but are not limited to, the following.
(1) General Information and Certification (Form G.1)
(2) Report G.1: Restricted Reserves; attach verification of account balances
(3) Report G.2: DMAP Members Approaching or Surpassing Stop-Loss Deductible
(4) Report G.3: (Rescinded)
(5) Report G.4: OHP Access to Services Statistics
(6) Report G.7: Quarterly Balance Sheet of Corporate Activity
(7) Report G.8: Quarterly Statement of Revenue, Expenses and Net Worth
(8) Report G.9: Cash Flow Analysis for Corporate Activity
(9) Report G.10: Corporate Relationship of Contractors (Parts I, II and IV) (Part III is an
annual requirement only, due August 31st of the following year)
(10) Report G.11: Incurred but not reported
b. DMAP will supply Contractor with an Excel spreadsheet containing the Quarterly Financial
Reports. Contractor shall submit the Quarterly Financial Reports to DMAP in an electronic
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Contract #126667 Exhibit G Page 103 of 242
format approved by DMAP. Contractor has the option of submitting the Excel spreadsheet to
DMAP either electronically or by mailing a diskette containing the Quarterly Financial Reports
to DMAP.
c. Contractor shall submit Quarterly Financial Reports for the 1st, 2nd, and 3rd quarters to DMAP
60 days after the end of each calendar quarter. Contractor shall submit the Quarterly Financial
Reports for the 4th quarter three calendar months after the end of the calendar quarter, as
follows:
End of Quarter Due Date of Report
March 31st May 31st
June 30th August 31st
September 30th November 30th
December 31st March 31st
d. Contractor shall use Generally Accepted Accounting Principles (GAAP) to define the
information requested. Contractors regulated by DCBS shall use National Association of
Insurance Commission Annual Statement Instructions and Accounting Practices and Procedures.
Contractors regulated by DCBS and who have supplied documentation of having a Unique
Certificate of Authority Number issued by DCBS may submit the completed Health Maintenance
Organization filing or Health form filing provided to DCBS in lieu of submitting Reports G.7,
G.8, and G.9 provided they include an OHP Contract column on the “Statement of Revenue and
Expense”.
e. Contractor shall immediately notify DMAP of a Material Change in circumstance from the
information contained in the latest-submitted Quarterly Financial Reports. If the Material
Change in circumstances requires restatement of prior Quarterly Financial Reports, Contractor
shall amend the Quarterly Financial Reports and submit to DMAP within 15 working days of the
date the Material Change is identified.
f. Reports annotated as an annual requirement only will include all data from the prior calendar
year and are due on the dates specified on the reports.
4. Provider Capacity Report:
Contractors shall submit, in an electronic format acceptable to DMAP, a Provider Capacity Report,
including the information specified in Exhibit K of this Contract. The Provider Capacity Report shall be
submitted to DMAP by March 31st each year(s) this Contract is in effect and will include the
Contractor’s Provider panel as of January 1st of the calendar year.
5. Assumption of Risk/Private Market Reinsurance:
Contractor assumes the risk for providing the Capitated Services required under this Contract.
Contractor shall obtain risk protection in the form of stop-loss or reinsurance coverage against
catastrophic and unexpected expenses related to Capitated Services to DMAP Members.
a. If Contractor is a Federally Qualified Health Maintenance Organization, no stop-loss or
reinsurance is required for purposes of this Contract, and Contractor shall submit Report G.2
indicating that no reporting under Report G.2 is required.
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b. Contractor shall submit Report G.2, Part I, of Exhibit G along with the Quarterly Financial
Reports, due May 31st, August 31st, November 30th and March 31st. Contractor shall report
DMAP Members approaching or surpassing the deductible amount of stop-loss or reinsurance.
Report G.2 contains instructions necessary to complete the form.
c. At the time of application, or within 30 days of signing this Contract, and thereafter at the time of
filing the second Quarterly Financial Report on August 15th, Contractor shall report to DMAP
on Report G.2, Part II, of Exhibit G, the deductible amounts and the amount and associated type
of stop-loss or reinsurance coverage (e.g., hospital, medical or aggregate coverage), and the
dollar amount or percentage of Claim amount whereby responsibility for covering the Claim
reverts back to the Contractor from the re-insurer.
6. Evidence of General and Professional Liability Insurance Coverage:
Contractors shall obtain and maintain during the term of this Contract insurance coverage as discussed
below and provide verification upon DMAP’s request:
a. Professional Liability Insurance - Contractor shall maintain, and shall require that all persons
and entities performing services under this Contract (except Oregon Licensed Direct Entry
Midwives, of whom professional liability insurance is not required) obtain and keep in effect
during the term of this Contract, professional liability insurance which provides coverage of
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. Contractor shall
maintain and shall require coverage of not less than the amount of $1,000,000 per person per
incident and $1,000,000 in the aggregate.
b. General Liability Insurance - Contractor shall obtain and maintain 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. The policy shall be endorsed to also include contractual
liability coverage for the Indemnity provided under this Contract. The policy shall provide that
the State of Oregon, Department of Human Services, Division of Medical Assistance Programs,
and its officers and employees are Additional Insured’s but only with respect to Contractor’s
services to be provided under this Contract.
7. Restricted Reserve Requirement:
Contractors, unless exempt, shall establish: 1) Restricted Reserve Account and 2) maintain adequate
funds in this account to meet DMAP’s Primary and Secondary Restricted Reserve requirements.
Reserve funds are held for the purpose of making payments to Providers in the event of the Contractor’s
insolvency. The reserves discussed within this Contract cover only Capitated Services provided by
Contractor notwithstanding Restricted Reserve amounts required to be maintained pursuant to separate
contracts with the Department of Human Services.
Contractors Exempt from the Restricted Reserve Requirement: Contractor regulated by DCBS and
who provides evidence of a unique Certificate of Authority Number issued by DCBS is not required to
establish a Restricted Reserve Account or maintain Primary and Secondary Restricted Reserves as set
forth by DMAP. Contractor shall indicate on the Quarterly Financial Report G.1 that no documentation
is required and shall submit to DMAP annually, on August 31st, a copy of the Unique Certification of
Authority Number with documentation showing the type and amount of additional assets required by
DCBS.
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Contract #126667 Exhibit G Page 105 of 242
a. Restricted Reserve Account: Contractor shall establish a Restricted Reserve Account with a
third party financial institution for the purpose of holding Contractor’s Primary and Secondary
Restricted Reserve Funds. Contractors shall use the Model Depository Agreement to establish a
Restricted Reserve Account.
(1) Model Depository Agreement shall be used by the Contractor to establish a Restricted
Reserve Account. Contractor shall request the Model Depository Agreement form from
DMAP. Contractor shall submit the Model Depository Agreement to DMAP at the time
of application and the Model Depository Agreement shall remain in effect throughout the
period of time that this Contract is in effect. The Model Depository Agreement cannot be
changed without the Administrator or his/her designee’s written authorization.
(2) Withdrawal of Funds from a Restricted Reserve Account: The Contractor shall not
withdraw funds, change third party financial institutions, or change account numbers
within the Restricted Reserve Account without the written consent of the Administrator
of DMAP or his/her designee.
(3) Filing requirements: Contractor shall submit a copy of the Model Depository
Agreement at the time of application. If Contractor requests and receives written
authorization from the Administrator of DMAP or his/her designee to make a change to
their existing Restricted Reserve Account, Contractor shall submit a Model Depository
Agreement reflecting the changes to DMAP within 15 days of the date of the change.
(4) Eligible Deposits: The following instruments are considered eligible deposits for the
purposes of DMAP’s Primary and Secondary Restricted Reserves:
(a) Cash,
(b) Certificates of Deposit,
(c) Amply secured obligations of the United States, a state or a political subdivision
thereof as determined by DMAP, or
(d) A Surety Bond provided it meets the requirements listed below:
(i) Such a bond is prepaid at the beginning of the Contract Year for 18
months;
(ii) Evidence of prepayment is provided to DMAP;
(iii) The Surety Bond is purchased by a surety bond company approved by the
Oregon Insurance Division;
(iv) The Surety Bond Agreement contains a clause stating the payment of the
bond will be made to the third party entity holding the Restricted Reserve
Account on behalf of the contracting company for deposit into the
Restricted Reserve Account;
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Contract #126667 Exhibit G Page 106 of 242
(v) The Surety Bond Agreement contains a clause that no changes to the
Surety Bond Agreement will occur until approved by the DMAP
Administrator or his/her designee; and
(vi) DMAP approves the terms of the Surety Bond Agreement.
b. Primary and Secondary Restricted Reserves: Contractor’s Primary and Secondary Reserve
balances are determined by calculating the Average Fee-For-Service Liability for Capitated
Services using either of the following methods: A) Enrollment Data, or B) Historical Expense
Data. The Average Fee-For-Service Liability represents the cost of Covered Services that are
offered by the Contractor to DMAP Members that would be owed to creditors in the event of the
Contractor’s insolvency. These are expenditures for Covered Services for which Contractor is at
risk. These services may include out-of-area services, primary care services, referral services,
and hospital services. Determination of the cost is based on the usual and customary fee
schedule of Contractor that has been developed to approximate the estimated Capitated Service
liability of the Contractor. Contractor shall deposit into the Restricted Reserve Account the
amount required by Paragraph (3) and (4), of this subsection.
(1) Average Fee-For-Service Liability based on Enrollment Data: If Contractor elects to
calculate reserve balances based on Enrollment Data, Contractor shall complete Report
G.1, Part I and II. The Average Fee-For-Service Liability is calculated by multiplying
the Average Capitation Rate times the Average Monthly Enrollees times the Medical
Loss Ratio, as follows:
Step 1: Enter the following data:
Capitation Rates: Capitation Rates received for each month of the calendar quarter,
Exhibit C, Attachment 2. If Contractor provides services in more than one service area,
use the capitation rate for the service area with the largest number of monthly enrollees in
the third month.
DMAP Members Enrolled: DMAP Members eligible for full month added to the prorated
number of DMAP Members enrolled for less than a month.
Medical Loss Ratio (Restricted Reserve): Contractor may elect to use either the Adjusted
or Unadjusted Medical Loss Ratio, whichever method Contractor elects to use to
determine the Medical Loss Ratio shall be used throughout the Contract Year. The
Medical Loss Ratio is determined for purposes of calculating the fee-for-service liability:
Step 2: Determine the Medical Loss Ratio (Restricted Reserve):
(a) Restricted Reserve, Adjusted Medical Loss Ratio:
Total Medical and Hospital Expenses, (Report G.8, Line 21)
Less: Subcapitation or Salaried Medical Expenses (Report G.10.II,
Columns A, C, D, E, F and G)
Divided by: Total Revenue (Report G.8, Line 7)
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Contract #126667 Exhibit G Page 107 of 242
(b) Restricted Reserve, Unadjusted Medical Loss Ratio:
Total Medical and Hospital Expenses, (Report G.8, Line 21)
Divided by: Total Revenue (Report G.8, Line 7)
Step 3: Calculate the Average Fee-For-Service Liability. The Excel spreadsheet provided
by DMAP will calculate the following:
Average Capitation Rate
Times: Average DMAP Members Enrolled
Times: Medical Loss Ratio.
Equals: Average Fee-For-Service Liability
(2) Average Fee-for-Service Liability based on Historical Expense Data: If Contractor
has submitted Report G.8, Quarterly Statements of Revenue, Expenses, and Net Worth
under this Contract for the current quarter and the prior 3 quarters, Contractor is eligible
to use the Historical Expense Data method. The Average Fee-For-Service Liability is an
average of the prior four (4) quarters Historical Expense Data. No form has been
provided. DMAP will calculate a Contractor’s Average Fee-For-Service Liability using
the Historical Method as follows:
(a) Average of: (current quarter plus 3 prior quarters) Medical/Hospital/Dental
Expenses Less Deduction (Report G.8 Line 21),
(b) Average (current quarter plus 3 prior quarters) Capitation Payment Expenses
(Report G.10.II, Columns C, D, E, F and G); Plus: Salary Service Payment
Expenses (Report G.10.II, Column A).
(c) Subtract line 2 from line 1.
(d) Divide line 3 by the number of months in a quarter or 3.
(3) Determine Primary Reserve: If Contractor’s Average Fee-For-Service Liability is less
than or equal to $250,000, Contractor shall deposit into the Restricted Reserve Account
an amount equal to the Average Fee-For-Service Liability from Report G.1 of this
Exhibit G. This amount will be referred to as the Contractor’s Primary Reserve and
Contractor shall have no Secondary Reserve, until such time as the Average Fee-For-
Service Liability exceeds $250,000.
(4) Determine Secondary Reserve: If Contractor’s Average Fee-For-Service Liability is
greater than $250,000, Contractor is required to deposit into the Restricted Reserve
Account funds equaling 50 percent of the difference between the Average Fee-For-
Service Liability less the Primary Reserve balance of $250,000.
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Contract #126667 Exhibit G Page 108 of 242
8. Net Worth Requirements:
Contractors shall maintain a level of Net Worth that will provide for minimum adequate operating
capital. A minimum adequate level of Net Worth is defined as the Discounted Premium Revenue to Net
Worth ratio less than or equal to 20:1 (premium to surplus ratio). Contractor shall maintain the
Minimum Net Worth level, as determined by this section, during the next calendar quarter. Contractors
regulated by DCBS shall follow the Insurance Code and Risk Based Capital Standards.
a. Minimum Net Worth level: Contractor shall calculate the Minimum Net Worth level by
following the steps outlined below:
Step 1: Determine Average Corporate Premium:
Corporate Premium Revenue for the current period
Add: Corporate premium revenue for the prior period
Divided by: 2
Step 2: Determine Annualized Average Corporate Premium:
Average Corporate Premium
Times: four (4)
Step 3: Determine Adjusted Annualized Average Corporate Premium:
Annualized Average Corporate Premium
Times: Medical Loss Ratio (Net Worth), see Step 4, below.
Step 4: Determine the Medical Loss Ratio (Net Worth):
Medical/Hospital Expense Subtotal (Report G.8, Line 16)
Less: Subcapitation or salaried medical expenses (Report G.10.II, Columns A,
C, D, E, F and G)
Divided by: Total Revenue (Report G.8, Line 7)
Step 5: Determine the Minimum level of Net Worth:
Adjusted Annualized Average Corporate Premium:
Divided by: Twenty (20)
b. Contractor is required to retain a dollar amount no less than 2 percent of Contractor’s Adjusted
Quarterly Corporate Premium Revenues as retained earnings each subsequent quarter until
Contractor has a premium to surplus ratio that meets the 20:1 requirement.
c. Contractor shall immediately notify DMAP of a Material Change in circumstance from the
information contained in the latest-submitted Quarterly Financial Reports G.8 and G.10. If
DMAP determines that a Contractor's premium to surplus ratio does not meet the required
premium to surplus ratio level of 20:1, DMAP will notify Contractor.
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Contract #126667 Exhibit G Page 109 of 242
9. Physician Incentive Regulation:
Contractor shall disclose to DMAP information about Physician Incentive arrangements with Providers.
If Contractor utilizes compensation arrangements placing Physicians or Physician Groups at Substantial
Financial Risk (SFR), as defined in Exhibit M, they must assure provision of adequate stop-loss
protection and conduct beneficiary surveys.
a. Contractors shall submit either the CMS Physician Incentive Plan (PIP) Disclosure Form (OMB
No.0938-0700 or the Physician Incentive Plan Disclosure Form, Report G.12 in this Exhibit G,
to DMAP no later than August 31st of each year that this Contract is in effect. If any of the
information that forms the basis for determining SFR, as defined in Exhibit M, is eliminated,
changed, or modified in any manner, Contractor shall immediately notify DMAP. It is expected
that all contractual levels in place between the Contractor and any Physician or Physician Group
providing services to DMAP Members shall be disclosed.
b. Contractors who are regulated by DCBS and disclose PIP information electronically to CMS
shall submit to DMAP a copy of the information submitted to CMS. Upon the request of DMAP,
Contractor shall submit documentation in enough detail for DMAP to determine if Contractor
has transferred SFR. If any of the information that forms the basis for determining SFR, as
defined in Exhibit M, is eliminated, changed, or modified in any manner, Contractor shall
immediately notify DMAP. It is expected that all contractual levels in place between the
Contractor and any Physician or Physician Group providing services to DMAP Members will be
disclosed.
10. Appeal Process:
If at any time, DMAP believes that Contractor has incorrectly computed the amount of either its Primary
or Secondary Restricted Reserve fund, or that Contractor’s premium to surplus ratio does not meet the
required premium to surplus ratio level of 20:1, DMAP will notify Contractor in writing. In the event
that DMAP believes that the Primary or Secondary Restricted Reserve fund has been incorrectly
computed, DMAP will notify Contractor of the amount Contractor must maintain as its new Restricted
Reserve fund and the basis on which such decision was made. In the event that DMAP believes that
Contractor’s premium to surplus ratio is below the 20:1 ratio, DMAP will notify Contractor of the dollar
amount of no less that 2 percent of its Adjusted Quarterly Premium Revenue required to be retained
each subsequent quarter until Contractor has a premium to surplus ratio that meets the 20:1 requirement.
a. Within 30 calendar days of any notice by DMAP under this Section, Contractor shall either:
(1) Adjust its Restricted Reserve funds to the amount specified by DMAP and provide
DMAP with a copy of the restrict reserve statement and updated Schedule A showing the
Restricted Reserve balance, adjust its Net Worth to the amount specified by DMAP and
provide assurances to DMAP that it is now maintaining that amount as its Net Worth, or
(2) File an appeal in writing with the DMAP Administrator stating in detail the reason for the
appeal, and submit detailed financial records that support the alternate amount.
(3) If Contractor files an appeal, the DMAP Administrator or designee shall issue an appeal
decision within 45 calendar days of the receipt of the appeal. That decision shall be
binding upon Contractor and not subject to further appeal.
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Contract #126667 Exhibit G Page 110 of 242
b. All information to be reported by Contractor under the requirements of this Exhibit shall be sent
to:
MCO Financial Solvency Program Coordinator
Delivery Systems Unit, 3rd Floor E-35
Division of Medical Assistance Programs
500 Summer Street NE
Salem, OR 97301-1077
11. Glossary of Terms:
a. Average Capitation Rate - calculation obtained from Report G.1 which represents Contractor’s
average OHP Capitation Rate paid per DMAP Member during the quarter.
b. Average Monthly Enrollee - calculation, obtained from Report G.1, which represents
Contractor’s average number of DMAP Members enrolled during the quarter.
c. Average Fee-For-Service Liability - The Average Monthly Fee-For-Service Liability is the cost
of health care services that are offered by Contractor to DMAP Members that would be owed to
creditors in the event of Contractor's insolvency. These are expenditures for health care services
for which Contractor is at risk and will vary in type and amount. These services may include
out-of-area services, primary care services, referral services, and hospital services.
Determination of the cost is based on the usual and customary fee schedule of Contractor and is
developed for the anticipated Capitated Services liability. Anticipated monthly non-service
liabilities (such as insolvency insurance, hold harmless contracts liabilities, regulated and non-
regulated guarantees liabilities, and other liabilities) are not included.
d. Catastrophic stop-loss - a mechanism by which Contractor obtains reinsurance coverage against
catastrophic and unexpected expenses related to Capitated Services to DMAP Members.
Catastrophic stop-loss is different from the stop-loss protection that maybe required under
Exhibit M related to Physician Incentive Plan Regulation Guidance.
e. Certification - statement signed by Contractor or its representative attesting to the accuracy of
the reported information.
f. Contractor - a PHP that contracts with DMAP to provide services under the OHP.
g. Corporation - a for-profit or not-for-profit organization authorized to conduct business as a
corporation in Oregon.
h. Corporate Activity - the financial position of a corporation relating to activities the corporation
performs. Includes the OHP line of business. Any PHP not a corporation should regard its total
PHP business as corporate activity.
i. Enrollment Year - A twelve month period beginning the first day of the month of enrollment of
the DMAP Member and, for any subsequent year(s) of continuous enrollment, that same day in
each such year(s). The Enrollment Year of DMAP Members who re-enroll within a calendar
month of Disenrollment shall be counted as if there were no break in enrollment.
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Contract #126667 Exhibit G Page 111 of 242
j. Financial information typically computed on a total corporate business only shall be
apportioned to reflect the proportion of corporate business that is reflected by the total
DMAP Member Capitation Payment during the quarter - allocation of financial information
by the indirect method which allocates costs by departments ignoring any services rendered by
department to each other and assumes no reciprocal services exist.
k. Financial solvency - the collection of resources belonging to a company and the sources of these
resources or claims on them at a particular point of time.
l. Hospital Stop-Loss - those Claims that are covered by Contractor’s hospital stop-loss insurance.
m. IBNR - incurred but not reported losses is 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.
n. Intermediary - a person, corporation or other business entity that performs, by contracting with
a Contractor, administrative services for that Contractor or a person, corporation or other
business entity that is not regulated by DCBS or by DMAP and arranges, by contracts with
physicians and other Providers, to deliver health services for a Contractor and its enrollees via a
separate contract between the intermediary and the MCO. Includes affiliates of the Contractor.
The payment for such services may vary from payment of a management fee based on a percent
of the Contractor's revenue or expenses to a per capita system. A Contractor paying a fiscal
intermediary for administrative services must report the actual costs of the appropriate expense
classification in the second column or can allocate the costs of the appropriate expenses
classification as if the costs had been paid directly by the Contractor.
o. Licensed health entities - those Contractors who have a unique Certificate of Authority issued
by DCBS as licensed Health Service Corporations, Dental Service Corporations, Vision Services
Corporations, and Health Maintenance Organizations.
p. DMAP Member - A DMAP Client enrolled with Contractor in accordance with the OHP
Contract.
q. OHP Business - activities Contractor performs that relate to this Contract.
r. Medical Loss Ratio, Restricted Reserve - represents that portion of total medical and hospital
expenditures after reinsurance recoveries incurred, co-payments, COB and Subrogation for
Covered Services to DMAP Members, either unadjusted or adjusted for medical sub-capitation
expenditures, divided by total OHP Revenues for which Contractor is at risk.
s. Medical Loss Ratio, Net Worth - represents that portion of total medical and hospital
expenditures before reinsurance recoveries incurred, co-payments, COB and Subrogation for
Covered Services to DMAP Members, adjusted for medical sub-capitation expenditures, divided
by total OHP Revenues for which Contractor is at risk.
t. Medical Stop-Loss - those Claims covered by Contractor’s medical stop-loss insurance.
u. National Association of Insurance Commissioners (NAIC) – an organization that develops
standardized procedures and definitions used by the insurance industry. For Exhibit G, the NAIC
procedures are those applicable to the Report Period, pursuant to DCBS requirements.
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Contract #126667 Exhibit G Page 112 of 242
v. NAIC "Annual Statement for Health Maintenance Organizations" - the model reporting
provisions developed by the National Association of Insurance Commissioners and referred to as
the Official NAIC Annual Statement Blank, Health Maintenance Organizations.
w. NAIC "Annual State Instructions for Health Maintenance Organizations" - the accounting
guidelines and annual statement instructions relating to health maintenance organizations
published by NAIC.
x. NAIC "Health Annual Statement " - the model reporting provisions developed by the National
Association of Insurance Commissioners and referred to as the Official NAIC Health Annual
Statement. These reporting provisions are also used for annual and quarterly reporting by
licensed health entities.
y. NAIC "Health Annual State Instructions" - the accounting guidelines and annual statement
instructions relating to licensed health entities and referred to as the instructions to the Official
NAIC Health Annual Statement. These reporting provisions are also used for both annual and
quarterly reporting by licensed health entities.
z. OHP Activity - the financial position of Contractor relating to activities that Contractor
performs that are associated with Capitated Services provided under this Contract.
aa. Provide quarterly - submitted four times a calendar year with information compiled over three
months (i.e., January-March information submitted by May15th; April-June information
submitted by August 15th; July-September information submitted by November 15th; October-
December information submitted by March 31st).
bb. Quarterly Financial Reports - accounting information covering a calendar quarter (i.e., January
through March, April through June, July through September, and October through December)
used to show significant relationships about the resources belonging to a company and the
sources of these resources that facilitates comparisons from period to period and among lines of
businesses or companies.
cc. Receipt of the Appeal - the date that the appeal document is delivered to DMAP, Analysis &
Evaluation Unit and is date-stamped.
dd. Receipt of the Information - the date that the information is delivered to DMAP Administrator.
ee. Report Period - the period of time the information in each report covers. This period is derived
from the requirements found in the OHP Contract. Use only those Claims paid in the report
period, except where noted on Report G.4. The date a Claim is paid is determined by the Claims
paid date or by the encounter data process date.
ff. Risk-sharing Intermediaries - a person, corporation or other business entity that is not
regulated by DCBS or by DMAP and for whom the Contractor has made arrangements to lessen
the fee-for-service liabilities within its contract with that person, corporation or other business
entity by requiring the retainment of risk.
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Contract #126667 Exhibit G Page 113 of 242
gg. Statement of Actuarial Opinion - a statement prepared by a qualified health maintenance
organization actuary setting forth his or her opinion relating to loss reserves, provision for
experience rating refunds, and any other actuarial or accounting items in accordance with the
description of Actuarial Certification found in the NAIC "Annual Statement Instructions, Health
Maintenance Organization" or the “Annual Health Statement”.
hh. Stop-Loss deductible - the amount of stop-loss protection obtained by Contractor to meet the
requirement in the OHP Contract.
ii. Total DMAP Member Months - the sum of the enrollment in the PHP for each month during
the report period. Individuals enrolled for less than a month will be prorated.
12. Instructions for Completing Reports G.1 – G.13 and Form G.1
a. Report G.1: Restricted Reserve
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.1. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.1.
General:
Form G.1 certifies all information submitted is accurate, complete, and truthful. It is to be
completed and signed by an authorized representative of Contractor. The original certificate is to
be mailed to DMAP.
Report G.1 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. Contractors shall use Report G.1 for the purposes
of determining: 1) Average Fee-For-Service Liability using Enrollment Data and 2) Primary and
Secondary Restricted Reserve requirements as required by Section 7 of this Exhibit G.
Instructions:
Column 3 - Capitation Rate - the amount DMAP pays on a per member per month basis to
Contractor in advance of and as payment for the DMAP Member's actual receipt of services. If
Contractor provides services in more than one Service Area, use the Capitation Rate for the
Service Area with the largest number of monthly enrollees in the third month.
Average Capitation Rate - sum of (Column 3, Capitation Rate (times) Column 4, Monthly
Enrollees) divided by (Average Monthly Enrollees) divided by (number of months in the
quarter).
Column 4 - Monthly Enrollees - the number of DMAP Members eligible for full month added
to the prorated number of individuals enrolled for less than a month. Monthly enrollees shall be
reported in decimal form rounded to the nearest 100th.
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Contract #126667 Exhibit G Page 114 of 242
Average Monthly Enrollees - sum of Column 4, Monthly Enrollees (divided by) the number of
months in the quarter.
Column 5 - Medical Loss Ratio - Contractor shall elect to use either an unadjusted or adjusted
Medical Loss Ratio.
(1) Medical Loss Ratio, (Restricted Reserve) unadjusted: The Medical Loss Ratio can be
no lower than .2 to leave adequate monies for administrative expenses and net income.
OHP Medical and Hospital Operating Expenses Less Deductions
(Line 19, Report G.8)
divided by: OHP Total Operating Revenues (Line 5, Report G.8)
(2) Medical Loss Ratio, (Restricted Reserve) adjusted - The Medical Loss Ratio can be no
lower than .2 to leave adequate monies for administrative expenses and net income.
OHP Medical and Hospital Operating Expenses Less Deductions
(Line 19, Report G.8)
less: OHP Salary payments (Column A, Report G.10)
less: OHP Subcapitation payments (Columns C, D, E, F and G; Report
G.10)
divided by: OHP Total Operating Revenues (Line 5, Report G.8)
Column 6 - Fee-For-Service Liability for Capitated Services - Column 3, Capitated Rate
(times) Column 4, Monthly Enrollees (times) Column 5, Medical Loss Ratio, (Restricted
Reserve).
Average Fee-For-Service Liability - Column 3, Average Capitation Rate (times) Column 4,
Average Monthly Enrollee (times) Column 5, Medical Loss Ratio.
b. Report G.2: DMAP Members Approaching or Surpassing Stop-Loss Deductible
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMETNS OF THIS REPORT G.2. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.2.
General:
Report G.2 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. This information is used by DMAP to assess the
catastrophic stop-loss exposure of each contractor.
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Contract #126667 Exhibit G Page 115 of 242
Instructions:
Part I - Contractor shall submit Part I of Report G.2 to DMAP quarterly on May 15th, August
15th, November 15th and March 31st. Contractor shall provide the following information about
the number of DMAP Members whose costs on approved health care Claims are within the range
of stop-loss deductible for the calendar quarter.
Part II - Contractors shall complete Part II of Report G.2, annually and submit on August 31st.
Provide answers to the question about Contractors reinsurance. Provide one report for each
reinsurer.
c. Report G.3: OHP Key Utilization Indicators
This report has been rescinded by DMAP and Contractor is no longer required to file this report
as part of the Exhibit G, Quarterly Financial Reports.
d. Report G.4: OHP Access to Services
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.4. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.4.
General:
Report G.4 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G.
Instructions:
(1) Usage of Services:
(a) DMAP Members enrolled during the Prior Quarter with Claims Paid - the number
of unduplicated DMAP Members enrolled in the prior quarter for whom Claims
had dates of service occurring in the prior report period and whose Claims were
paid in the prior or current report quarter.
(b) DMAP Members enrolled during the Prior Quarter with unpaid Claims - the
number of unduplicated DMAP Members enrolled in the prior quarter for whom
there were no paid Claims having dates of service occurring in the prior report
period or for whom there were Claims with a date of service occurring in the prior
report quarter, but no paid date in the prior or current report quarter.
(c) Total number of DMAP Members enrolled in Prior Quarter - the sum of Line 1
and Line 2 will equal DMAP Members enrolled during the Prior Quarter.
Contractor shall verify that this number is equal to the amount from the prior
period Report G.4 (III Membership Line 3 of either part A or B).
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Contract #126667 Exhibit G Page 116 of 242
(2) Membership:
Use Member’s primary insurance to define which policy type (Group, Medicare,
Individual, etc.) is associated with the Member. Contractor shall report total number of
Members currently enrolled in their plan on the last day of the reporting period.
Contractor shall provide membership information for each policy type. Entities regulated
by DCBS (use Section A of this report) - any Contractor with a unique Certificate of
Authority number issued by DCBS. Entities not regulated by DCBS (use Section B of
this report) - any Contractor without a unique Certificate of Authority number issued by
DCBS. Contractor shall provide the following membership information:
(a) Members with Group Policies - the number of Members who are enrolled in
group policies where the premiums are determined as a group rate. Excludes
Members counted in other lines.
(b) Members with Medicare Policies - the number of Members who are enrolled in
Medicare policies. Excludes Members counted in other lines.
(c) Members covered by this Contract - the number of DMAP Members enrolled
with Contractor in accordance with this Contract. Excludes Members counted in
other lines.
(d) Medicaid Members Other than DMAP Members - the number of Members
whose health care costs are covered by Medicaid but are not DMAP Members
covered by this Contract. Excludes Members counted in other lines.
(e) Members with Individual Policies - the number of Members whose health care
premiums are paid by an individual. Excludes Members counted in other lines.
(f) Other Members - all other Members who do not fall into one of the previous
mentioned categories. Excludes Members counted in other lines.
(g) Total Members - the total number of Members enrolled with Contractor on the
last day of the report period. Use Member’s primary insurance for purposes of
reporting which policy type is associated with the Member. Each Member
enrolled with Contractor shall not be reported more than once.
e. Report G.5: Audited Yearly – Balance Sheet of Corporate Activity
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.5. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.5.
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Contract #126667 Exhibit G Page 117 of 242
General:
Contractor shall include information specified in Report G.5 and file Report G.5 in accordance
with Section 2 of this Exhibit G. Contractor shall report in the column labeled Corporate
Activity the Contractor’s financial information of a for-profit or not-for-profit corporation, which
is not a foreign corporation, incorporated under or subject to the provisions of Chapter 60 and
ORS 732.005 of the Oregon Insurance Code. If Contractor is not a corporation, Contractor shall
report its total PHP business in the column labeled Corporate Activity.
Contractor shall provide Details of Write-Ins - Any item which is a component of any other
line, is greater than 10% of the amount on the Subtotal Line (lines 9, 17, 23, 32, 37 and 47), and
whose value is greater than $1,000 will need to be described on these lines and the amount of the
item disclosed. On the description line please reference the line number of the Other Line (i.e.
Line 8, 16, 22, 31, 36 or 46), identify the expense and disclose the amount of expense claimed.
Instructions:
(1) Cash and Cash Equivalents - cash in the bank or on hand, available for current use.
Cash equivalents are investments maturing 90 days or less from date of purchase.
(2) Short-term Investments - investments in securities that are readily marketable, maturing
one year or less from date of purchase.
(3) Premiums Receivable - gross amounts collectible from premiums receivable (groups or
individuals who receive services from Contractor, less the amount accrued for premiums
determined to be uncollectible).
(4) Investment Income Receivables - income earned on investments but not received
(5) Health Care Receivables - gross amounts collectible from other sources, less the amount
accrued for receivables determined to be uncollectible during the period. Includes fee-
for-service, TPR, COB, subrogation, co-payments, reinsurance recoveries and non-
affiliated Provider receivables.
(6) Amounts Due from Affiliates - any receivable from an affiliate or a person affiliated
with, a specific person that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the person specified.
(7) Reinsurance Recoverable on Paid Losses - any receivable from a reinsurer for monies
already paid for reinsurance coverage.
(8) Other Current Assets - other current assets, such as aggregate write-ins for current
assets found on NAIC Report #1.
(9) TOTAL CURRENT ASSETS - the sum of Line 1 through Line 8.
(10) Bonds - bonds with a maturity longer than one year from date of purchase that must be
valued at the book value, defined as the amortized or market value.
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Contract #126667 Exhibit G Page 118 of 242
(11) 11.1 Preferred stocks - preferred stock investments that are considered long-term
invested assets.
11.2 Common stocks - common stock investments that are considered long-term
invested assets.
(12) Other Long-Term Invested Assets - other investments with a maturity date more than
one year from date of purchase or no stated maturity date.
(13) Receivable for Securities - amounts received within 15 days of the end of the reporting
period, due from brokers when a security had been sold, but the proceeds have not yet
been received.
(14) Amounts Due from Affiliates - any receivable from an affiliate or a person affiliated
with, a specific person that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the person specified.
(15) Restricted Cash and Restricted Securities - assets restricted for statutory insolvency
requirements such as cash, securities, receivables, etc.
(16) Other Assets - other assets, such as aggregate write-ins for other assets found on NAIC
Report #1.
(17) TOTAL OTHER ASSETS - the sum of Line 10 through Line 16.
(18) Land, Building and Improvements - real estate owned by Contractor, buildings owned
by Contractor, improvements made to Contractor-owned buildings, and building or
improvements in progress or under construction.
(19) Furniture and Equipment - medical equipment, office equipment, and furniture owned
by Contractor.
(20) Leasehold Improvements- improvements to facilities not owned by Contractor. Provide
gross amount, less amortization.
(21) EDP Equipment - EDP hardware and software that constitute a data processing system
used by the insurer if the cost of such a system is at least $50,000 and is to be amortized
in full in not more than 10 years.
(22) Other Property and Equipment - other tangible, fixed assets of a long-term nature used
in the continuing operation of the business, including land, building, building
improvements, furniture, equipment and leasehold improvements not included above.
(23) TOTAL PROPERTY AND EQUIPMENT - the sum of Line 18 through Line 22.
(24) TOTAL ASSETS - the sum of Line 9, Line 17, and Line 23.
(25) Accounts Payable - short-term monetary amounts due to creditors for the acquisition of
goods and services (trade and vendors rather than health care practitioners) on a credit
basis. Report taxes and payroll taxes on Other Current Liabilities line.
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Contract #126667 Exhibit G Page 119 of 242
(26) Claims Payable - Claims reported and booked as payables and IBNR Claims. This
liability relates to claims expenses found on the Statement of Revenues, including
percentage withholds but excluding medical incentive pool. Include the net of
reinsurance ceded. Other categories of liabilities netted into claims payable are 1) Claims
recoverable, 2) Unallocated loss reserve, 3) Recoverable on unpaid losses, 4) Monies set
aside for claims processing, and 5) Claims adjustment expenses, among others.
Incurred but Not Reported (IBNR) - incurred but not reported losses are estimates of
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.
(27) Accrued Medical Incentive Pool - liability for arrangements whereby Contractor agrees
to share utilization savings with Individual Practice Associations, physician groups, or
other Providers.
(28) Unearned Premiums - revenue received or booked in advance of the reporting period
for services that have not been performed during the current accounting period. A
liability exists to render service in the future.
(29) Loans and Notes Payable - the principal amount on loans due within one year.
(30) Amounts Due to Affiliates - any payable to an affiliate, including items that would
otherwise be reported on other lines.
(31) Other Current Liabilities - current liabilities not included in the current liabilities
categories listed above, including MCO tax.
(32) TOTAL CURRENT LIABILITIES - the sum of Line 25 through Line 31.
(33) 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).
(34) Amounts Due to Affiliates - any payable to an affiliate or a person affiliated with, a
specific person that directly, or indirectly through one or more intermediaries, controls, or
is controlled by, or is under common control with, the person specified. This line
includes items that would otherwise be reported on other lines.
(35) Payable for Securities - amounts that are due to brokers when a security has been
purchased, but has not yet been paid; any payable for securities that is due as of the last
date of the report period.
(36) Other Liabilities - other liabilities not included in the liabilities categories listed above.
(37) TOTAL OTHER LIABILITIES - the sum of Line 33, Line 34, Line 35 and Line 36.
(38) TOTAL LIABILITIES - the sum of Line 32 and Line 37.
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Contract #126667 Exhibit G Page 120 of 242
(39) Common Stock - the residual interest in the asset of the stock which represents the most
basic rights to ownership of a corporation. It should equal the par value per share
multiplied by the number of issued shares or in the case of no-par shares, the total stated
value.
(40) Preferred Stock - the residual interest in the asset of stock that has some preference over
common stock, usually including dividends; should equal the par value per share
multiplied by the number of issued shares, or in the case of no-par shares, the total stated
or liquidation value.
(41) Paid in Surplus - the gross amount of paid in and contributed surplus without reduction
of account of commissions or other expenses in connection with such transactions, but
reduced by a distribution declared and paid as a return of such surplus.
(42) Contributed Capital - capital donated to nonprofit organizations.
(43) Surplus Notes - notes that qualify as equity; also called subordinated debt or debentures.
Include accrued interest on surplus notes.
(44) Contingency Reserves- reserves held for contingency purposes as defined in State
statutes and regulations.
(45) Retained Earnings/Net Worth - the undistributed and unappropriated amount of
surplus.
(46) Other Net Worth - other net worth items not reported on any other lines.
(47) TOTAL NET WORTH - the sum of Line 39 through Line 46.
(48) TOTAL LIABILITIES AND NET WORTH - the sum of Line 38 and Line 47.
f. Report G.6 – Audited Yearly – Statement of Revenue, Expenses, and Net Worth
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.6. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUBMERS OR HEADINGS ON THE
REPORT G.6.
General:
Contractor shall include information specified in Report G.6 and file Report G.6 in accordance
with Section 2 of this Exhibit G. Contractor shall report in the column labeled Corporate
Activity the Contractor’s financial information of a for-profit or not-for-profit corporation that is
not a foreign corporation, incorporated under or subject to the provisions of Chapter 60 and ORS
732.005 of the Oregon Insurance Code. If Contractor is not a corporation, Contractor shall
report its total PHP business in the column labeled Corporate Activity.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 121 of 242
Contractor shall submit Details of Write-Ins - Any item which is a component of any other
line, is greater than 10% of the amount on the Subtotal Line (i.e. Line 5, 14 or 22), and whose
value is greater than $1,000 will need to be described on these lines and the amount of the item
disclosed. On the description line please reference the line number of the Other Line (i.e. Line 4,
13, 22 or 41e) identify the expense, and disclose the amount of expense claimed.
Instructions:
(1) Premiums - revenue recognized (net of reinsurance premium paid to the reinsurer on a
prepaid basis from individuals and groups for provision of a specified range of health
services over a defined period of time. Include DMAP capitation and Maternity case rate
payments and the net of reinsurance premiums ceded. If advance payments are made to
Contractor for more than one report period, the portion of the payment that has not yet
been earned must be treated as a liability (unearned premiums).
(2) Fee-For-Service - revenue recognized by Contractor for provision of health services to
non-DMAP Members by Contractor practitioners and to DMAP Members through
provision of health services excluded from their prepaid benefit packages.
(3) Title XIX-Other Medicaid - other Medicaid revenues as a result of other non-capitated
arrangements between Contractor and a Medicaid State Agency, for services to a
Medicaid beneficiary.
(4) Other Health Care - Related Revenues - revenue recognized for provision of health
services over a defined period of time not included in previous revenue categories.
(5) TOTAL OPERATING REVENUES - the sum of Line 1 through Line 4.
(6) Physician/Professional Services - expenses for physician services provided under
contractual arrangement to Contractor including physician salaries, fringe benefits,
Capitated Payments paid to physicians, fees paid to physicians on a fee-for-service basis
for delivery of medical services, including capitated referrals. Compensations, as well as
fringe benefits, paid by Contractor to non-physician practitioners engaged in the delivery
of medical services and to personnel engaged in activities in direct support of the
provision of medical services. Include expenses for practitioners not under contractual
arrangements with Contractor. Exclude expenses for medical personnel time devoted to
administrative tasks.
Physician shall be defined to include practitioner who is an allopathic, osteopathic,
homeopathic, podiatric, chiropractic, or naturopathic physician, physician assistant, and
nurse practitioner.
Professionals include dentists, psychologists, optometrists, nurses, clinical personnel such
as ambulance drivers, technicians, paraprofessionals, quality assurance analysts,
administrative supervisors and medical record clerks.
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Contract #126667 Exhibit G Page 122 of 242
(7) Hospital Services
(a) Inpatient – Inpatient hospital costs for Contractor members while confined to an
acute care hospital, including out of area hospitalization. Include the cost of
skilled nursing and intermediate care facilities.
(b) Outpatient – Outpatient hospital costs for Contractor members not confined to an
acute care hospital, including out of area Outpatient services.
(c) Emergency Room – expenses for emergency room services, including out of area
emergency services.
(8) Pharmacy – retail pharmacy costs, net of rebates and administrative fees.
(9) Lab and X-ray – independent laboratory and x-ray services for Contractor members.
(10) Vision - non-medical/routine vision exams and related hardware.
(11) Chemical Dependency – services provided by alcohol or chemical dependency
Providers.
(12) DME & Supplies - independent Providers of DME and Supplies. Equipment that can
stand repeated use and is primarily and customarily used to serve a medical purpose and
non-reusable medical supply items used in the treatment of illness or injury.
(13) Other Medical and Hospital Expenses - other expenses for medical and hospital
services not included in the above categories, including IBNR costs.
(14) MEDICAL AND HOSPITAL OPERATING EXPENSES SUBTOTAL - the sum of
Line 6 through Line 13.
(15) Reinsurance Recoveries Received - reinsurance recovered from the reinsurer on paid
losses and those amounts that have been billed to the reinsurer and not yet received.
Include reinsurance recovered and recoverables on paid losses. Unpaid losses are netted
against the appropriate medical and hospital expense lines89 -15. NOTE: this is NOT a
net figure.
(16) Co-payments Received - revenue recognized by Contractor from members on a
utilization-related basis for certain health services included in the benefit package.
(17) TPR, COB, and Subrogation Amounts Received – All Third Party payments,
Coordination of Benefits payments, and Subrogation payments received by the
Contractor. This total amount, nor any portion of it, should not be netted against
expenses.
(18) OPERATING DEDUCTIONS SUBTOTAL - the sum of Lines 15 through 17.
(19) TOTAL MEDICAL AND HOSPITAL OPERATING EXPENSES LESS
DEDUCTIONS - the sum of Line 14 minus Line 28.
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Contract #126667 Exhibit G Page 123 of 242
(20) Compensation - Include salaries and wages, bonuses and incentive compensation to
employees, overtime payments, continuation of salary during temporary short-term
absences, dismissal allowances, payments to employees while in training and other
compensation to employees not specifically designated to another expense category.
Include fees and other compensation to directors for attendance at board or committee
meetings and any other fees and compensation paid to them in their capacities as
directors or committee members. Report agency compensation other than commissions.
(21) Other Administrative Expenses – payment made for other administrative expenses
associated with the overall management and operations of Contractor not included in the
above categories.
(22) TOTAL ADMINISTRATIVE EXPENSES - the sum of items of Line 20 and Line 21.
(23) TOTAL OPERATING EXPENSES - the sum of Line 19 and Line 22.
(24) NET OPERATING INCOME (LOSS) - the result of Line 5 minus Line 23.
(25) Net Investment Income – Interest earnings on investments (securities, bank accounts,
etc.) less directly-related expenses (brokerage fees, bank fees, etc.).
(26) Non-Healthcare-Related Revenues – Management fees or other fees received from
Non-OHP businesses. No amount should be shown in the “OHP Contract Activity”
column.
(27) Other Non-Operating Revenues and Expenses – Any revenues and expenses not
already included in operating revenues, operating expenses or Lin 25 or Line 26.
(28) TOTAL NON-OPERATING REVENUES - The sum of Lines 25, 26 and 27.
(29) NET INCOME (LOSS) BEFORE TAXES – Line 5 minus Line 23 plus Line 28.
(30) MCO Tax – the expense for Managed Care taxes.
(31) Provision for Income Taxes - the expense for income taxes for the report period.
(32) TOTAL TAXES - Line 30 plus Line 31
(33) NET INCOME (LOSS) - the result of Line 29 minus Line 30 minus Line 31.
(34) Net Worth Beginning of Year - the total of common stock, preferred stock, paid in
surplus, contributed capital, surplus notes, contingency reserves, retained earnings/fund
balance, and other items at the beginning of the report period.
(35) Increase (Decrease) in Common Stock - the change in the net worth of common stock
from the last report period to the current report period.
(36) Increase (Decrease) in Preferred Stock - the change in the net worth of preferred stock
from the last report period to the current report period.
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Contract #126667 Exhibit G Page 124 of 242
(37) Increase (Decrease) in Paid in Surplus - the change in the net worth of paid in surplus
from the last report period to the current report period.
(38) Increase (Decrease) in Contributed Capital - the change in the net worth of contributed
capital from the last report period to the current report period.
(39) Increase (Decrease) in Surplus Notes - the change in the net worth of surplus notes
from the last report period to the current report period.
(40) Increase (Decrease) in Contingency Reserves - the change in the net worth of
contingency reserves from the last report period to the current report period.
(41) Increase (Decrease) in Retained Earnings/ Net Worth- the change in the net worth of
retained earnings/net worth from the last report period to the current report period.
(a) Net Income – the excess of total revenues minus total expenses during the
reporting period.
(b) Dividends to Stockholders – distributions of retained earnings to shareholders,
based upon the number of shares owned by each shareholder.
(c) Interest on Surplus Notes – interest expense paid on surplus notes. Surplus
notes are notes that qualify as equity and are also called subordinated debt.
(d) Other Charges - all other changes made to net worth that are not already reported
on lines 34 through 41.c.
(42) Net Worth at End of Year - the total of common stock, preferred stock, paid in surplus,
contributed capital, surplus notes, contingency reserves, retained earnings/fund balance,
and other items at the end of the report period.
g. Report G.7: Quarterly Financial Report – Balance Sheet of Corporate Activity
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.7. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.7.
General:
Report G.7 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. Contractor shall report in the column labeled OHP
Contract Line the expenses associated with providing service to DMAP Members and shall
report in the column labeled Corporate Activity the Contractor’s total financial information of
the for-profit or non-for-profit corporation which is not a foreign corporation, incorporated under
or subject to the provisions of Chapter 60 and ORS 732.005 of the Oregon Insurance Code. If
Contractor is not a corporation, Contractor shall report in the column labeled OHP Contract Line
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 125 of 242
the expenses associated with providing service to DMAP Members and shall report in the
column labeled Corporate Activity the Contractor’s total financial information. Amounts
appearing on Report G.7 shall equal the total reported annually on Report G.5.
Allocation of expenditures between OHP Contract Line of Business and Corporate Line of
Business: If separate accounts are not kept for the OHP, revenue, expenses and net worth
information for the OHP shall be allocated using an estimation procedure approved by DMAP.
Such a procedure and all assumptions must be disclosed in Notes to Report G.7. This estimation
procedure must be used throughout the reports. The assumptions underlying the allocation must
be based on a methodology that clearly represents the true costs associated with providing
services to DMAP Members.
Contractor shall submit a Details of Write-Ins for - Any item which is a component of any
other line, is greater than 10% of the amount on the Subtotal Line (i.e. Line 9, 17, 23, 32, 37 or
47), and whose value is greater than $1,000, must be described on these lines and the amount of
the item disclosed. On the description line, please reference the line number of the Other Line
(i.e. Line 8, 16, 22, 31, 36 or 46), identify the expense, and disclose the amount of expense
claimed.
Instructions:
(1) Cash and Cash Equivalents - cash in the bank or on hand, available for current use.
Cash equivalents are investments maturing 90 days or less from date of purchase.
(2) Short-term Investment - investments in securities that are readily marketable, maturing
one year or less from date of purchase.
(3) Premiums Receivable - gross amounts collectible from premiums receivable (groups or
individuals who receive services from Contractor, less the amount accrued for premiums
determined to be uncollectible).
(4) Investment Income Receivables - income earned on investments but not received
(5) Health Care Receivables - gross amounts collectible from other sources, less the amount
accrued for receivables determined to be uncollectible during the period. Includes fee-
for-service, TPR, COB, subrogation, co-payments, reinsurance recoveries and non-
affiliated Provider receivables.
(6) Amounts Due from Affiliates - any receivable from an affiliate or a person affiliated
with, a specific person that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the person specified.
(7) Reinsurance Recoverable on Paid Losses - any receivable from a reinsurer for monies
already paid for reinsurance coverage.
(8) Other Current Assets - other current assets, such as aggregate write-ins for current
assets.
(9) TOTAL CURRENT ASSETS - the sum of Line 1 through Line 8.
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Contract #126667 Exhibit G Page 126 of 242
(10) Bonds - bonds with a maturity longer than one year from date of purchase and must be
valued at the book value as defined as the amortized or market value.
(11) Stocks:
(a) Preferred stocks - preferred stock investments that are considered long-term
invested assets.
(b) Common stocks - common stock investments which are considered long-term
invested assets.
(12) Other Long-Term Invested Assets - other investments with maturity longer than one
year from date of purchase or no stated maturity date.
(13) Receivable for Securities - amounts received within 15 days of the end of the reporting
period, due from brokers when a security had been sold, but the proceeds had not yet
been received.
(14) Amounts Due from Affiliates - any receivable from an affiliate or a person affiliated
with, a specific person that directly, or indirectly through one or more intermediaries,
controls, or is controlled by, or is under common control with, the person specified.
(15) Restricted Cash and Restricted Securities - assets restricted for statutory insolvency
requirements such as cash, securities, receivables, etc.
(16) Other Assets - other assets, such as aggregate write-ins for other assets
(17) TOTAL OTHER ASSETS - the sum of Line 10 through Line 16.
(18) Land, Building and Improvements (net of accumulated depreciation)- real estate
owned by Contractor, buildings owned by Contractor, improvements made to Contractor-
owned buildings, and building or improvements in progress or under construction.
(19) Furniture and Equipment (net of accumulated depreciation) - medical equipment,
office equipment, and furniture owned by Contractor.
(20) Leasehold Improvements (net of accumulated depreciation) - improvements to
facilities not owned by Contractor. Provide gross amount, less amortization.
(21) EDP Equipment (net of accumulated depreciation) - EDP hardware and software that
constitute a data processing system used by the insurer if the cost of such a system is at
least $50,000 and is to be amortized in full in not more than 10 years.
(22) Other Property and Equipment (net of accumulated depreciation) - other tangible,
fixed assets of a long-term nature used in the continuing operation of the business,
including land, building, building improvements, furniture, equipment and leasehold
improvements not included above.
(23) TOTAL PROPERTY AND EQUIPMENT - the sum of Line 18 through Line 22.
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Contract #126667 Exhibit G Page 127 of 242
(24) TOTAL ASSETS - the sum of Line 9, Line 17, and Line 23.
(25) Accounts Payable - short-term monetary amounts due to creditors for the acquisition of
goods and services (trade and vendors rather than health care practitioners) on a credit
basis.
(26) Claims Payable - Claims reported and booked as payables and IBNR Claims. This
liability relates to Claims expenses found on the Statement of Revenues, including
percentage withholds but excluding medical incentive pool. Include the net of
reinsurance ceded. Other categories of liabilities netted into Claims payable are 1)
Claims recoverable, 2) Unallocated loss reserve, 3) Recoverable on unpaid losses, 4)
Monies set aside for Claims processing, and 5) Claims adjustment expenses, among
others.
IBNR - (Incurred but not reported losses) an estimate for Claims that 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.
(27) Accrued Medical Incentive Pool - liability for arrangements whereby Contractor agrees
to share utilization savings with Individual Practice Associations, physician groups, or
other Providers.
(28) Unearned Premiums - revenue received or booked in advance of the reporting period
for services that have not been performed during the current accounting period. A
liability exists to render service in the future.
(29) Loans and Notes Payable - the principal amount on loans due within one year.
(30) Amounts Due to Affiliates - any payable to an affiliate, including items that would
otherwise be reported on other lines.
(31) Other Current Liabilities - current liabilities not included in the current liabilities
categories listed above. Include taxes, MCO tax, and payroll taxes.
(32) TOTAL CURRENT LIABILITIES - the sum of Line 25 through Line 31.
(33) 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).
(34) Amounts Due to Affiliates - any payable to an affiliate or a person affiliated with, a
specific person that directly, or indirectly through one or more intermediaries, controls, or
is controlled by, or is under common control with, the person specified. This line
includes items that would otherwise be reported on other lines.
(35) Payable for Securities - amounts that are due to brokers when a security has been
purchased, but has not yet been paid; any payable for securities that is due as of the last
date of the report period.
(36) Other Liabilities - other liabilities not included in the liabilities categories listed above.
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Contract #126667 Exhibit G Page 128 of 242
(37) TOTAL OTHER LIABILITIES - the sum of Line 33, Line 34, Line 35 and Line 36.
(38) TOTAL LIABILITIES - the sum of Line 32 and Line 37.
(39) Common Stock - the residual interest in the asset of the stock which represents the most
basic rights to ownership of a corporation. It should equal the par value per share
multiplied by the number of issued shares or in the case of no-par shares, the total stated
value.
(40) Preferred Stock - the residual interest in the asset of stock that has some preference over
common stock, usually including dividends; should equal the par value per share
multiplied by the number of issued shares, or in the case of no-par shares, the total stated
or liquidation value.
(41) Paid in Surplus - the gross amount of paid in and contributed surplus without reduction
of account of commissions or other expenses in connection with such transactions, but
reduced by a distribution declared and paid as a return of such surplus.
(42) Contributed Capital - capital donated to nonprofit organizations.
(43) Surplus Notes - notes that qualify as equity; also called subordinated debt or debentures.
Include accrued interest on surplus notes.
(44) Contingency Reserves - reserves held for contingency purposes as defined in State
statutes and regulations.
(45) Retained Earnings/ Net Worth - the undistributed and unappropriated amount of
surplus.
(46) Other Net Worth - other net worth items not reported on any other lines.
(47) TOTAL CORPORATE NET WORTH - the sum of Line 39 through Line 46.
(48) TOTAL LIABILITIES AND NET WORTH - the sum of Line 38 and Line 47.
h. Report G.8: Quarterly Financial Report – Statement of Revenue, Expenses and Net Worth:
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.8. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.8.
General:
Report G.8 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. Contractor shall report in the column labeled OHP
Contract Line the expenses associated with providing service to DMAP Members and shall
report in the column labeled Corporate Activity the Contractor’s total financial information of
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 129 of 242
the for-profit or not-for-profit corporation which is not a foreign corporation, incorporated under
or subject to the provisions of Chapter 60 and ORS 732.005 of the Oregon Insurance Code. If
Contractor is not a corporation, Contractor shall report in the column labeled OHP Contract Line
the expenses associated with providing service to DMAP Members and shall report in the
column labeled Corporate Activity the Contractor’s total financial information. Amounts
appearing on Report G.8 shall equal the total reported annually on Report G.6.
Allocation of expenditures between OHP Line of Business and Corporate Line of Business: If
separate accounts are not kept for the OHP, revenue, expenses and net worth information for the
OHP shall be allocated using an estimation procedure approved by DMAP. Such a procedure
and all assumptions must be disclosed in Notes to Report G.8. This estimation procedure must
be used throughout the reports. The assumptions underlying the allocation must be based on a
methodology that clearly represents the true costs associated with providing services to DMAP
Members
Contractor shall submit Details of Write-Ins - Any item which is a component of any other
line, is greater than 10% of the amount on the Subtotal Line (i.e. Line 5, 14 or 22), and whose
value is greater than $1,000 will need to be described on these lines and the amount of the item
disclosed. On the description line, please reference the line number of the Other Line (i.e. Line
4, 13, 22, or 41e), identify the expense, and disclose the amount of the expense being claimed.
Instructions:
(1) Premiums - revenue recognized (net of reinsurance premium paid to the reinsurer on a
prepaid basis from individuals and groups for provision of a specified range of health
services over a defined period of time. Include DMAP Capitation and Maternity case rate
payments and net of reinsurance premiums ceded. If advance payments are made to
Contractor for more than one report period, the portion of the payment that has not yet
been earned must be treated as a liability (unearned premiums).
(2) Fee-For-Service - revenue recognized by Contractor for provision of health services to
non-DMAP Members by Contractor practitioners and to DMAP Members through
provision of health services excluded from their prepaid benefit packages.
(3) Title XIX-Other Medicaid - other Medicaid revenues as a result of other non-capitated
arrangements between Contractor and a Medicaid State Agency, for services to a
Medicaid beneficiary.
(4) Other Health Care Related Revenues - revenue recognized for provision of health
services over a defined period of time not included in previous revenue categories.
(5) TOTAL OPERATING REVENUES - the sum of Line 1 through Line 4.
(6) Physician/Professional Services - expenses for physician services provided under
contractual arrangement to Contractor including physician salaries, fringe benefits,
Capitated Payments paid to physicians, fees paid to physicians on a fee-for-service basis
for delivery of medical services, including capitated referrals. Compensations, as well as
fringe benefits, paid by Contractor to non-physician practitioners engaged in the delivery
of medical services and to personnel engaged in activities in direct support of the
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Contract #126667 Exhibit G Page 130 of 242
provision of medical services. Include expenses for practitioners not under contractual
arrangements with Contractor. Exclude expenses for medical personnel time devoted to
administrative tasks.
Physician shall be defined to include practitioner who is an allopathic, osteopathic,
homeopathic, podiatric, chiropractic, or naturopathic physician, physician assistant, and
nurse practitioner.
Professionals include dentists, psychologists, optometrists, nurses, clinical personnel such
as ambulance drivers, technicians, paraprofessionals, quality assurance analysts,
administrative supervisors and medical record clerks.
(7) Hospital Services:
(a) Inpatient – Inpatient hospital costs for Contractor members while confined to an
acute care hospital, including out of area hospitalization. Include the cost of
skilled nursing and intermediate care facilities.
(b) Outpatient – Outpatient hospital costs for Contractor members not confined to an
acute care hospital, including out of area Outpatient services.
(c) Emergency Room – expenses for emergency room services, including out of area
emergency services.
(8) Pharmacy – retail pharmacy costs, net of rebates and administrative fees.
(9) Lab and X-ray – independent laboratory and x-ray services for Contractor members.
(10) Vision - non-medical/routine vision exams and related hardware.
(11) Chemical Dependency – services provided by alcohol or chemical dependency
Providers.
(12) DME & Supplies - independent Providers of DME and Supplies. Equipment that can
stand repeated use and is primarily and customarily used to serve a medical purpose and
non-reusable medical supply items used in the treatment of illness or injury.
(13) Other Medical and Hospital Expenses - other expenses for medical and hospital
services not included in the above categories, including IBNR costs.
(14) MEDICAL AND HOSPITAL OPERATING EXPENSES SUBTOTAL - the sum of
Line 6 through Line 13.
(15) Reinsurance Recoveries Received - reinsurance recovered from the reinsurer on paid
losses and those amounts that have been billed to the reinsurer and not yet received.
Include reinsurance recovered and recoverables on paid losses. Unpaid losses are netted
against the appropriate medical and hospital expense lines 9 -16. NOTE: this is NOT a
net figure.
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Contract #126667 Exhibit G Page 131 of 242
(16) Co-payments - revenue recognized by Contractor from members on a utilization-related
basis for certain health services included in the benefit package.
(17) TPR, COB, and Subrogation Amounts Received - All Third Party payments,
Coordination of Benefits, and Subrogation payments received by the Contractor. This
total amount, nor any portion of it, should not be netted against expenses.
(18) OPERATING DEDUCTIONS SUBTOTAL - the sum Lines 15 through 17.
(19) TOTAL MEDICAL AND HOSPITAL OPERATING EXPENSES LESS
DEDUCTIONS - the sum of Line 14 minus Line 18.
(20) Compensation - Include salaries and wages, bonuses and incentive compensation to
employees, overtime payments, continuation of salary during temporary short-term
absences, dismissal allowances, payments to employees while in training and other
compensation to employees not specifically designated to another expense category.
Include fees and other compensation to directors for attendance at board or committee
meetings and any other fees and compensation paid to them in their capacities as
directors or committee members. Report agency compensation other than commissions.
Use allocation method described above.
(21) Other Administrative Expenses – payment made for other administrative expenses
associated with the overall management and operations of Contractor not included in the
above categories. Use allocation method described above.
(22) TOTAL ADMINISTRATIVE EXPENSES - the sum of items of Line 20 and Line 21.
(23) TOTAL OPERATING EXPENSES - the sum of Line 19 and Line 22.
(24) NET OPERATING INCOME (LOSS) - the result of Line 5 minus Line 23
(25) Net Investment Income – Interest earnings on investments (securities, bank accounts,
etc.) less directly-related expenses (brokerage fees, bank fees, etc.).
(26) Non-Healthcare-Related Revenues – Management fees or other fees received from
Non-OHP businesses. No amount should be shown in the “OHP Contract Activity”
column.
(27) Other Non-Operating Revenues and Expenses – Any revenues and expenses not
already included in operating revenues, operating expenses or Lin 25 or Line 26.
(28) TOTAL NON-OPERATING REVENUES AND EXPENSES - The sum of Lines 25,
26 and 27.
(29) NET INCOME (LOSS) BEFORE TAXES – Line 5 minus Line 23 plus Line 28.
(30) MCO Tax – the expense for MCO Tax.
(31) Provision for Income Taxes - the expense for income taxes for the report period.
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Contract #126667 Exhibit G Page 132 of 242
(32) TOTAL TAXES – Line 30 plus Line 31.
(33) NET INCOME (LOSS) - the result of Line 29 minus Line 30 minus Line 31.
(34) Net Worth Beginning of Quarter - the total of common stock, preferred tock, paid in
surplus, contributed capital, surplus notes, contingency reserves, retained earnings/fund
balance, and other items at the beginning of the report period.
(35) Increase (Decrease) in Common Stock - the change in the net worth of common stock
from the last report period to the current report period.
(36) Increase (Decrease) in Preferred Stock - the change in the net worth of preferred stock
from the last report period to the current report period.
(37) Increase (Decrease) in Paid in Surplus - the change in the net worth of paid in surplus
from the last report period to the current report period.
(38) Increase (Decrease) in Contributed Capital - the change in the net worth of contributed
capital from the last report period to the current report period.
(39) Increase (Decrease) in Surplus Notes - the change in the net worth of surplus notes
from the last report period to the current report period.
(40) Increase (Decrease) in Contingency Reserves - the change in the net worth of
contingency reserves from the last report period to the current report period.
(41) Increase (Decrease) in Retained Earnings/ Net Worth - the change in the net worth of
retained earnings/net worth from the last report period to the current report period.
(a) Net Income – the excess of total revenues minus total expenses during the
reporting period.
(b) Dividends to Stockholders – distributions of retained earnings to shareholders,
based upon the number of shares owned by each shareholder.
(c) Interest on Surplus Notes – interest expense paid on surplus notes. Surplus
notes are notes that qualify as equity and are also called subordinated debt.
(d) Other Charges – all other changes made to net worth that are not already
reported on lines 34 through 41.c.
(42) Net Worth at End of Quarter - the total of common stock, preferred stock, paid in
surplus, contributed capital, surplus notes, contingency reserves, retained earnings/fund
balance, and other items at the end of the report period.
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Contract #126667 Exhibit G Page 133 of 242
i. Report G.9: Quarterly Financial Reporting – Cash Flow Analysis for Corporate Activity:
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.9. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.9.
General:
Report G.9 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. The Statement of Cash Flow shall be prepared
using the Direct Method of reporting cash flow. Cash from operations shall be reported
consistent with the Statement of Income, excluding the effect of current and prior year accruals.
Only the cash portion of a transaction shall be reported in the Statement of Cash Flow.
Instructions:
Corporate Activity - the financial position of a for-profit or not-for-profit corporation, which is
not a foreign corporation, incorporated under or subject to the provisions of Chapter 60, ORS
and ORS 732.005 relating to activities that the corporation performs. Includes the OHP line of
business. Any PHP not a corporation should regard its total PHP business as corporate activity.
CASH FLOWS PROVIDED BY OPERATING ACTIVITIES - financial report estimating
cash generated or lost from operating activities for both not-for-profit as well as for-profit
corporations.
(1) Net Income (Loss) report Corporate Activity of Report G.8, Line 30 for the current
quarter.
(2) Depreciation and Amortization - report back items not requiring the use of cash, such
as depreciation.
(3) Premium Receivable - report any cash flow generated or lost by changes in premium
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) Due from Affiliates - report any cash flow generated or lost by changes in amounts due
to affiliates. 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) 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.
(6) Other (Increase) Decrease in 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.
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Contract #126667 Exhibit G Page 134 of 242
(7) 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.
(8) Claims Payable - report any cash flow generated or lost by changes in medical Claims
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.
(9) Accrued Medical Incentive Pool - report any cash flow generated or lost by changes in
accrued medical 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.
(10) Unearned Premiums - report any cash flow generated or lost by changes in unearned
premiums. Include non-cash or non-cash equivalent transactions. Remove the effects of
all deferrals of receipts and payments and accruals of receipts and payments.
(11) Due to Affiliates - report any cash flow generated or lost by changes in amounts due to
affiliates. Include non-cash or non-cash equivalent transactions. Remove the effects of
all deferrals of receipts and payments and accruals of receipts and payments.
(12) Other Increase (Decrease) from Operating Activities - 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.
(13) NET CASH PROVIDED (USED) FROM OPERATING ACTIVITIES - sum of Line
1 through Line 12. To arrive at net cash provided by operating activities, remove from net
income the effects of all deferrals of receipts and payments and accruals of receipts and
payments.
(14) Receipts from 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.7.
(15) Receipts for Sales of Property and Equipment - cash generated by the transfer of cash
into property and equipment sales transactions reported in Report G.7. 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.
(16) Payments for Investments - cash lost by the transfer of cash into either short-term or
long-term investment transactions reported in Report G.7. Include cash lost by transfer
of cash into restricted cash reserves and other assets that relate to transactions reported in
Report G.7.
(17) Payments for Property and Equipment - cash lost by the transfer of cash into property
and equipment sales transactions reported in Report G.7. 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.
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Contract #126667 Exhibit G Page 135 of 242
(18) Other Increase (Decrease) in Cash Flow for Investing Activities - report any other
cash flow generated or lost by changes in investing activities.
(19) NET CASH PROVIDED BY INVESTING ACTIVITIES - sum of Lines 14 through
18.
(20) Proceeds from Paid in Capital or Issuance of Stock - cash generated by the transfer of
cash from paid in capital surplus or issuance of stock.
(21) Loan Proceeds from Non-Affiliates - cash generated by the transfer of cash from loan
proceeds transactions from non-affiliates.
(22) Loan Proceeds from Affiliates - cash generated by the transfer of cash from loan
proceeds transactions from affiliates. Include loan and notes payable transactions
reported in Report G.7. Exclude interest.
(23) Principal Payments on Loans from Non-Affiliates - cash lost by the transfer of cash
from loan proceeds transactions from non-affiliates.
(24) Principal Payments on Loans from Affiliates - cash lost by the transfer of cash from
loan proceeds transactions from affiliates. Include loan and notes payable transactions
reported in Report G.7.
(25) Dividends Paid - cash lost by paying dividends reported in Report G.8.
(26) Principal Payments under Lease Obligations - cash lost by the transfer of cash from
loan proceeds transactions from lease obligations. Include loan and notes payable
transactions reported in Report G.7.
(27) Other Cash Flow Provided by Financing Activities - any cash flow generated or lost
by the transfer of cash in a financial transaction.
(28) NET CASH PROVIDED BY FINANCING ACTIVITIES - sum of Line 20 through
Line 27.
(29) NET INCREASE/(DECREASE) IN CASH AND CASH EQUIVALENTS - the sum
of Line 13, Line 19 and Line 28.
(30) 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 date specified in the report period on Report G.7.
(31) CASH AND CASH EQUIVALENTS AT END OF REPORT PERIOD - the sum of
Line 29 and Line 30.
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Contract #126667 Exhibit G Page 136 of 242
j. Report G.10: Corporate Relationships of Contractors:
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.10. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.10, SECTIONS (A), (B) AND (C).
General:
Report G.10 Part I, Part II, and Part IV are part of the Quarterly Financial Reports and shall be
submitted to DMAP in accordance with Section 3 of this Exhibit G. Report G.10 Part III is an
annual requirement, and shall be submitted with the 4th quarter report.
Instructions:
Part I. Corporate Relationship and Organizational Structure:
Organizational chart - submit on August 31st of each year(s) Contract is in effect.
Part II. Summary of Risk-Sharing Transactions with Provider Groups:
Health Care Delivery Systems - an organized method of providing health care services
such as Independent Provider Association (IPA) as a group, Primary Care Providers
(PCP) as individuals or groups, etc.
Line 1 Independent Provider Association (IPA) - a type of health care delivery system
consisting of an IPA or group with which Contractor negotiates price discounts in
exchange for the Providers affiliated with that IPA or group having guaranteed access to
enrolled DMAP Members.
Line 2 Primary Care Providers (PCP) - a type of health care delivery system consisting
of either an individual practitioner or a group of Affiliated PCPs with which Contractor
negotiates price discounts in exchange for the affiliated Providers having guaranteed
access to enrolled DMAP Members.
Affiliated PCPs - Physicians, Dentists, Nurse Practitioners, and Physician Assistants
whose practice type is Family Practice, General Practice, Internal Medicine, Pediatrics, or
Obstetrics/Gynecology.
Line 3 Specialist Practitioners - a type of health care delivery system consisting of
either an individual practitioner or a group of affiliated specialist practitioners with whom
Contractor negotiates price discounts in exchange for the affiliated Providers having
guaranteed access to enrolled DMAP Members.
Affiliated Specialist Practitioners - Physicians other than a PCP. Under most
circumstances, these services would be performed by Providers to whom the DMAP
Member has been referred by his or her PCP. Ancillary services (defined in OAR 410-
141-0480) should not be included here.
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Contract #126667 Exhibit G Page 137 of 242
Line 4 Lab/X-ray Service Providers, Individual or Group - a type of health care delivery
system consisting of individual or a group of affiliated laboratory or x-ray Providers with
which Contractor negotiates price discounts in exchange for the affiliated Providers
having guaranteed access to enrolled DMAP Members.
Line 5 Hospital Providers, Individual or Group - a type of health care delivery system
consisting of individual or a group of affiliated hospital Providers with which Contractor
negotiates price discounts in exchange for the affiliated Providers having guaranteed
access to enrolled DMAP Members.
Line 6 Other Inpatient Providers - a type of health care delivery system consisting of
individual or a group of affiliated Other Inpatient Providers with which Contractor
negotiates price discounts in exchange for the affiliated Providers having guaranteed
access to enrolled DMAP Members, such as an Independent Rehabilitation Contractor.
Line 7 Other Providers, Individual or Group - a type of health care delivery system
consisting of a group of affiliated Other Providers organized and affiliated Providers with
which Contractor negotiates price discounts in exchange for the affiliated Providers
having guaranteed access to enrolled DMAP Members, such as an Independent Home
Health Agency or Durable Medical Equipment Contractor.
Columns 1 through 9 - Service Payment Arrangements - arrangements developed
between Contractor and Providers that determine the billed amount for health care
services performed for DMAP Members enrolled with Contractor.
Column 1 Salary Payments - arrangements developed between Contractor and
Providers where Providers receive a salary from Contractor in exchange for the provision
of health care services for DMAP Members enrolled with Contractor.
Column 2 Fee-For-Service Payments - arrangements developed between Contractor
and Providers where Providers receive a payment from Contractor in exchange for the
provision of health care services for DMAP Members enrolled with Contractor,
dependent on the actual number and nature of services provided to each DMAP Member.
Columns 3 through 7 - Capitation Payments - arrangements developed between
Contractor and affiliated Providers who contract directly with Contractor, where
Providers receive a fixed amount from Contractor in exchange for the provision of health
care services for DMAP Members enrolled with Contractor, regardless of the actual
number or nature of services provided to each DMAP Member.
Column 3 To Primary Care Providers - total Capitation Payments derived from
DMAP premiums made by Contractor to PCPs in a specific delivery system.
Column 4 To Specialist Providers - total Capitation Payment derived from DMAP
premiums made by Contractor to Specialist Providers in a specific delivery system.
Column 5 To Lab/X-ray Service Providers - total Capitation Payment derived from
DMAP premiums made by Contractor to Laboratory or Radiology Service Providers in a
specific delivery system.
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Contract #126667 Exhibit G Page 138 of 242
Column 6 To Hospital Providers - total Capitation Payment derived from DMAP
premiums made by Contractor to Hospital Providers in a specific delivery system.
Column 7 To Other Providers - total Capitation Payment derived from DMAP
premiums made by Contractor to other Providers types of health care delivery systems
not included in table.
Column 8 Payments to Non-Affiliated Providers - arrangements developed between
Contractor and Providers not contracted with Contractors.
Column 9 Stop-Loss Protection Payments - payments derived from DMAP
premiums made by Contractor to specific delivery systems to provide monies used to
cover future stop-loss protection expenses for those specific delivery systems.
Part III Incentive Arrangements:
Columns 1 through 3 - Total Dollar Amount - total dollars to be returned to all
Providers providing services to Contractor's enrolled DMAP Members as specified in the
incentive arrangement.
Columns 1 through 6 - Incentive Arrangements - arrangements between Contractor and
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 health care services to Contractor's enrolled DMAP Members.
Column 1 Provider Bonuses - an incentive arrangement where a certain amount is
paid to Providers within the health care delivery system at a given point in time, in
addition to the negotiated usual and customary payment arrangement on the basis of
certain performance criteria.
Column 2 Capitation Withhold - an incentive arrangement where a certain amount is
removed from the negotiated Capitation Payment and set aside to be paid to the Providers
within the health care delivery system at a given point in time on the basis of certain
performance criteria.
Column 3 Fee-For-Service Withhold - an incentive arrangement where a certain
percentage of the usual and customary fee is removed from the base amount of the usual
and customary fee and set aside to be paid to the Providers within the health care delivery
system on the basis of certain performance criteria.
Column 4 Total Across Delivery System - sum of (Columns 1, 2 and 3)
Column 5 Multiple Risk Pools - an incentive arrangement where a certain amount is
removed from the negotiated Capitation Payment of Providers within the health care
delivery system and is set aside to be paid to all participating Providers at a given point in
time on the basis of certain performance criteria.
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Contract #126667 Exhibit G Page 139 of 242
Column 6 Group/Individual Based Risk Pools - an incentive arrangement where a
certain amount is removed from the negotiated Capitation Payment from individual
Providers or organized groups of Providers within the health care delivery system and set
aside to be paid to all participating Providers at a given point in time on the basis of
certain performance criteria.
Column 7 Name of Provider Responsible for Deficits in Excess of Withhold - the
Provider within the health care delivery system determined through the incentive
arrangement process to be responsible for any deficits that may be incurred in excess of
withhold in the event that the total withhold is less than the expenses of the Providers
participating in the withhold pool.
Part IV. Intermediary Arrangements:
General:
Contractor shall complete this Section if the Contractor pays 16% or more of its total
administrative expenses to an individual intermediary or more than 25% of the DMAP
premium revenue in a month to any individual intermediary to provide
medical/hospital/dental services. If Contractor meets this standard, detail the
administrative and medical/hospital/dental expenses paid by the Contractor to
Intermediaries to perform the duties associated with the OHP Line of Business only.
Instructions:
(1) Total Salary and Wages/Compensation - Include salaries and wages, bonuses
and incentive compensation to employees, overtime payments, continuation of
salary during temporary short-term absences, dismissal allowances, payments to
employees while in training and other compensation to employees not specifically
designated to another expense category. Include fees and other compensation to
directors for attendance at board or committee meetings and any other fees and
compensation paid to them in their capacities as directors or committee members.
Report agency compensation other than commissions. - Include the wages and
salaries of employees who are employed in the review of utilization such as
Medical Director, ENCC staff, utilization review staff, etc. Include the wages and
salaries of employees who are employed in the certification and accreditation of
Providers.
(2) External Utilization Management Fees - Include management fees paid for
utilization review services performed by Subcontractors.
(3) External Certifications and accreditation Fees - Include fees paid to
organizations for certifications and accreditation of Providers.
(4) External Legal fee and expenses - Expenses directly related to legal activities
and lobbying efforts.
(5) External Auditing, actuarial and other consulting services expenses - Exclude
fees for examinations made by DCBS and expenses of internal audits by company
employees.
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Contract #126667 Exhibit G Page 140 of 242
(6) Marketing and advertising - Expenses directly related to marketing activities.
Include such items as 1) newspaper, magazine and trade journal advertising for
the purpose of solicitation and conservation of business, 2) all calendars, blotters,
wallets, advertising novelties, etc., for distribution to the public, 3) print, paper
stock, etc. in connection with advertising, 4) prospect and mailing lists when used
for advertising purposes and 4) pamphlets on educational subjects or other
member materials specifically relating to the OHP Line of Business. Omit
salaries and expenses of advertising department personnel, help-wanted
advertisements, and advertising in connection with investments.
(7) Claims processing - Include payments to other entities for
medical/hospital/dental Claims processing. Include management fees associated
with administration of Claims processing systems. Do not include payments to
intermediaries that would be distributed by those intermediaries for service
payments. Include payments to other entities for pharmacy Claims processing.
Include management fees associated with administration of Claims processing
systems. Do not include payments to intermediaries that would be distributed by
those intermediaries for service payments.
(8) Reimbursements from intermediaries - Payment to the Contractor from the
intermediaries based on performance standards.
(9) Reimbursements to intermediaries - Payments to intermediaries from the
Contractor based on performance standards.
(10) Other administrative expenses - Other administrative expenses not described in
the lines above that are associated with the overall management and operation of
Contractor.
(11) Total administrative expenses - Sum of Lines 4 through Line 10.
12. through 20. - Please refer to the definitions found on Report G.8, Line 9
through Line 20.
(21) Total Medical/Hospital/Dental Expenses - Sum of Lines 12 through Line 20.
k. Report G.11: Incurred But Not Reported:
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.11. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.11.
General:
Report G.11 is one of the Quarterly Financial Reports and shall be submitted to DMAP in
accordance with Section 3 of this Exhibit G. Contractors shall submit to DMAP the claims lag
form for the Corporate Line of Business.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 141 of 242
Instructions:
Part 1. Show the payment activity for each month, indicating on each line a paid month, the
dollar amount of Claims paid in the incurred month, the dollar amount of Claims paid one, two,
three, four, five or six months after incurred, and the total dollar amount of Claims paid. Please
note that the months are in descending order
Part 2. Fill out the cumulative percentage of paid claims lag form below for the corporate line of
business, showing the cumulative paid claims as a percentage of current estimated incurred based
on Claims paid and incurred provided in the previous table (1.). Please note the months are in
descending order.
l. Report G.12: Instructions for Filing the Physician Incentive Plan Disclosure Form:
NOTWITHSTANDING ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF THIS REPORT G.12. THE NUMBERED TERMS
SET FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE
REPORT G.12.
General:
Contractor shall submit to DMAP a Physician Incentive Plan (PIP) Disclosure Form, on August
31st of each year that this Contract is in effect, to comply with the requirements of 42 CFR
422.208-422.210. Contractors may submit to DMAP either the Physician Incentive Plan
Disclosure Form within this Exhibit G or CMS’s PIP Disclosure Form (OMB No. 0938-0700),
except in the case of Contractor who is regulated by DCBS, who will submit the same
information to be provided to CMS. Contractor shall provide DMAP with additional information
upon request. Contractor shall submit this report either electronically or by mail. Contractors
shall disclose physician incentive arrangements for Providers within the Contractor’s network on
an annual basis. A PIP disclosure shall include:
(1) The disclosure Cover Sheet - this sheet should be the first page of the PIP submission.
(2) PIP Disclosure Form - This form may be duplicated as necessary to capture all of the
arrangements in effect amongst the applicant’s Provider contractors and Subcontractors
down to the level of physicians.
The PIP Worksheet may be used as a guide in determining if there is substantial financial risk in
any Provider arrangement and to assist the Contractors in entering data on the disclosure form.
Contractors may modify the CMS Worksheet for their internal use as long as the necessary
information is captured that will document the data. Generally, a separate Worksheet should be
used for each type of contractual relationship. Reproduce as many of these forms as needed. Do
not submit the Worksheets, but retain them and any other supporting information for review by
DMAP or CMS.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 142 of 242
Contractors should analyze the data from different Providers to determine whether information
from the same type of contracting entity can be aggregated for disclosure to DMAP. Contractors
need to determine if they have received all information from their contractors down to the level
of physicians, even if the Providers bear no risk or there is no substantial financial risk.
(1) An intermediate entity should report its direct contracts with physicians as well as
arrangements with its physician groups and the physician groups’ physicians. Even if
there is no substantial financial risk in any contractual arrangement, the lower levels must
be disclosed.
(2) A physician group should report arrangements with its physicians, even if there is no
substantial financial risk between the Contractor and the physician group.
Nine contractual relationships are listed. Disclose one type of relationship on each Form you
complete. Submit as many Forms as you need to represent all of the arrangements that serve the
Contractors Medicaid enrollees.
(1) Contractor to physician group
(2) Contractor to intermediate entity
(3) Contractor to individual physician
(4) Intermediate entity to physician group
(5) Intermediate entity to physician
(6) Physician group to physician group
(7) Physician group to physician
(8) Physician to physician
(9) Intermediate entity to intermediate entity.
Each submission from a Contractor must include contractual relationships (1), (2) or (3), but
Contractors may have multiple arrangements and need all three. The Contractor must disclose
the subcontracting arrangements to the level of the physician. All disclosures relating to one
hierarchy of contracts should be stapled together. The hierarchies are:
Selection of: (1) Contractor to physician group requires a disclosure of:
(7) Physician group to physician OR (6) Physician group to physician group
If (6) is selected, you must have (7) to disclose incentives to physicians
There can be selection of: (8) Physician to physician [this is not required].
Selection of: (2) Contractor to intermediate entity requires disclosure of:
(4) Intermediate entity to physician group OR
(5) Intermediate entity to physician OR
(9) Intermediate entity to intermediate entity. The intermediate entity can have
multiple contracting arrangements.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 143 of 242
If (4) is selected, you must have (7) to disclose incentives to physicians
If (9) is selected, you must have (4) or (5) to disclose incentives to
Subcontractors. There can be selection of: (8) Physician to physician [this is not
required].
Selection of: (3) Contractor to individual physician does not require any subcontract.
There can be selection of: (8) Physician to physician [this is not required].
Single or aggregate disclosure: The Disclosure Form may reflect a single incentive arrangement
if that is a unique arrangement. However, Contractors should aggregate information on one form
for contractual arrangements that are substantially the same and the stop-loss requirements are
the same. For example, if a Contractor contracts with 100 physician groups under a very similar
Capitation Payment that does not pass referral risk to the groups, the Contractor should check
category 1 on the Disclosure Form and disclose all 100 on one Form. If 55 physician groups do
not pass risk to their doctors and these 55 groups have a total of 450 physicians under this no risk
compensation, then the Contractor should check category 7 on a new Disclosure Form and
disclose all 450 on the Form. Similarly, the Contractor should disclose the physician
group-physician incentive arrangements for the other 45 groups, aggregating those physicians
who are placed at substantially the same risk and who have the same stop loss requirements, if
the risk exceeds the SFR cutoff. Staple together all the forms that relate to the 100 physician
groups.
Instructions:
Line 1.A. Give the name or identifier of a single Provider (e.g., the intermediate entity,
physician group, or individual physician) or the Providers who are aggregated for the disclosure.
The Provider named or identified is the party who receives payment under the Provider contract
to which the Disclosure Form applies. The purpose here is to allow the user to be able to identify
the Provider(s) after entering the data.
Line 1.B. Give the number of aggregated Providers whose arrangements are being
disclosed. (See the discussion above.) Do not send lists of Provider names. For example, if #1 is
selected, then give the number of physician groups.
Line 1.C. Asks for disclosure of Federally Qualified Health Centers and Rural Health
Clinics (FQHC/RHCs). Please distinguish FQHC/RHCs by using a separate Disclosure Form to
report each FQHC/RHC, however you may aggregate those with substantially the same incentive
arrangements. If the MCO is owned or controlled by a consortium of FQHC/RHCs or has
FQHC/RHCs in its network, be sure to indicate this on the cover sheet.
Line 1.D. Applies only to physicians of physician groups (selection of #7 contracting type)
and asks for a breakout of the number of physicians who are members of the group and those
who independently contract with the group. Members are typically owners, partners, or
employees of the physician group.
If either arrangement with Providers that are intermediate entities (IE) is selected on the
Disclosure Form (either #2 or #9), complete items 1.A - 1.C only since stop loss requirements do
not apply to intermediate entities (IE). However, fully complete disclosures for IE’s
relationships with Provider groups and their physicians (#4 and #7) and IE with individual
physicians (#5) because stop loss requirements apply to these levels.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 144 of 242
Question 2 Identifies whether the incentive arrangement transfers any risk. A Capitation
Payment is considered a transfer of risk for this question, even if the capitation is for services
provided only by the contracting physician or physician group. [This information is found in the
Worksheet.]
Check "yes" or "no", as applicable. If "no" is checked, then this disclosure is complete. If "yes"
is checked, identify the type of risk transfer; then go to Question 3.
Risk transfer choices are: "capitation, bonus, withhold, percent of premium or other." Check the
appropriate choice or choices; more than one choice should be checked if the arrangement has
features of each type of risk-sharing.
A choice of "Other" is provided if a combination of the four types of risk arrangement does not
define the arrangement. For the purpose of this Disclosure Form, the obligation for the Provider
to fund deficits is considered as a "withhold." A bonus for low utilization of referral services is
considered to be risk transference.
Question 3 Identifies whether risk is transferred for referrals. [This information is in the
Worksheet.] Check "yes" or "no", as applicable. A bonus for low utilization of hospital,
specialist or other services is considered to be a risk for referral services. If "no" is checked, then
this disclosure is complete. If "yes" is checked, go to Question 4 to identify the type of risk
transfer.
Question 4 Identifies the type of risk-sharing arrangement. [This information is found in the
Worksheet.] See #2 above for instructions on identifying risk arrangements.
The risk-sharing arrangement may be described briefly on the Disclosure Form, particularly if
‘other’ is selected.
Question 5 The percentage of risk attributable to referrals only should be stated in Question 5.
This percentage corresponds to the "% Of Total Compensation At Risk For Referrals" from the
Worksheet. If the percentage is equal to or below 25 %, the arrangement is not considered to be
at substantial financial risk and this disclosure is complete. Percent of premium is treated as
capitation for this calculation. If above 25 percent, proceed to Question 6.
Question 6 Information for Question 6, about the number of patients, is found in the
Worksheet. Specific criteria must be met before pooling is allowed, as stated in regulations. Any
entity that meets all five criteria (below) required for the pooling of risk will be allowed to pool
that risk in order to determine the amount of stop-loss required by the regulation. If the number
of patients is 25,000 or fewer, then go to Question 7. If greater than 25,000, the disclosure is
complete.
(1) Pooling of patients is otherwise consistent with the relevant contracts governing the
compensation arrangements for the physician or group (i.e., no contracts can require risk
be segmented by Contractor or patient category);
(2) The physician or group is at risk for referral services with respect to each of the
categories of patients being pooled;
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 145 of 242
(3) The terms of the compensation arrangements permit the physician or group to spread the
risk across the categories of patients being pooled (i.e., payments must be held in a
common risk pool);
(4) The distribution of payments to physicians from the risk pool is not calculated separately
by patient category (either by Contractor or by Medicaid, Medicare, or commercial); and
(5) The terms of the risk borne by the physician or group are comparable for all categories of
patients being pooled.
Note that pooling and stop-loss requirements applicable to a group cannot be extended to
a subcontracting level. For example:
A physician group has greater than 25,000 patients that meet pooling criteria. This group
contracts with another physician group, which has 25,000 or fewer patients and bears risk
for referrals above 25%.
The first group is exempt from stop-loss requirements; the second group must comply
with stop-loss requirements and the Contractor must comply with survey requirements.
Question 7 Note the type and the levels or thresholds of the stop-loss insurance if stop-loss
coverage for the physician group or physician is required.
Check the type of stop-loss, aggregate, individual per patient, or other coverage. * If individual,
give the threshold (deductible) as a dollar amount. If aggregate or other, briefly describe the
stop-loss coverage. If there are arrangements that merit explanation, describe the coverage (if
needed, attach a sheet for additional space).
A description should include whether the coverage is:
(1) Combined (professional and institutional);
(2) Broken down into institutional, professional and other components;
(3) The deductible, co-insurance percentage, maximum liability/pay-out by the policy;
(4) Whether the stop-loss coverage applies to all costs or only the cost of referral services;
and
(5) Any other key features of the coverage.
This information is found in the Worksheet.
If Providers can be aggregated because of the similarity of risk arrangements, the Contractor
should sort the Providers by stop loss requirements and then use a separate Disclosure Form for
each requirement. For example: 100 groups exceed the 25% risk threshold; 50 have a patient
pool exceeding 25,000 (under a very similar risk arrangement); 25 have a patient pool of
between 1,001 and 5,000 (under a very similar risk arrangement); and another 25 of these groups
have a patient pool of between 8,001 and 10,000. The Contractor should use three Disclosure
Forms to represent the groups that aggregate into three stop loss requirements.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 146 of 242
m. Notwithstanding ANY DEFINITIONS IN THIS CONTRACT THAT MAY BE
INCONSISTENT, THE FOLLOWING DEFINITIONS APPLY ONLY FOR PURPOSES OF
EXPLAINING THE REQUIREMENTS OF REPORT G.13. THE NUMBERED TERMS SET
FORTH BELOW CORRESPOND WITH THE NUMBERS OR HEADINGS ON THE REPORT
G.13.
General
Report G.13 shall be required for reporting the three highest executive salary and benefit
packages, to comply with ORS 414.725(1)(d) and (e), and shall be submitted to DMAP by
March 31st of every contract year starting in 2009.
Instructions
"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.
Disclose the amounts of OHP compensation 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 sources. Only OHP compensation is disclosed on the form.
Column 3 – “Payroll-Related Benefits” includes, but is not limited to insurance premiums and
retirement plan deposits paid by Contract for the Executive’s benefit.
Column 4 – “All Other Compensation” is anything of value that the Executive received
because of the relationship, not already reported in Column (2) or Column (3).
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 147 of 242
EXHIBIT G – Attachment 1 Form G.1
Report Period: __________________________through ________________
GENERAL INFORMATION AND CERTIFICATION
I. General Information
A. Contractor ____________________________________________
B. Address ____________________________________________
____________________________________________
C. Prepared by ____________________________________________
D. Phone Number ____________________________________________
E. Email Address ____________________________________________
II. Certification is to be signed by an official of the company and the original is to be
mailed to DMAP.
I, the undersigned, hereby attest that I have authority to certify the data and information
and I, the undersigned, hereby certify based on best knowledge, information, and belief
that the data and information is accurate, complete and truthful.
Signed _____________________________
Title _____________________________
Date _____________________________
*REPORT FORMS G.1 THROUGH G.12 AND FORM G.1 ARE REPLICATIONS OF
ELECTRONIC FILES.
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OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 151 of 242
EXHIBIT G – Attachment 3 - Report G.2 – DMAP Member
Approaching or Surpassing Stop-Loss Deductible
I. Contractor
Report Period: through
General - This information is used by DMAP to assess the catastrophic stop-loss exposure of each Contractor.
II. Provide the following information about the number of DMAP Members whose costs on approved
health care Claims are within the range of catastrophic stop-loss deductible for the calendar quarter. All
Contractors shall complete this Part II and submit to DMAP, quarterly.
Plan Health Care Claims: Medical Stop-
Loss Claims
Hospital Stop-
Loss Claims
Aggregate
Stop-Loss
Claims
1. Number of DMAP Members with Claims
Greater than $100,000
2. Number of DMAP Members with Claims
Greater than Reinsurance Cap.
III. Provide the following information about reinsurance. Provide one report for each reinsurer. All
Contractors shall submit this Part III, annually, unless there is a change then Contractors shall submit
within 15 days of the date of the change.
A. What is the amount of the stop-loss thresholds (i.e. the deductible amounts) and the associated
type of stop-loss coverage (hospital, professional or aggregate coverage)?
Professional:
Hospital:
Aggregate:
B. What is the dollar amount of a Claim or the percentage of the total Claim amount whereby the
responsibility for covering the Claim reverts back to the Contractor from the reinsurer?
C. What is the stop-loss fiscal year of reinsurance coverage?
D. Who is the carrier?
E. Is this carrier authorized in Oregon?
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 152 of 242
EXHIBIT G – Attachment 4 - Reserved
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 153 of 242
EXHIBIT G – Attachment 5 - Report G.4 – OHP Access to Services Statistics
I. Contractor
Report Period: through
II. Usage of Services
Please indicate the usage of services by members for which Claims were incurred in the prior report
quarter and the number of members for which no Claims were incurred in the prior quarter as of the
end of the current report quarter. Use date of service reflecting the prior quarter's report period to
compile the data. Use the unduplicated number of members enrolled during the quarter to determine
the number of members not receiving services.
Number
1. Number of unduplicated Members Enrolled during the Prior
quarter with Paid Claims.
2. Number of unduplicated Members Enrolled during the Prior
Quarter with No Paid Claims.
3. Total number of unduplicated Members Enrolled in Prior
Quarter. (Prior Quarter Report: Part III(B) , Line 3) 0
III. Membership
A. For those entities that are regulated by DCBS, provide general membership information for your
corporate business.
Number
1. Members with Group Policies
2. Members with Medicare Policies
3. DMAP Members
4. Medicaid Members other than DMAP Members
5. Members with Individual Policies
6. Other Members
7. TOTAL MEMBERS 0
B. For those entities that are not regulated by DCBS that have risk-based contracts, provide general
membership information for your corporate business.
Number
1. Members enrolled through a Workers' Compensation Risk-Based
Contract.
2. Members enrolled through a Medicare Policy
3. DMAP Members
4. Medicaid Members other than DMAP Members
5. Members with Individual Policies
6. Other Members
7. TOTAL MEMBERS 0
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 154 of 242
EXHIBIT G – Attachment 6 - Report G.4.1 – OHP Chemical Dependency Service Utilization
I. Contractor
Report Period: through
II. Report the total Member months during the report period.
III. Provide utilization, cost and DMAP Member information for chemical dependency services
provided during the report period.
Chemical
Dependency
Services
Number of
Visits
Number of
DMAP
Members
Rate per 1000
DMAP
Members per
Report Period
Total Chemical
Dependency Cost
Per Capita
Cost
Outpatient
Chemical
Dependency
Services
Methadone
Services
Residential
Services
Outpatient
CPMS
Services
Other
Chemical
Dependency
Services
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 155 of 242
EXHIBIT G – Attachment 7 - Report G.5 – Audited Yearly Balance Sheet of Corporate Activity
Contractor
Report Period: through
Corporate
Total
CURRENT ASSETS 1. Cash and cash equivalents
2. Short-term investments
3. Premiums Receivable
4. Investment Income Receivables
5. Health Care Receivables
6. Amounts Due from Affiliates
7. Reinsurance Recoverable on Paid Losses
8. Other Current Assets
9. TOTAL CURRENT ASSETS
-
OTHER ASSETS 10. Bonds
11.1 Preferred Stocks
11.2 Common Stocks
12. Other Long-Term Invested Assets
13. Receivable for Securities
14. Amounts Due from Affiliates
15. Restricted Cash and Restricted Securities
16. Other Assets
17. TOTAL OTHER ASSETS
-
18. Land, Building and Improvements (net of
depreciation)
19. Furniture and Equipment (net of depreciation)
20. Leasehold Improvements (net of depreciation)
21. EDP Equipment (net of depreciation)
22. Other Property and Equipment (net of
depreciation)
23. TOTAL PROPERTY AND EQUIPMENT (net of depreciation)
-
24. TOTAL ASSETS
-
Details of Write-Ins (Lines 8, 16 and 22):
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 156 of 242
Report G.5. Audited Yearly Balance Sheet of Corporate Activity (continued)
Contractor
Report Period: through
Corporate
Total
CURRENT 25. Accounts Payable
LIABILITIES 26. Claims Payable
27. Accrued Medical Incentive Pool
28. Unearned Premiums
29. Loans and Notes Payable
30. Amounts Due to Affiliates
31. Other Current Liabilities
32. TOTAL CURRENT LIABILITIES
-
OTHER LIABILITIES 33. Loans and Notes Payable
34. Amounts Due to Affiliates
35. Payable for Securities
36. Other Liabilities
37. TOTAL OTHER LIABILITIES
-
38. TOTAL LIABILITIES
-
NET WORTH 39. Common Stock
40. Preferred Stock
41. Paid in Surplus
42. Contributed Capital
43. Surplus Notes
44. Contingency Reserves
45. Retained Earnings/Net Worth
46. Other Net Worth
47. TOTAL NET WORTH
-
48. TOTAL LIABILITIES AND NET WORTH
-
Details of Write-Ins (Lines 31, 36 and 46):
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 157 of 242
EXHIBIT G – Attachment 8 - Report G.6 – Audited Yearly
Statement of Revenue, Expenses & Net Worth
Contractor
Report Period: through
Corporate
Total
OPERATING REVENUES 1. Premiums
2. Fee-For-Service
3. Title XIX-Other Medicaid
4. Other Health Care-Related Revenues
5. TOTAL OPERATING REVENUES -
6. Physician/Professional Services
MEDICAL AND HOSPITAL 7. Hospital Services
OPERATING EXPENSES a. Inpatient
b. Outpatient
c. Emergency Room
8. Pharmacy
9. Lab and X-ray
10. Vision
11. Chemical Dependency
12. DME & Supplies
13. Other Medical and Hospital Expenses
14. MEDICAL AND HOSPITAL OPERATING EXPENSES SUBTOTAL -
Details of Write-Ins (Lines 4 and 13)
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 158 of 242
Report G.6 – Audited Yearly Statement of Revenue, Expenses & Net Worth (continued)
Corporate
Total
OPERATING DEDUCTIONS 15. Reinsurance Recoveries Received
16. Co-payments Received
17. TPR, COB, and Subrogation Amounts Received
18. OPERATING DEDUCTIONS SUBTOTAL -
19. TOTAL MEDICAL AND HOSPITAL OPERATING EXPENSES LESS DEDUCTIONS -
ADMINISTRATIVE 20. Compensation
EXPENSES 21. Other Administrative Expense
22. TOTAL ADMINISTRATIVE EXPENSES -
23. TOTAL OPERATING EXPENSES -
24. NET OPERATING INCOME (LOSS) -
NON-OPERATING REVENUES 25. Net Investment Income
AND EXPENSES 26. Non-Healthcare-Related Revenues
27. Other Non-Operating Revenues and Expenses
28. TOTAL NON-OPERATING REVENUES AND EXPENSES
29. NET INCOME (LOSS) BEFORE TAXES
TAXES 30. MCO Tax
31. Provision for Income Taxes
32. TOTAL TAXES -
33. NET INCOME (LOSS)-
34. Net Worth Beginning of Quarter
35. Increase (Decrease) in Common Stock
36. Increase (Decrease in Preferred Stock
37. Increase (Decrease) in Paid in Surplus
38. Increase (Decrease) in Contributed Capital
39. Increase (Decrease) in Surplus Notes
40. Increase (Decrease) in Contingency Reserves
41. Increase (Decrease) in Retained Earnings/Net Worth:
a. Net Income -
b. Dividends to Stockholders
d. Interest on Surplus Notes
e. Other Changes
42. Net Worth at End of Quarter -
Details of Write-Ins (Lines 21, 26, 27, 41e):
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 159 of 242
EXHIBIT G – Attachment 9 - Report G.7 – Quarterly Balance Sheet of Corporate Activity
Contractor
Report Period: through
Corporate
Total
CURRENT ASSETS 1. Cash and cash equivalents
2. Short-term investments
3. Premiums Receivable
4. Investment Income Receivables
5. Health Care Receivables
6. Amounts Due from Affiliates
7. Reinsurance Recoverable on Paid Losses
8. Other Current Assets
9. TOTAL CURRENT ASSETS -
OTHER ASSETS 10. Bonds
11.1 Preferred Stocks
11.2 Common Stocks
12. Other Long-Term Invested Assets
13. Receivable for Securities
14. Amounts Due from Affiliates
15. Restricted Cash and Restricted Securities
16. Other Assets
17. TOTAL OTHER ASSETS -
18. Land, Building and Improvements (net of
depreciation)
19. Furniture and Equipment (net of depreciation)
20. Leasehold Improvements (net of depreciation)
21. EDP Equipment (net of depreciation)
22. Other Property and Equipment (net of
depreciation)
23. TOTAL PROPERTY AND EQUIPMENT -
24. TOTAL ASSETS -
Details of Write-Ins (Lines 8, 16 and 22)
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 160 of 242
Report G.7. Quarterly Balance Sheet of Corporate Activity (continued)
Corporate
Total
CURRENT 25. Accounts Payable
LIABILITIES 26. Claims Payable
27. Accrued Medical Incentive Pool
28. Unearned Premiums
29. Loans and Notes Payable
30. Amounts Due to Affiliates
31. Other Current Liabilities
32. TOTAL CURRENT LIABILITIES -
OTHER LIABILITIES 33. Loans and Notes Payable
34. Amounts Due to Affiliates
35. Payable for Securities
36. Other Liabilities
37. TOTAL OTHER LIABILITIES -
38. TOTAL LIABILITIES -
NET WORTH 39. Common Stock
40. Preferred Stock
41. Paid in Surplus
42. Contributed Capital
43. Surplus Notes
44. Contingency Reserves
45. Retained Earnings/Net Worth
46. Other Net Worth
47. TOTAL NET WORTH -
48. TOTAL LIABILITIES AND NET WORTH -
Details of Write-Ins (Lines 31, 36 and 46):
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 161 of 242
EXHIBIT G – Attachment 10 - Report G.8 – Quarterly Statement of Revenue, Expenses & Net Worth
Contractor
Report Period: through
A. OHP Line of Business:
1. Are separate accounts kept for the OHP Business revenues, expenses and net worth?
___ Yes ___No
2. If separate accounts are not kept, describe the allocation method used and include
all underlying assumptions that justify the use of this method.
OHP Contract Corporate
Activity Total
OPERATING REVENUES 1. Premiums
2. Fee-For-Service
3. Title XIX-Other Medicaid
4. Other Health Care-Related Revenues
5. TOTAL OPERATING REVENUES - -
6. Physician/Professional Services
MEDICAL AND HOSPITAL 7. Hospital Services
OPERATING EXPENSES a. Inpatient
b. Outpatient
c. Emergency Room
8. Pharmacy
9. Lab and X-ray
10. Vision
11. Chemical Dependency
12. DME & Supplies
13. Other Medical and Hospital Expenses
14. MEDICAL AND HOSPITAL OPERATING EXPENSES SUBTOTAL - -
Details of Write-Ins (Lines 4 and 13)
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 162 of 242
Report G.8 – Quarterly Statement of Revenue, Expenses & Net Worth (continued)
OHP Contract Corporate
Activity Total
OPERATING DEDUCTIONS 15. Reinsurance Recoveries Received
16. Co-payments Received
17. TPR, COB, and Subrogation Amounts Received
18. OPERATING DEDUCTIONS SUBTOTAL - -
19. TOTAL MEDICAL AND HOSPITAL OPERATING EXPENSES LESS DEDUCTIONS - -
ADMINISTRATIVE 20. Compensation
EXPENSES 21. Other Administrative Expense
22. TOTAL ADMINISTRATIVE EXPENSES - -
23. TOTAL OPERATING EXPENSES - -
24. NET OPERATING INCOME (LOSS) -
NON-OPERATING REVENUES 25. Net Investment Income
AND EXPENSES 26. Non-Healthcare-Related Revenues
27. Other Non-Operating Revenues and Expenses
28. TOTAL NON-OPERATING REVENUES AND EXPENSES
29. NET INCOME (LOSS) BEFORE TAXES
TAXES 30. MCO Tax
31. Provision for Income Taxes
32. TOTAL TAXES -
33. NET INCOME (LOSS)- -
34. Net Worth Beginning of Quarter
35. Increase (Decrease) in Common Stock
36. Increase (Decrease in Preferred Stock
37. Increase (Decrease) in Paid in Surplus
38. Increase (Decrease) in Contributed Capital
39. Increase (Decrease) in Surplus Notes
40. Increase (Decrease) in Contingency Reserves
41. Increase (Decrease) in Retained Earnings/Net Worth:
a. Net Income - -
b. Dividends to Stockholders
d. Interest on Surplus Notes
e. Other Changes
42. Net Worth at End of Quarter - -
Details of Write-Ins (Lines 21, 26, 27, 41e):
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 163 of 242
EXHIBIT G – Attachment 11 - Report G.8.1 – Net Worth Adjusted Medical Loss Ratio
Contractor
Report Period: through
Please provide the following information and calculate the adjusted medical loss ratio to be used
in determining the discounted premium to net worth ratio.
The adjusted medical loss ratio is defined as the result obtained when the OHP Line of Activity
adjusted medical and hoptiatal expenses is divided by the OHP Line of Activity total revenue.
The adjusted medical and hospital expenses is calculated by subtracting the capitated service
payments and the salaried service payments from the OHP Line of business medical and hospital
expenses subtotal.
Instructions Dollar Amounts
1. Copy the dollar amount found on G8, Line 14, the OHP Contract Activity
(Medical and Hospital Operating Expenses Subtotal)
2. Copy the Total of All Systems amount found on G10, II. A. Service Payment
Arrangements, Salary Payments.
3. Sum the five dollar amounts for the Total of All Systems found on G10, II. A.
Service Payment Arrangements, Capitation Payments to Affiliated Provider
and
copy that amount here.
4. Subtract Lines 2, 3, and 4 from Line 1
5. Copy the dollar amount found on G8, Line 7, the OHP Contract Activity
(Total Operating Revenue).
6. Divide Line 4 by Line 5. This number is the adjusted medical loss ratio
and needs to be reported to the fourth decimal place. If the adjusted
medical loss ratio is less than .2000, the adjusted medical loss ratio used
in the premium to surplus ratio will be .2000.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 164 of 242
EXHIBIT G – Attachment 12 - Report G.8.2 – OHP Medical Loss Ratios
Contractor
Report Period: through
(All amounts are per "OHP Contract Activity Column")
Total Revenues per Line 5, Report G8
Less: Taxes and Assessments-
MCO Tax per Line 30, Report G8
Income Taxes per Line 31, Report G8
Other (describe______________________)
Total Taxes and Assessments
Net Revenue Available for Medical Expenses
Total Medical and Hospital Operating Expenses per Line 19, Report G8
OHP Medical Loss Ratio
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 165 of 242
EXHIBIT G – Attachment 13 - Report G.9 – Cash Flow Analysis Corporate Activity/Indirect Method
Contractor
Report Period: through
Provide the cash flow information for Corporate Activity. Note that cash flows resulting from an
increase in operating assets, a decrease in operating liabilities, and a payment out are debits. Note
that cash flows resulting in receipt of cash or proceeds are credits.
CASH FLOWS PROVIDED BY Operating Activities: Corporate
Activity
1. Net Income (loss)
Adjustment to reconcile net 2. Depreciation and Amortization
income (loss) to net cash
Increase (Decrease) in 3. Premium Receivable
Operating Assets 4. Due from Affiliates
5. Health Care Receivable
6. Other (increase) decrease in Operating
Assets
Increase (Decrease) in 7. Accounts Payable
Operating Liabilities 8. Claims Payable
9. Accrued Medical Incentive Pool
10. Unearned Premiums
11. Due to Affiliates
12. Other Increase (Decrease) from
Operating Activities
13. NET CASH PROVIDED (USED) FROM OPERATING ACTIVITIES
-
CASH FLOWS PROVIDED BY Corporate
Activity
CASH 14. Receipts from Investments
FLOWS
15. Receipts for Sales of Property and
Equipment
PROVIDED 16. Payments for Investments
BY 17. Payments for Property and Equipment
INVESTING
18. Other Increase (Decrease) in Cash
Flow for
ACTIVITIES Investing Activities
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 166 of 242
Report G.9 – Cash Flow Analysis Corporate Activity/Indirect Method (cont.)
19. NET CASH PROVIDED BY INVESTING ACTIVITIES
-
20. Proceeds from Paid in Capital or
Issuance of
Stock
21. Loan Proceeds from Non-Affiliates
22. Loan Proceeds from Affiliates
23. Principal Payments on Loans from
Non-
Affiliates
24. Principal Payments on Loans from
Affiliates
25. Dividends Paid
CASH
FLOWS
PROVIDED
BY
FINANCING
ACTIVITIES
26. Principal Payments under Lease
Obligations
27. Other Cash Flow Provided by
Financing
Activities
28. NET CASH PROVIDED BY FINANCING ACTIVITIES
-
29. NET INCREASE/ (DECREASE) IN CASH AND CASH EQUIVALENTS
-
30. CASH AND CASH EQUIVALENTS AT BEGINNING OF REPORT PERIOD
31. CASH AND CASH EQUIVALENTS AT END OF REPORT PERIOD
-
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 167 of 242
EXHIBIT G – Attachment 14 - Report G.10 – Corporate Relationships of Contractors
Contractor
Report Period: through
PART
I. Corporate Relationships and Organizational Structure
A. Provide an organizational chart with your submittal on August 31st or if a change occurs during the
current report quarter indicating the relationship of Contractor to the full corporate structure, including all
entities, all subsidiaries, all affiliates and all organizations fully or partially owned by other entities in the
corporate family. If your company is not registered under a Holding Company Act, illustrate the direct
parent or controlling person, if any.
B. Does a financial guarantee agreement exist between Contractor and any parent entity? If so, provide the
current annual audited financial statement of the parental entity.
C. DMAP requires Contractors to provide financial information for purposes of evaluating financial information
for purposes of evaluating financial solvency that, but for the Contract, would not be disclosed to individuals
or entities outside of the Contractor's organization. Under ORS 192.501(2), OMAP may conditionally
withhold from disclosure records that meet all four of the following criteria:
1 The information must not be patented;
2 The information must be known only to certain individuals within the organization and used for business
the organization conducts;
3 The information must have actual or potential commercial value; and
4 The information must give its users an opportunity to obtain a business advantage over competitors who
do not know or use it.
Indicate whether Contractors consider any of the following financial records submitted to OMAP under
the contract to meet all of the above listed criteria:
Service Payment Arrangement Form (Part II)
Incentive Arrangement Form (Part III)
Intermediate Arrangement Form (Part VI)
Model Depository Agreement Form and attachments.
Bank Statements; if any
Other; please
identify
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OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 170 of 242
Report G.10 – Corporate Relationships of Contractors (continued)
Contractor
Report Period: through
PART IV. Intermediary Arrangements
1 Please detail the administrative and medical/hospital/dental expenses paid by the
Corporate Entity to Intermediaries to perform the duties associated with the OHP Line
of Business only. The attachment need only be completed if the Contractor pays 16%
or more of its total administrative expenses to an individual intermediary or more than
25% of the DMAP premium revenue in a month to any individual intermediary to provide
medical/hospital/dental services. If Contractor meets this standard, please complete this
attachment by showing these expenses in the appropriate expense classification.
Allocate the costs to the appropriate expense classification as if the expenses were
borne directly by the Contractor.
Services Paid by
Corporate Entity to
Intermediaries
1. Total Salary and Wages/Compensation
2. External Utilization Management Fees
3. External Certifications and accreditation Fees
4. External Legal fee and expenses
5. External Auditing, actuarial, & other consulting services
6. Marketing and advertising
7. Claims processing
8. Reimbursements from intermediaries
9. Reimbursements to intermediaries
10. Other administrative expenses
Administrative Expenses
11. Total administrative expense
12. Physician/Professional Services
13. Hospital Services
a. Inpatient
b. Outpatient
c. Emergency
Room
14. Pharmacy
15. Lab and X-ray
16. Vision
17. Chemical Dependency
18. DME & Supplies
19. Incentive Pool and Withhold Adjustments
20. Other Medical and Hospital Expenses
Medical/Hospital/Dental
Expenses
21. Total Medical/Hospital/Dental Expenses
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 171 of 242
EXHIBIT G – Attachment 15 - Report G.11
1. Fill out the claims lag form below for the corporate line of business. Show the payment activity for each month, indicating on each line a paid
month, the dollar amount of Claims paid in the incurred month, the dollar amount of Claims paid one, two, three, four, five or six months after
incurred, and the total dollar amount of Claims paid. Please note that the months are in descending order.
ENDING MONTH PAID
THRU
MONTH
INCURRED
MONTH
INCURRED
1 MONTH
INCURRED
2 MONTH
INCURRED
3 MONTH
INCURRED
4 MONTH
INCURRED
5 MONTH
INCURRED
6 MONTH
ALL OTHER
PRIOR MONTHS
PAID
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
13
TOTALS
ENDING MONTH PAID
THRU
MONTH
INCURRED
MONTH
INCURRED
1 MONTH
INCURRED
2 MONTH
INCURRED
3 MONTH
INCURRED
4 MONTH
INCURRED
5 MONTH
INCURRED
6 MONTH
ALL OTHER
PRIOR MONTHS
PAID
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
13
T O T A L S
ENDING MONTH PAID
THRU
MONTH
INCURRED
MONTH
INCURRED
1 MONTH
INCURRED
2 MONTH
INCURRED
3 MONTH
INCURRED
4 MONTH
INCURRED
5 MONTH
INCURRED
6 MONTH
ALL OTHER
PRIOR MONTHS
PAID
TOTAL
1
2
3
4
5
6
7
8
9
10
11
12
13
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 172 of 242
EXHIBIT G – Attachment 16 - Report G.12 – Physician Incentive Plan
Disclosure Form – Contractor Relationships
This following report is a modified form (OMB No. 0938-0700). DMAP will accept either the following
Physician Referral Incentive Relationship Form or the CMS PIP Disclosure Form (OMB No. 0938-0700) to
determine compliance with 42 CFR 422.208-422.210. This report shall be submitted annually with the second
quarter reports due August 15th of each calendar year. Contractor is also required to submit these forms when
service area designations are changed or when there is an incentive arrangements change in any subcontract
Contract with plan Providers. It is expected that all contractual levels in place between the Contractor and any
physician providing services to Medicaid members will be disclosed.
Cover Sheet
PHYSICIAN INCENTIVE PLAN DISCLOSURE FORM
DMAP Contractor’s Disclosure Compliance Package
Under the Physician Incentive Regulation
Name of Contractor _____________________________________________________
Contractor is owned/controlled by a Federally Qualified Health Center or Rural Health Clinic (FQHC/RHC) or
consortium of FQHC/RHCs or includes FQHC/RHCs in its network:
YES _______ ; NO _______
Printed Name of Contractor’s Contact Person ______________________________
Phone # _________________
This represents our organization’s disclosure compliance package submitted to DMAP. I certify that the
information made in this disclosure is true, complete and current to the best of my knowledge,
information and belief and is made in good faith.
Printed Name of CEO ___________________________________
Signature of CEO ________________________________ Date: ____________
Note: Please include this Cover Sheet as the first page of the Contractor’s Disclosure Compliance Package.
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 173 of 242
Report G.12 – Physician Incentive Plan Disclosure Form – Contractor Relationships (continued)
PHYSICIAN INCENTIVE PLAN DISCLOSURE FORM
Contractor Name: ____________________________________
Reporting year: ______________
Note: Disclosure is required even if risk or substantial risk is not being transferred or panel exceeds 25,000.
CHECK ONE - Use this Disclosure Form to disclose the incentive arrangement between the first party (in the
list below) that contracts with a second party (underlined on list below) for services to the Contractor’s
Medicaid enrollees. Be sure to disclose subcontracting arrangements down to physician levels.
-- Repeat forms as many times as needed to capture the various levels of contractual relationships.
-- For simplicity, “Provider” is used here to refer to the second party. See instructions for completing
this Form under “Single or aggregate disclosure” for aggregating either the first or second party.
-- The CMS Provider Data Worksheet can be the basis for this summary form.
(1) Contractor to physician group (2) Contractor to intermediate entity
(3) Contractor to individual physician (4) Intermediate entity to physician group
(5) Intermediate entity to physician (6) Physician group to physician group
(7) Physician group to physician (8) Physician to physician
(9) Intermediate entity to intermediate entity
1. Provider(s) named or counted should be the underlined Provider in the line checked above.
A. Name or Identifier of Provider: _____________________________. Use the actual name or
any identifier for the entity or aggregated entities disclosed on this chart.
B. Number of Providers in the category selected: _______________. Give # of Providers who are
aggregated on this form; e.g., if this form is for physician groups, category #1, then give the # of
physician groups; groups can be aggregated if risk arrangements are substantially the same and
stop loss requirements are the same.
C. Is Provider an FQHC/RHC? Yes ; No _____
If Providers are aggregated, see instructions for disclosing FQHCs.
D. If #7 above is selected, give number of physicians who are:
Members (e.g. owners, employees) of the group # ; Contracted with the group
#_____.These numbers must equal the number of physicians given in I.B.
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Contract #126667 Exhibit G Page 174 of 242
Report G.12 – Physician Incentive Plan Disclosure Form – Contractor Relationships (continued)
NOTE: If either #2 or #9 is checked above, this form is complete since stop loss requirements do not apply to
intermediate entities (IE). However, be sure to complete disclosures for the IE’s relationships with Provider
groups and their physicians (#4 and #7) and with individual physicians (#5) because stop loss requirements
apply to these levels.
2. Is risk transferred to the Provider? Yes ; No _____
Note: A bonus for low utilization of referral services is considered to be risk transference.
If YES, check all the risk transfer methods with the Provider and go to question 3.
Capitation ; Bonus ; Withhold ; Percent of Premium ; Other _____
Note: Consider the obligation for the Provider to fund deficits as a “withhold”.
Describe briefly:
3. Is risk transferred for referrals? Yes ; No _____
Note: A bonus for low utilization of hospital, specialist or other services is considered to be at risk for
referral services. If NO, this chart is finished. If YES, proceed to next question.
4. Check all the referral risk transfer methods with the Provider and go to question 5.
Capitation ; Bonus ; Withhold ; Percent of Premium ; Other _____
Note: Consider the obligation for the Provider to fund deficits as a “withhold”.
If needed, describe briefly:
5. What percent of the total potential payment is at risk for referrals: %
If above 25% proceed to question 6; if 25% or below you have completed this disclosure.
6. Number of Contractor’s patients served by the Provider or the number of pooled patients, if patients can
be pooled (see criteria for pooling in the instructions). Check one category:
A 1-1,000; B 1,001-5,000; C 5,001-8,000; D 8,001-10,000; E 10,001- 25,000; F 25,000+
If number is 25,000 or below, answer #7. If the number exceeds 25,000, you have completed this
disclosure.
7. State the type and amount of stop loss insuring the physician group and/or physician:
Aggregate insurance is excess loss coverage that accumulates based on total costs of the entire
population for which they are at risk and which reimburses after the expected total cost exceeds a pre-
determined level. Individual insurance is where a specific Provider excess loss accumulates based on
per member per year Claims.
Type: Aggregate ; Individual ; Other _____ [describe below if aggregate or other]
If individual [based on costs per patient], enter threshold/deductible amount: [enter only one amount]
Threshold: Professional $ ; Institutional $ ; Combined
$__________ Describe, if needed:
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit G Page 175 of 242
EXHIBIT G – Attachment 17 – Report G.13 –
Disclosure of Compensation
Contractor:
Report Period (Previous Contract Year):
OHP Line of Business
(1) (2) (3) (4) (5)
Name and Principal Position Gross Salary Payroll-Related All Other
Benefits Compensation TOTALS____________________________________________
Name and Position of Highest
Compensated Executive
Name:
Position:
Name and Position of Second Highest
Compensated Executive
Name:
Position:
Name and Position of Third Highest
Compensated Executive
Name:
Position:
Signed ______________________________
Title ______________________________
Date ______________________________
OHP – Chemical Dependency Organization Effective: January 1, 2009
Contract #126667 Exhibit H Page 176 of 242
EXHIBIT H - Encounter Data Minimum Data Set Requirements and Corrective Action.
Introduction
The information in this Exhibit H applies to Encounter Data Transaction 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 the Contractor will transmit data to DMAP 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.
• 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
Transmission (EDT) Rules, OAR 410-001-0100 et seq., applicable to the conduct of HIPAA
Standard Transactions with trading partners.
• Upon Contractor’s compliance with testing and other requirements in the DHS EDT rules, and
when DHS determines that Encounter Transactions may be placed into the production
environment, Contractor shall submit encounter data that complies with the data requirements of
this Exhibit.
The parties understand and agree that this Exhibit H may be further amended for purposes of complying
with 45 CFR Parts 160 and 162.
1. General Provisions
a. Encounter Definitions
An “Encounter” is a service or bundle of medically related services provided to one DMAP
Member by one Provider in one time period. Encounters are divided into Medical,
Inpatient Hospital, Nursing Facility and Outpatient (including Outpatient Hospital,
Outpatient Nursing Facility, Kidney Dialysis, Home Health and Hospice).
(1) “Adjudicated Encounters” are Claims that process through DMAP system edits.
(2) “Corrective Action Plan” is a DMAP initiated request for Contractor to develop
and implement a time specific plan, that is acceptable to DMAP, for the correction
of DMAP identified areas of noncompliance, as described in this Exhibit and
Exhibit B, Part II, Section 2, Sanctions.
(3) “Encounter Data” means health care Claims or equivalent encounter information
transaction transmitting either of the following:
(a) A request to obtain payment, and the necessary accompanying information
from a Provider to Contractor, for health care or
(b) If there is no direct Claim, because the reimbursement contract is based on a
mechanism other than charges or reimbursement rates for specific services,
the transaction of encounter information for the purpose of reporting
Contractor’s health care.
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Contract #126667 Exhibit H Page 177 of 242
(4) “Encounter Only Provider” is a Provider that provides Medicaid services to OHP
Clients only as a Subcontractor to Contractor.
(5) “Inpatient Hospital and Inpatient Nursing Facility Encounters” are services
provided by a facility to a DMAP Member who has been admitted to the facility as
an Inpatient, as defined in the DMAP administrative rules, for the purposes of
receiving services.
(6) “Medical Encounters” are professional and ancillary services including durable
medical equipment (DME) and medical transportation.
(7) “Nursing Facility” means an establishment, which is licensed and certified by
Seniors and People with Disabilities (SPD).
(8) “Outpatient Hospital”, “Outpatient Nursing Facility”, “Kidney Dialysis”,
“Home Health”, and “Hospice Encounters” are services provided by a facility to
a DMAP Member who has not been admitted to the facility as an Inpatient, as
defined in the DMAP administrative rules, for the purposes of receiving services.
(9) “Pended Encounters” are Encounters with critical errors that will not process
through DMAP system edits because of missing or erroneous data
(10) “Report Errors” are Encounters that will process through DMAP system edits.
They are, however, a notice to Contractor to review the Encounter for errors such
as inaccurate coding, maximum unit exceeded or contract limitations. Examples:
services provided below the Health Services Commission (HSC) line.
(11) “Repended Encounters” are Pended Encounters that Pend again during the
adjustment process.
(12) “Validation Period” is the Contract Year, beginning January 1 and ending
December 31 of the Contract period, or as specified in a duly executed amendment.
b. Encounter Data Submission and Processing
(1) Contractor must submit Encounter Data at least once per calendar month. The
Encounter Data must represent at least 50% of all Encounter types received and
adjudicated by Contractor that month.
(2) Contractor shall submit all initial and unduplicated Encounter Data to DMAP
within 180 days of the date of service. Corrective Action may be initiated if more
than 10% of the Encounter Claims submitted are over 180 days after the date of
service or known exact duplicate Claims exceed 10% per month.
(3) DMAP will Pend Encounter Data if the Encounter Data cannot be processed
because of missing or erroneous information.
(4) DMAP will notify Contractor of the status of all Encounter Data processed.
Notification of all Pended Encounter Data shall be provided to Contractor each
week that an Encounter remains Pended.
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Contract #126667 Exhibit H Page 178 of 242
(5) Contractor shall submit corrections to all Pended Encounters within 63 days of the
date DMAP sends Contractor notice that the Encounters were Pended. Claims for
correction that are not submitted within 63 days are subject to Corrective Action.
See Section 4, Subsection c, Timeliness Errors in Resubmitted Encounters.
(6) To prevent Corrective Action, Contractor may submit documentation to DMAP
citing specific circumstances that delay Contractor’s timely submittal of adjusted or
original Encounter Data (within 180 days from the date of service). DMAP will
review the documentation and make a determination within 30 days on whether the
circumstances cited are Acceptable. These “Acceptable” circumstances may
include, but are not limited to:
(a) DMAP Member's failure to give the Provider necessary Claim information,
(b) Third-Party Resource liability coordination,
(c) Delays associated with resolving out-of-area Claims,
(d) DMAP Member pregnancy,
(e) Third-Party submitter coordination,
(f) Hardware or software modifications,
(g) Staffing, and
(h) DMAP recognized system issues preventing timely submission of
corrections.
(7) Contractor shall submit Encounter Data, for all services rendered to Contractor’s
enrolled DMAP Members under this Contract, including Encounters where
Contractor determined no liability exists. Contractor shall submit Encounter Data
even if the Contractor did not make any payment for a Claim, including Claims for
services to enrolled DMAP Members provided under subcontract, capitation or
special arrangement with another facility or program. Contractor shall submit
Encounter Data for all services provided under this Contract to DMAP Members
who also have Medicare coverage, if a Claim has been submitted to Contractor.
(8) Contractor shall include a provision in all Subcontracts that to the extent any
provision in this Contract applies to Contractor with respect to the Work Contractor
is providing to DMAP under a Subcontract, that provision shall be incorporated by
reference into the Subcontract and shall apply equally to Subcontractor.
(9) Contractor shall not submit known exact duplicate Encounters to DMAP. DMAP
may ask Contractor to participate in a Corrective Action Plan, if more than 10% of
Contractor’s monthly submissions contain exact duplicate Encounters.
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Contract #126667 Exhibit H Page 179 of 242
c. Data Transmission and Format
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 DMAP.
d. Data Set Requirements
(1) The Data Elements specified in this section constitute the minimum data elements
required for DHS processing. Non-compliance shall be considered a breach of the
terms of this Contract.
(2) Contractor shall submit the following identifying information for all Encounters:
(a) Contractor’s DMAP PHP Provider number, or the National Plan Identifier,
when available,
(b) DMAP Member name,
(c) DMAP Member number, also known as the DMAP prime number, and
(d) Valid Claim Adjustment Reason Code(s) (CARC) (Contractor’s
determination at the service line that a liability exists).
(3) For Medical Encounters, in addition to the identifying information listed in
Paragraph (2), of this subsection, DHS requires an 837P format and the following
minimum data elements for DHS processing of Encounters:
(a) For the billing and rendering Provider the NPI and Provider Taxonomy
Code, as applicable, must be used pursuant to 45 CFR 162.410 and 162.412.
(b) ICD-9-CM diagnosis code(s) at the highest level of specificity,
(c) Date(s) of service,
(d) Modifier(s) (if applicable),
(e) Procedure code(s) (e.g. CPT, HCPC),
(f) Line item charge(s) based on the usual and customary charge(s) even
though a Third Party Resource has made complete or partial payment, and
(g) Quantity of units of service.
(4) For Outpatient Hospital, in addition to the identifying information listed in
Paragraph (2), of this subsection, DHS requires an 837I format and the following
minimum data elements for DHS processing of Encounters:
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Contract #126667 Exhibit H Page 180 of 242
(a) For the facility Provider the NPI and Provider Taxonomy Code, as
applicable, must be used pursuant to 45 CFR 162.410 and 162.412.
(b) Revenue center code(s) (National Uniform Billing Committee (NUBC)
Rule),
(c) Date of service for each line item,
(d) Quantity of units of service,
(e) Line item charge(s) based on the usual and customary charge(s) even
though a Third Party Resource has made complete or partial payment,
(f) ICD-9-CM diagnosis code(s) at the highest level of specificity, and
(g) Procedure codes (e.g. CPT/HCPCs) for the revenue center codes.
2. Submission Standards
a. The use of DMAP default Provider numbers including default NPIs are not acceptable as a
Provider number. Only NPI and taxonomy codes for covered entities registered with
DMAP are allowed in Encounter Data. Legacy Provider numbers are allowed for DMAP
enrolled atypical Providers only.
b. Contractor shall not delete Pended Encounter Data for the sole purpose of avoiding
Corrective Action. Contractor may only delete Pended Encounter Data that DMAP has
determined cannot be corrected or through other mutually agreed upon reasons.
c. Contractor must make adjustments to Encounter Data when Contractor discovers the data
are incorrect or no longer valid.
d. If DMAP discovers errors with previously Adjudicated Encounter Data defined in this
Exhibit for that Contract Year resulting from a federal or State mandate or request that
requires the completeness and accuracy of the Encounter Data, Contractor shall be required
to correct the errors.
e. DMAP will not impose Sanctions on Contractor for Encounter Data affected by DMAP
system limitations.
f. Contractor shall ensure that all Contractors’ subcontracted Providers are enrolled with
DMAP as either a Medicaid Provider or an Encounter Only Provider prior to submission of
Encounter Data. Encounter Only Providers are enrolled using DMAP Form 3108, available
at: http://egov.orgon.gov/DHS/healthplan/forms/omapforms.shtml#3100. A Form 3108
submitted without all required information will not be accepted and will be returned to
Contractor.
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Contract #126667 Exhibit H Page 181 of 242
3. Error Types and Data Elements
a. Error Types
DMAP will look for the following types of errors when validating Encounter Data:
(1) “Accuracy Errors” are differences between the information in Contractor's
DMAP Member medical records and the Encounter data reported by Contractor to
DMAP.
(2) “Inadequate Submission Errors” occur when Contractor fails to submit at least
once per calendar month. The Claims must represent at least 50% of all the
Encounters received and adjudicated by Contractor that month.
(3) “Missing Medical Record Errors” are Encounters Data that the Contractor is
unable to provide the complete medical record.
(4) “Omission Errors” are Encounters that are not submitted to DMAP.
(5) “Resubmission Errors” are Pended Encounters that have been resubmitted for
correction and Pend for errors after resubmission.
(6) “Timeliness Errors” are Encounters for which the time period between the date
the Encounter is submitted to DMAP by Contractor and the date of service is
greater than 180 days.
(7) “Timeliness Errors in Resubmitted Encounters” are Pended Encounters that
Contractor has not resubmitted within 63 days of the date DMAP sends Contractor
a notice that the Encounters were Pended. Timeliness Errors occur each 63 days
thereafter that the Pended Encounter remains on the Pend file without successfully
being corrected.
(8) “Timeliness In Corrective Action Errors” are Encounters for which Contractor
has not submitted corrections within 63 days of the date DMAP sends Contractor a
notice that Encounters need to be corrected.
b. Data Elements for Validation Methodology
(1) For purposes of Corrective Action, DMAP shall consider the required data
elements listed in Section 1, Subsection d, Data Set Requirements, of this Exhibit.
(2) DMAP may conduct validations, quality checks and analyses of Encounter
Data previously received from Contractor at DMAP’s sole discretion and
without notice to Contractor.
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Contract #126667 Exhibit H Page 182 of 242
4. Timeliness
DMAP will not take Corrective Action for Timeliness Errors, if the error occurred as the result of
a DMAP Encounter Data system problem and are beyond the control of the Contractor. If the
Timeliness errors are the result of Contractor’s Encounter Data system breakdown, Contractor
may provide documentation to DMAP. DMAP will review Contractor’s documentation before
determining if Corrective Action is indicated.
a. Timeliness Errors
(1) Schedule
For the purposes of validating Encounter Data for Timeliness Errors, DMAP will
collect and tabulate information in the DMAP Encounter Data system once every
three months during the Contract Year, at DMAP’s sole discretion, and without
notice to Contractor.
(2) Method
(a) The unit of analysis is the date of service on the Encounter.
(b) Definition of Method
(ii) The number of Encounters submitted to the DMAP Encounter Data
system with a date of service greater than 180 days from date of
service until submission to DMAP is tabulated weekly.
(iii) If the number of Encounters submitted over 180 days from the date
of service exceeds 10% of the Encounter Data submitted, Corrective
Action may be initiated.
b. Resubmission Errors
(1) Schedule
For the purposes of validating Encounter Data for Resubmission Errors, DMAP
will collect and tabulate information in the DMAP Encounter Data system no less
than once every three months during the Contract Year, at DMAP’s sole discretion,
and without notice to Contractor.
(2) Method
(a) The unit of analysis is the number of Pended Encounters that have been
resubmitted.
(b) Definition of Method
(i) The number of Pended Encounters resubmitted to the DMAP
Encounter Data system that Pend again are calculated weekly.
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Contract #126667 Exhibit H Page 183 of 242
(ii) If the number of resubmitted Encounters that Pend again exceeds
10% of resubmitted Encounters, Corrective Action may be initiated.
c. Timeliness Errors in Resubmitted Encounters
(1) Schedule
For the purposes of validating Encounter Data for timeliness in resubmitted
Encounters, DMAP will collect and tabulate information in the DMAP Encounter
Data system no less than once every three months during the Contract Year, at
DMAP’s sole discretion, and without notice to Contractor.
(2) Method
(a) The initial unit of analysis is the original Pend notification date and date of
resubmitted Pended Encounters as determined by the Internal Control
Number (ICN), or lack of resubmission of Pended Encounters by the
notification date. Subsequent units of analysis are set at 63 day intervals
after the initial deadline date (63 days from original notification).
(b) Definition of Method
The number of Encounters Pended in the DMAP Encounter Data system
with a Pend date greater than 63 days before resubmission to DMAP, or
Encounters that are not resubmitted to DMAP is calculated weekly.
Thereafter, the number of Encounters that remain Pended in the DMAP
Encounter Data system in 63-day increments is calculated until the
Encounters adjudicate.
5. Validation Methodology
DMAP may draw samples from Enrollment information and Encounter Data for the purpose of
performing validation audits, to be consistent with the protocol for Validating Encounter Data, set
forth by the Department of Health and Human Services, Centers for Medicare & Medicaid
Services, available at: http://www.cms.hhs.gov/MedicaidManagCare/ .
a. Omission Errors
(1) Schedule
Omission Errors are not tabulated continuously as part of the Encounter Data
system; therefore, an annual sampling of Contractor’s DMAP Member medical
records, as provided by Contractor’s Provider, is required in order to assess these
errors. For the purposes of validating Encounter Data for Omission Errors, DMAP,
or its designee, may collect information from Contractor’s DMAP Member medical
records. DMAP, or its designee, shall give Contractor no less than 30 days written
notice prior to reviewing or collecting information from Contractor’s DMAP
Member medical records. Contractor shall submit medical records to DMAP, or
make the records available at Contractor’s office, within 30 days of receiving the
written request for the medical records.
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Contract #126667 Exhibit H Page 184 of 242
(2) Method
(a) The DMAP Member’s medical record is the basis of comparison.
(b) Definition of Method
(i) For a Validation Period, the number of Encounters observed in the
medical record sampling above, but not reported by Contractor to
DMAP as Encounters, is determined and computed as a percentage.
This percentage is then the Contractor’s Rate of Omission.
(ii) The Rate of Omission is extrapolated to the total number of reported
Encounters to determine the total Omission Error.
(iii) If the Omission Error rate exceeds 10% of reported Encounters,
Corrective Action may be initiated.
b. Missing Medical Records
(1) Schedule
(a) Missing Medical Record Errors are tabulated from the samples drawn for
Omission and Accuracy Errors. DMAP, or its designee, may collect
information from Contractor’s DMAP Member medical records, as
provided by Contractor’s Provider, no less than once for each Contract
Year. DMAP or its designee, shall give Contractor no less than 30 days
written notice prior to reviewing or collecting information from
Contractor’s DMAP Member medical records. Contractor shall submit
medical records to DMAP, or make the records available at Contractor’s
office, within 30 days of receiving the written request for the medical
records.
(b) Upon review of the submitted medical records, DMAP staff will notify the
Contractor of missing medical records. Contractor will have the
opportunity to submit these missing medical records within 30 days written
notice from DMAP.
(2) Method
(a) The unit of analysis is the DMAP Member’s medical record.
(b) Definition of Method
(i) The number of medical records not submitted to DMAP within the
30-day period after receiving the second written notice shall be the
number of Missing Medical Record Errors.
(ii) If medical records are missing, Corrective Action may be initiated.
c. Accuracy Errors
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Contract #126667 Exhibit H Page 185 of 242
For the purpose of determining Accuracy Errors, DMAP will consider subsequent
adjustments to Encounter Data, if the adjustments are made prior to the sample selection.
After that time, Encounter Data will be considered final for the purpose of determining
Accuracy Errors.
(1) Schedule
Accuracy Errors are not tabulated continuously as part of the Encounter Data
system; therefore, an annual sampling of Contractor’s submitted Encounter Data is
required in order to assess these errors. DMAP, or its designee, may collect
information from Contractor’s DMAP Member medical records, as provided by
Contractor’s Participating Provider, to validate specific Encounter Data elements
no less than once for each Contract Year. DMAP, or its designee, shall give
Contractor no less than 30 days written notice prior to reviewing or collecting
information from Contractor’s DMAP Member medical records. Contractor shall
request and submit medical records to DMAP or make the records available at
Contractor’s office within 30 days of receiving the written request for the medical
records.
(2) Method
(a) Contractor’s Accuracy Errors in the Encounter Data are computed as
follows:
(i) The DMAP Encounter medical review team shall determine the
number of errors in the test samples of Encounters that were
reported to DMAP with one or more Accuracy Errors in the data
elements. This determination shall be based on a comparison of
information available in the medical record and the information
reported to the DMAP Encounter Data system.
(ii) A calculated percentage of Accuracy Errors determined from the test
sample shall be applied to the population of the Encounters. This
number shall be reduced by a 5% error tolerance adjustment.
(iii) The result is the estimated number of Accuracy Error Encounters. If
the Accuracy Errors exceed the 5% tolerance adjustment, Corrective
Action may be initiated.
(iv) See Table below:
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Contract #126667 Exhibit H Page 186 of 242
Table
Examples of recommended data quality standards for evaluation of submitted Encounter Data fields
Data Element Expectation Validity Criteria
DMAP Member Should be valid ID as found in the
DHS eligibility or Enrollment file.
100% valid.
DMAP Member
Name
Should be captured in such a way
that makes separating pieces of
name easy. There may be some
confidentiality issues that make this
difficult to obtain. If collectable,
expect data to be present and of
good quality.
85% present. Lengths should vary and there
should be at least some last names >8 digits and
some first names <8 digits. This will validate that
fields have not been truncated. Also verify that a
high percentage have at least a middle initial.
Date of Birth Should not be missing and should
be a valid date.
< 2% missing or invalid.
PHP ID or NPI Critical Data Element. 100% valid.
Provider NPI Should be an enrolled Provider
listed in the Provider/Capacity
Report.
95% valid.
Attending Provider
NPI
Should be an enrolled Provider
listed in the Provider/Capacity
Report.
> 85% match with Provider/Capacity Report by
either NPI or UPIN.
Provider Location As specified in the Provider/
Capacity Report. Minimal
requirement is county code, with
zip code being strongly advised.
> 95% with valid county code
> 95% with valid zip code (if available).
Specialty or
Taxonomy Codes
Coded mostly on physician and
other practitioner, optional on other
types of Providers.
Expect > 80% non-missing and valid on
physician or other applicable Provider type
Encounters (e.g. other practitioners).
Principal
Diagnosis
Well coded except by ancillary
type Providers
>90% non-missing and valid codes (using ICD-9-
CM lookup tables) for practitioner Providers (not
including transportation, lab and other ancillary
Providers).
Other Diagnosis This is not expected to be coded on
all Encounters even with applicable
Provider types, but should be coded
with a fairly high frequency.
90% valid when present.
Date of Service Dates should be evenly distributed
across time.
If looking at a full year of data, 5-7% of the
records should be distributed across each month.
Unit of Service
(Quantity)
The number should be routinely
coded.
98% non-zero
< 70% should be one if CPT code in range
99200-99215, 99241-99291.
Procedure Code This is a critical data element and
should always be coded.
99% present (not zero, blank, 8- or 9- filled).
100% should be valid, State approved codes.
There should be a wide range of procedures with
the same frequency as previously encountered.
Procedure Code This is important to pick up to > 20% non-missing. Expect a variety of
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Contract #126667 Exhibit H Page 187 of 242
Table
Examples of recommended data quality standards for evaluation of submitted Encounter Data fields
Data Element Expectation Validity Criteria
Modifier separate out surgical procedures/
anesthesia/assistant surgeon. It is
not applicable for all procedure
codes.
modifiers both numeric (CPT) and Alpha
(HCPCS). The more common codes should
appear with at least a minimal frequency are: 47
(anesthesia) and 80 (assistant surgeon).
Patient Discharge
Status Code
(Hospital)
Should be valid codes for Inpatient
Encounters with the most common
code to be Discharged to Home.
For Outpatient Encounters it can be
coded as not applicable.
For Inpatient Encounters, expect > 90%
Discharged to Home. Expect 1-5% in all other
values (expect non-applicable or unknown).
Revenue Center
Code (Hospital)
Should always be present, when
appropriate.
100% valid
d. Inadequate Submission Errors
(1) Schedule
For the purposes of validating Encounter Data for Inadequate Submission Errors,
DMAP will collect and tabulate information in the DMAP Encounter Data system
during the Contract Year, at DMAP’s sole discretion, and without notice to
Contractor.
(2) Method
The rate of comparison is the number of original Encounters received in DMAP’s
Encounter Data system as a proportion of the total Encounters.
(a) DMAP staff will develop submission rates for Contractor’s expected rate of
Encounter Data submission for each applicable Encounter type.
(b) Projections will consider factors including, but not limited to: Enrollment
information, expected utilization of services and lag time for Contractor to
receive Encounter information from Providers.
(c) Each month, DMAP will review the number of Encounter Data received
from Contractor for each Encounter type for comparison to the expected
number of Encounter Data from the Contractor for that Encounter type.
(d) If the number of submissions of Encounter Data received by DMAP from
Contractor for any Encounter type is less than 50% of the expected number
of Encounter Data for that Encounter type, Corrective Action may be
initiated.
(e) DMAP will examine Encounter submissions, for any Encounter type, using
descriptive and inferential statistics.
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Contract #126667 Exhibit H Page 188 of 242
6. Corrective Action and Sanction Penalties
a. Corrective Action
(1) Previous Contract requirements will be subject to Corrective Action
according to the terms of that Contract Year. Termination of this Contract
does not relieve Contractor of Contractor’s obligation to submit all required
Encounter Data for dates of service within the Contract Year, nor does it
relieve Contractor of the obligation to complete Corrective Action Plans or
pay recovery costs.
(2) When DMAP intends to implement Corrective Action the procedures stated
in this subsection and in Exhibit B, Part II, Section 2, Sanctions, of this
Contract shall apply.
(3) DMAP's contractual compliance monitoring of Contractor's Work, as it
relates to this Exhibit, will occur on a daily basis. Any noncompliance
issues identified by DMAP will be reported to Contractor in writing within
10 Business Days with detailed information including the area of
noncompliance, severity and recommended solution(s). Contractor must
respond within 10 Business Days in writing by citing Acceptable
circumstances as specified in Section 1, Subsection b Paragraph (6), of this
Exhibit, or proposed solutions including specific time frames for resolution.
(4) Noncompliance issues report by DMAP and not responded to within 10
Business Days by Contractor will be escalated to a formal Corrective
Action Plan.
(5) A Corrective Action Plan(s) is/are developed and mutually agreed to by
DMAP and Contractor. A Corrective Action Plan(s) not met by Contractor
will be subject to Sanction penalties as described in Exhibit B, Part II,
Section 2, Sanctions and/or this Exhibit, Section 6, Subsection b, Sanction
Penalties for Pended Encounters, or both, as determined by DMAP.
(6) Corrective Action may be initiated if more than 10% of the Encounter Data
submitted are over 180 days of the date of service or known exact duplicate
Encounters exceed 10% per month.
(7) Contractor shall not incur additional penalties caused by errors directly
related to an active Corrective Action Plan if the matter is resolved within a
mutually agreed upon time frame. DMAP will initiate a revised Corrective
Action Plan if new errors not directly related to the current Corrective
Action Plan occur.
b. Sanction Penalties for Pended Encounters
(1) Failure to comply with a Corrective Action Plan related to the requirements
of data submissions as described in Exhibit B, Part V, Section 3, Encounter
and Pharmacy Data and this Exhibit, Sections 3 and 4 shall be subject to
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Contract #126667 Exhibit H Page 189 of 242
sanctions imposed at DMAP’s sole discretion and as specified in Subsection
b, of this section, Paragraph (3), Sanctions Penalty Table for Pended
Encounters.
(2) Sanction penalties imposed by DMAP for Pended Claims not corrected
within 63 days as described in Section 3 and 4 shall be calculated based on
the Sanction Penalty Table below. For penalty levels of 1% of Monthly
Capitation refer to Exhibit B, Part VI, Section 2, Sanctions, Subsection b
(2).
(3) Sanction Penalty Table for Pended Encounters
(a) Capacity is the average of the Contractual Enrollment Limit for the 12
month period preceding the month a Sanction will be applied based on
Contractor's Enrollment Limits established in Contract to provide Covered
Services in a specific Service Area(s) as indicated in Part V, Enrollment
Limits, of this Contract.
(b) The Pended Encounter penalty is calculated by dividing the number of
Pended Encounters, as identified by DMAP, by Contractor's Capacity. The
resulting ratio of Pended Encounters to Capacity is the percentage value that
is used to determine the financial penalty due to DMAP from Contractor,
unless a Pended Encounter penalty has been levied within the last two
consecutive Contract years. If so, the sanction amounts are then multiplied
by the number of times DMAP or Contractor initiated a Pended Encounter
penalty during the last two consecutive Contract Years. Encounter sanction
penalties will not exceed 1% of Contractor's Monthly Capitation Payment.
Penalty Table for Pended Encounters
Percent of Encounters Pended
1 2 3 4 5 6 7 8
100
Encounters
or Less (or
less than
1%)
1.0%
-
1.9%
2.0%-
4.9%
5%-
9.9%
10%-
19.9%
20%-
29.9%
30%-
39.9%
40% or higher
Zero
dollars
$5,0
00
$10,000 $15,000 $20,000 $25,000 $30,000 $35,000 or 1% of
Monthly Capitation
(unless the 1% is the
lesser of the two)
Percentages are rounded up to the nearest tenth of a percent.
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Contract #126667 Exhibit H Page 190 of 242
EXHIBIT H – Attachment 1 - Data Certification and Validation
Instructions H.1 - Encounter Data Submission
1. Contractor shall demonstrate to DMAP through proof of Data Certification and Validation that
Contractor is able to attest to the accuracy, completeness and truthfulness of Information required by
DMAP. The requirements in this Exhibit H 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 DMAP 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 DMAP in the manner described in this Contract
and on each form or report.
H.1 Signature Authorization Form
H.2 Data Certification and Validation Report Form
H.3 Claim Count Verification Acknowledgement and Action Form
Form H.2 – A Data Certification and Validation Report Form must be submitted concurrently with each
Encounter Data submission. DMAP will notify Contractor if Form H.2 does not meet the requirements.
Contractor shall submit missing or erroneous Form H.2 Data Certification and Validation Reports
immediately upon notification from DMAP 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 this Contract.
After MMIS processing, DMAP 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 – Claim Count Verification Form
Data Validation – Weekly Balancing
Data Validation – Cumulative Pends
Data Validation – Duplicate Check Criteria
Data Validation – OMART (data system maintained by DMAP)
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Contract #126667 Exhibit H Page 191 of 242
EXHIBIT H – Attachment 2 - Form H.2 – Signature Authorization Form
Contracted Plan
Name _____________________________ DMAP Assigned Plan Number: ______________
Encounter Data information submitted to DMAP must be certified by one of the following:
Chief Executive Officer (CEO),
Chief Financial Officer (CFO), or
An individual who has delegated authority to sign for and reports directly to the
CEO or CFO.
________________________________ ______________________________
Print name and title of CEO/CFO Signature
_________________________________
Date
As CEO/CFO I authorize the following designated person(s) to certify Encounter Data:
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
DMAP:
____________________________________ ______________________________
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 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 DMAP,
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 Encounter Data Liaison. Contractor must
complete a new Signature Authorization Form immediately each time there is a change to any one of the
designated certifying person(s).
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Contract #126667 Exhibit H Page 192 of 242
EXHIBIT H – Attachment 3 - Form H.3 – 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: ________________________
Month/Day/Year
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 DMAP 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 DMAP for processing (new,
adjustments or deletes)
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Contract #126667 Exhibit H Page 193 of 242
EXHIBIT H – Attachment 4 - Form H.4 – 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 DMAP 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 Chief Executive Officer, Chief Financial Officer, or the individual who
has delegated authority to certify data by Form H.1, Signature Authorization Form.
_____________________________________________________________________________
Print Name Print Title
_________________________________________ ______________________________
S i g n a t u r e D a t e
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Contract #126667 Exhibit I Page 194 of 242
EXHIBIT I – Third Party Resources and Personal Injury Liens
1. Contractor shall take all reasonable actions to pursue recovery of Third Party Resources for Capitated
Services provided during the Contract Year. “Third Party Resources” means any individual, entity, or
program that is, or may be, liable to pay all or part of the medical cost of any medical assistance
furnished to a DMAP Member. Third Party Resources include but are not limited to:
a. Private health insurance;
b. Employment-related health insurance;
c. Medical support from absent parents;
d. Automobile insurance;
e. Workers’ compensation;
f. Medicare; and
g. Other federal programs, unless excluded by statute as, for example:
(1) Services provided to DMAP Members pursuant to 42 CFR 36.61 Indian Health Service
(IHS) is the payor of last resort and is not considered a Third Party Resource; or
(2) Services provided to DMAP Members at a tribal facility operated under a “638”
agreement pursuant to the Memorandum of Agreement between IHS and CMS (see
Native American Services Provider Guide) 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.
2. Contractor will develop and implement written policies describing its procedures for Third Party
Resource recovery. DMAP may review Contractor’s policies and procedures for compliance with this
Contract and, to the extent DMAP determines applicable, for consistency 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. Describe Contractor’s procedures for 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 a DMAP Member
might have other health insurance. Any Contractor that also provides or has an affiliate
that provides commercial insurance shall have a systematic process for identifying
DMAP Members with dual or overlapping coverage with Contractor and shall notify the
Health Insurance Group or DMAP at the Department of Human Services, 500 Summer
St. NE, E44, Salem, Oregon 97310 Attention: HMU, within fifteen (15) Business Days of
the time such a DMAP Member is identified. The notification to DMAP will include the
DMAP Member’s name, Social Security Number, State Medical Identification, the name
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Contract #126667 Exhibit I Page 195 of 242
of the policy holder, the name and address of the insurance company, the group and/or
policy number, and any other identifying information available to the Contractor, such as
dates of coverage, etc.
(2) Contractor shall immediately report that a DMAP 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 DMAP Member’s caseworker and the
DHS’s 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. Describe Contractor’s procedures for determining the liability of Third Party Resource.
(1) Contractor shall require DMAP Members to cooperate in securing payment from Third
Party Resources, except when the DMAP Member asserts good cause as defined in OAR
461-120-0350. Contractor may not require DMAP Members to file a claim other than for
Personal Injury Protection coverage.
(2) If Contractor is unable to gain cooperation from the DMAP Member or their authorized
Representative or a Third Party Resource in pursuing the Third Party Resource, or if the
DMAP Member or their Representative 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. Describe the circumstances in which Contractor will apply “Cost-avoidance” to Third Party
Resources.
(1) “Cost-avoidance” is defined as a method for avoiding payment of Medicaid Claims when
Medicare or other insurance resources are available to the DMAP Member. Using this
method, whenever Contractor is billed first, Claims are denied and returned to the
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 the DMAP Member or a Third
Party Resource to obtain recovery from a Third Party Resource. Upon notification,
Contractor shall process the Claim as a Valid Claim consistent with Exhibit B, Part IV,
Section 3 of this Contract. Contractor may pursue alternative remedies or may seek to
recover payment as outlined in this Exhibit.
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Contract #126667 Exhibit I Page 196 of 242
d. Describe the circumstances in which Contractor will “Pay and Chase” Third Party Resources.
“Pay and Chase” is defined as a method used where Contractor pays the recipient’s medical bills
and then attempts to recover from liable Third Party Resources. “Pay and Chase” is mandatory
whenever the following conditions exist:
Contractor must Pay and Chase in situations where the Claim is for prenatal care (including labor
and delivery and post-partum care) for pregnant women or preventive pediatric services that are
Covered Services, although Contractor may cost-avoid Claims associated with the Inpatient
hospital stay for labor and delivery and post-partum care.
e. Describe the procedures for identifying and requesting payment from a Third Party Resource that
applies to personal injury.
(1) Contractor’s recourse for obtaining an 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 a DMAP Member or their Representative.
(2) When another party may be liable for a personal injury, Contractor may make the
payments and (consistent with Subsection (1) of this Section 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 DMAP Member or their
finally 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 DMAP review.
(1) Contractor shall report all Third Party Resource payments to DMAP on the OHP
Coordination of Benefits and Subrogation Recovery Section on the Quarterly Report,
Report G.8 of Exhibit G.
(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.
(3) Contractor shall provide documentation about personal injury recovery actions and
documentation about personal injury liens to the DHS’s 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 a DMAP 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 DMAP’s
discretion or at the request of the Contractor, DMAP may retroactively Disenroll a DMAP Member to
the time the DMAP Member acquired Third Party Resource insurance, pursuant to OAR 410-141-
0080(2)(b)(D) or 410-141-0080(3)(a)(A), based on DMAP’s determination that services may be
provided cost effectively on a fee-for-service basis. When a DMAP Member is retroactively Disenrolled
under this section of this Contract, DMAP will recoup all Capitation Payments to Contractor after the
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Contract #126667 Exhibit I Page 197 of 242
effective date of the Disenrollment. Contractor and its Providers may not seek to collect from a DMAP
Member (or any financially responsible Representative of the DMAP 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 a DMAP
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 DMAP, described in
Section 2, Subsection e, of this Exhibit I.
6. When engaging in Third Party Resource recovery actions, Contractor shall comply with, and require its
Subcontractors or agents to comply with, federal and State confidentiality requirements, described in
Exhibit E of this Contract. DMAP considers the disclosure of DMAP Member Claims information in
connection with Contractor’s Third Party Resource recovery actions a purpose that is directly connected
with the administration of the Medicaid program.
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Contract #126667 Exhibit J Page 198 of 242
EXHIBIT J - Prevention and Detection of Fraud and Abuse
1. Prevention/Detection of Fraud and Abuse
a. Contractor shall have in place fraud and abuse policies, which enable the Contractor to
prevent and detect fraud and abuse activities as such activities relate to the OHP. This
shall include operational policies and controls in areas such as Claims, prior
authorization, service verification, utilization management and quality review, DMAP
Member Grievance and Appeal resolution, Participating Provider credentialing and
contracting, Participating Provider and staff education, and Corrective Action Plans to
prevent potential fraud and abuse activities.
b. Contractor shall review its fraud and abuse policies annually. If the Contractor has
updated the current policies, a written copy of the updated fraud and abuse policies
must be submitted by March 15th of the Contract Year, to Department of Human
Services, Division of Medical Assistance Programs, Medical Section, Quality
Assurance and Improvement Unit.
c. At a minimum fraud and abuse policies should include the following twelve elements:
(1) The development and distribution to Contractor’s employees and
Subcontractors, of written standards of conduct, that articulate the Contractor’s
commitment to comply with all applicable federal and State laws as well as
written policies and procedures that:
(a) Require a mandatory compliance plan;
(b) Address specific areas of potential fraud, such as Claims submission
process, and financial relationships with its Subcontractors;
(c) 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
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Contract #126667 Exhibit J Page 199 of 242
(whistleblowing); ORS 659A.230 to 659A.233 (whistleblowing); OAR
410-120-1395 to 410-120-1510 (program integrity, sanctions, fraud 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.
(d) Provide as part of the written policies, detailed provisions regarding the
Contractor’s policies and procedures for detecting and preventing fraud,
waste and abuse; and
(e) Include in any employee handbook for the Contractor, a specific
discussion of the laws described in Item (c ) of this paragraph, the rights
of employees to be protected as whistleblowers, and the Contractor’s
policies and procedures for detecting and preventing fraud, waste and
abuse.
(2) The designation of a chief compliance officer and other appropriate bodies
charged with the responsibility of operating and monitoring the fraud and abuse
program and who report directly to the CEO and the governing body;
(3) The development and implementation of regular, effective education and
training programs for all affected employees and Subcontractors;
(4) The creation and maintenance of a process to receive Grievances and the
adoption of procedures to protect the anonymity of complainants and to protect
callers from retaliation;
(5) The development of a system to respond to allegations of improper/illegal
activities and the enforcement of appropriate disciplinary action against
employees or Subcontractors, who have violated internal fraud and abuse
policies, applicable statutes, regulations, federal or State health care program
requirements;
(6) The use of risk evaluation techniques to monitor compliance and assist in the
reduction of identified problem areas;
(7) The investigation and correction of identified systemic problems and the
development of policies addressing the non-employment of sanctioned
individuals by Contractor and its Subcontractors;
(8) The referral process required under Subsection e., of this section;
(9) Enforcement of standards through well-publicized disciplinary guidelines;
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Contract #126667 Exhibit J Page 200 of 242
(10) Provision for internal monitoring and auditing;
(11) Provision for prompt response to detected offenses, and for development of
Corrective Action initiatives relating to the Contractor's contract; and
(12) Effective lines of communication between the DHS’s compliance office and
Contractor’s employees.
d. Participation of Suspended or Terminated Providers
(1) The Covered Services provided by the Contractor pursuant to Contract may not
be provided by the following persons (or their affiliates as defined in the Federal
Acquisition Regulations):
(a) Persons or entities 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 or entities who are currently suspended or terminated from the
Oregon Medical Assistance Program or excluded from participation in
the Medicare program; or
(c) Persons who have been convicted of a felony or misdemeanor related to
a crime or violation of Title XVIII, XIX or XX of the Social Security
Act and/or related laws (or entered a plea of nolo contendere).
(i) Contractor shall not refer DMAP Members to such persons and
shall not accept billings for services to DMAP Members
submitted by such persons.
(ii) Contractor may not knowingly:
(A) Have a person described in Item (a) of this Paragraph (1)
as a director, officer, partner, or person with beneficial
ownership of more than 5 percent of Contractor’s equity;
or
(B) Have an employment, consulting, or other agreement with
a person described in Item (a) of this Paragraph (1) for the
provision of items and services that are significant and
material to the Contractor’s obligations under Service
Agreement.
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Contract #126667 Exhibit J Page 201 of 242
(2) Contractor shall not pay Providers who are suspended, terminated or excluded
by Medicare, Medicaid, or SCHIP under Paragraph (1), of this Subsection d,
except for Emergency Services. If Contractor makes any unauthorized
payments to any excluded Providers, Contractor shall recover those payments
from the Provider.
e. Referral Policy
(1) Contractor is required to promptly refer all suspected cases of fraud and abuse,
including fraud by its employees and Subcontractors to the Medicaid Fraud
Control Unit (MFCU). Contractor may also refer cases of suspected fraud and
abuse to the MFCU or to the Department of Human Services Audit Unit prior to
verification.
(2) Fraud and Abuse Referral Characteristics of a Case that should be referred.
(a) Examples of fraud and abuse within Contractor’s network:
(i) 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. This would include any suspected case where it
appears that the Provider knowingly or intentionally did not
deliver the service or goods billed;
(ii) 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;
(iii) Any suspected case where the Provider intentionally or recklessly
billed Contractor more than the usual charge to non-Medicaid
recipients or other insurance programs;
(iv) Any suspected case where the Provider purposefully altered,
falsified, or destroyed clinical record documentation for the
purpose of artificially inflating or obscuring his/her compliance
rating and/or collecting Medicaid payments otherwise not due.
This would include any deliberate misrepresentation or omission
of fact that is material to the determination of benefits payable or
services which are covered or should be rendered, including dates
of service, charges or reimbursements from other sources, or the
identity of the patient or Provider;
(v) Providers who intentionally or recklessly make false statements
about the credentials of persons rendering care to DMAP
Members;
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Contract #126667 Exhibit J Page 202 of 242
(vi) Primary Care Physicians who intentionally misrepresent medical
information to justify referrals to other networks or out-of-
network Providers when they are obligated to provide the care
themselves;
(vii) Providers who intentionally fail to render Medically Appropriate
Covered Services that they are obligated to provide to DMAP
Members under their Subcontracts with the Contractor and under
OHP regulations;
(viii) Providers who knowingly charge DMAP Members for services
that are Covered Services or intentionally balance-bill a DMAP
Member the difference between the total fee-for-service charge
and Contractor’s payment to the Provider, in violation of DMAP
rules;
(ix) Any suspected case where the Provider intentionally submitted a
Claim for payment that already has been paid by DMAP or
Contractor, or upon which payment has been made by another
source without the amount paid by the other source clearly
entered on the Claim form, and receipt of payment is known to
the Provider; and
(x) Any case of theft, embezzlement or misappropriation of Title
XIX or Title XXI program money.
(b) Examples of fraud and abuse in the administration of the OHP program:
(i) Evidence of corruption in the Enrollment and Disenrollment
process, including efforts of State employees or Contractors to
skew the risk of unhealthy patients toward or away from one of
the Contractors; and
(ii) Attempts by any individual, including employees and elected
officials of the State, to solicit kickbacks or bribes, such as a
bribe or kickback in connection with placing a DMAP Member
into a carved out program, or for performing any service that the
agent or employee is required to provide under the terms of his
employment.
(c) Examples of patient abuse and neglect:
(i) Any Provider who hits, slaps, kicks, or otherwise physically
abuses any patient;
(ii) Providers who sexually abuse any patient;
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Contract #126667 Exhibit J Page 203 of 242
(iii) Any Provider who intentionally fails to render Medically
Appropriate care, as defined in this Contract, by the OHP
Administrative Rules and the standard of care within the
community in which the Provider practices. If the Provider fails
to render Medically Appropriate care in compliance with the
DMAP Member’s decision to exercise his or her right to refuse
Medically Appropriate care, or because the DMAP Member
exercises his rights under Oregon’s Death with Dignity Act or
pursuant to advance directives, such failure to treat the member
shall not be considered patient abuse or neglect; and
(iv) Providers, e.g. residential counselors for developmentally
disabled or personal care Providers, who deliberately neglect
their obligation to provide care or supervision of vulnerable
persons who are OHP Members (children, the elderly or
developmentally disabled individuals).
f. When to Report Fraud and Abuse
(1) An incident with any of the referral characteristics listed in Subsection e, of this
section must be reported to the MFCU, and any other incident found to have
characteristics which indicate fraud or abuse which Contractor has verified
should also be reported. Reports to the MFCU shall include:
(a) Contractor name, contact person and phone number; and
(b) Number of complaints of fraud and abuse that warrant investigation. For
each which warrants investigation Contractor shall include:
(i) Provider’s name and Provider’s phone number;
(ii) The source of the complaint;
(iii) The type of Provider;
(iv) The nature of the complaint;
(v) The approximate range of dollars involved; and
(vi) The legal and administrative disposition of the case, including
actions taken by law enforcement officials to whom the case has
been referred.
Contractor may also refer cases of suspected fraud and abuse to the MFCU or to
the Department of Human Services Audit Unit, or both, prior to verification.
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Contract #126667 Exhibit J Page 204 of 242
(2) Contractor shall comply with all patient abuse reporting requirements and fully
cooperate with the State for purposes of ORS 410.610 et.seq., ORS 419B.010
et.seq., ORS 430.735 et.seq., ORS 433.705 et.seq., ORS 441.630 et.seq., and all
applicable Administrative Rules. Contractor shall ensure that all Subcontractors
comply with this provision.
g. How to Refer a Case of Provider Fraud or Abuse
The Department of Justice Medicaid Fraud Control Unit (MFCU) phone number is
(503) 229-5725, address 1515 SW 5th Avenue, Suite 410, Portland, Oregon 97201, and
fax is (503) 229-5459. The Department of Human Services Audit Unit phone number is
(503) 945-6691, address 500 Summer St. NE, Salem, Oregon 97310-1097, and fax is
(503) 945-7029.
h. Obligations to Assist the MFCU and DHS
(1) Contractor shall promptly report all suspected fraud and abuse as required under
this Exhibit J.
(2) Contractor shall permit the MFCU or DHS or both to inspect, evaluate, or audit
books, records, documents, files, accounts, and facilities maintained by or on
behalf of Contractor or by or on behalf of any Subcontractor, as required to
investigate an incident of fraud and abuse.
(3) Contractor shall cooperate and require its Subcontractors to cooperate with the
MFCU and DHS investigator during any investigation of fraud or abuse.
(4) In the event that Contractor reports suspected fraud, or learns of an MFCU or
DHS investigation, it should not notify or otherwise advise its Subcontractors of
the investigation. Doing so may compromise the investigation.
(5) Contractor shall provide copies of reports or other documentation, including
those requested from the Subcontractors regarding the suspected fraud at no cost
to MFCU or DHS during an investigation.
i. Prevention and Detection of Member Fraud and Abuse
Contractor, if made aware of suspected fraud or abuse by a DMAP Member, (i.e. a
Provider reporting DMAP Member fraud and abuse) shall report the incident to the
DHS Fraud Unit. Address suspected DMAP Member fraud and abuse reports to DHS
Fraud Investigation P.O. Box 14150 Salem, Oregon 97309-5027, phone number 1-888-
FRAUD01 (888-372-8301), facsimile number 503-373-1525 ATTN: HOTLINE.
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Contract #126667 Exhibit K Page 205 of 242
EXHIBIT K – Provider Capacity Report
1. Requirements:
Contractor shall submit a Certified Provider Capacity Report and a Publicly Funded Program
Involvement Status Report to the Division of Medical Assistance Programs (DMAP) with specific
information about each of Contractor’s Providers.
The Provider Capacity Report shall include data for each variable name appearing on the table below.
To be in compliance with this requirement and that of Exhibit M, Contractor shall not omit the required
information from the table below for any Participating Provider on the Provider panel. Providers include
physicians (PCPs and specialists), dentists, hospitals, hospices, laboratories, Extended Care Facilities,
DME Participating Providers, County Health Programs, Rural Health Centers, Federally Qualified
Health Centers and any other Participating Provider, as defined in this Contract, with which Contractor
has a subcontract. If a Participating Provider has more than one practice address, submit a separate
record for each practice address of the Participating Provider.
For the purposes of this Exhibit related to Credential Verification (Data Element #15 listed in the table
below) Contractor shall refer to Exhibit B, Part II, Section 4 and OAR 410-141-0120, pursuant to
42CFR438.214.
2. Filing Requirements:
Contractor shall submit to DMAP a Certified Provider Capacity Report containing information about
each Provider on their Provider panel as of January 1st (submit reports to DMAP by March 31st) of each
year that this Contract is in effect. Contractor shall submit to DMAP a new Provider Capacity Report,
anytime there has been a Material Change in Contractor’s operations that would affect capacity or
services, including (1) changes in services, benefits, service area or payments or (2) enrollment of a new
population to Contractor. Contractor shall submit supplemental reports during the year, if requested by
DMAP.
Contractor shall submit Form K.1, certifying to the accuracy, completeness, and truthfulness of the
information in the Provider Capacity Report, by fax to the number below.
Contractor shall submit to DMAP the Provider Capacity Report in an electronic format which has been
approved by DMAP via e-mail by contacting your designated PHP Coordinator or designee or by
mailing a disk or compact disk (CD) containing the required information, as specified in Section 3, of
this Exhibit, to the following address:
Prepaid Health Plan Coordinator
Division of Medical Assistance Programs
Delivery Systems Unit
500 Summer Street NE, E-35
Salem, OR 97301-1077
Fax: (503) 947-5221
A Provider Capacity Report that is not certified or that does not contain all of the data elements specified
in Section 3, of this Exhibit shall not be accepted by DMAP, and Contractor must submit a corrected
Provider Capacity Report as directed by DMAP’s designated PHP Coordinator or designee.
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Contract #126667 Exhibit K Page 206 of 242
DMAP will review the Provider Capacity Report and communicate preliminary findings to Contractor
within 30 Business Days of receipt. If errors or omissions are found DMAP will communicate detailed
findings including expected resolution timelines for the Contractor within 60 Business Days of receipt.
Contractor will have 30 Business Days from the date of notice to correct errors or omissions and re-
submit the report. Failure to submit the required report or correct errors or omissions may result in
sanctions, per contract.
3. Format:
Contractor shall submit the Provider Capacity Report to DMAP in the electronic format of Microsoft
Excel. The field types and sizes are required and may be submitted in an alternate format if Contractor
obtains prior approval from DMAP by contacting Contractor’s PHPC or designee.
Required Data Elements
LINE VARIABLE NAME TYPE SIZE SPECIAL INSTRUCTIONS
1 CONTRACTOR NAME A 50 The name of the Contractor that this Provider
Capacity Report pertains to and is submitted by.
2 LAST NAME A 50 Last name of the Provider.
If the Provider has practices in multiple areas,
complete a record line for each practice location.
3 FIRST NAME A 25 First name of the Provider.
4 BUSINESS/PRACTICE
ADDRESS
A/N 50 Address of the Provider’s practice, including
suite number. If the Provider does not have a
practice address, list the business address. (i.e.
lab/ diagnostic companies)
5 BUSINESS/PRACTICE
CITY
A 20 City where the Provider’s business is located.
6 BUSINESS/PRACTICE
ZIP CODE
N 10 Formatted zip code - (9999) four digit code
(i.e. 97214-1014)
7 BUSINESS COUNTY A 15 The county in which the Provider’s business is
located.
8 PROVIDER TYPE A 5 Table 1 in Section 6 of this Exhibit K must be
used.
9 SPECIALTY A 15 Table 2 in Section 6 of Exhibit K must be used. If
a specialty code does not apply, please use “not
applicable”.
10 PROVIDER’S DMAP
NUMBER
A/N 6 DMAP assigned Provider number as supplied
with Encounter Data.
11 OTHER PROVIDER # A/N 13 UPIN; The Provider’s unique Provider
identification number or (NPI).
12 PRIMARY CARE
PROVIDER (PCP)
IDENTIFIER
A 1 Y = This Provider is a PCP.
N = This Provider is not a PCP.
DMAP
13 # MEMBERS ASSIGNED N 4 Number of Contractor’s DMAP Members
currently assigned to this PCP or clinic.
14 # OF ADDITIONAL
MEMBERS THAT CAN BE
N 5 Estimated number of additional members PCP
will accept.
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Contract #126667 Exhibit K Page 207 of 242
LINE VARIABLE NAME TYPE SIZE SPECIAL INSTRUCTIONS
ASSIGNED TO PCP If #12 = N, answer “0”
15 CREDENTIAL
VERFICATION
N 8 Date Contractor verified or certified Provider’s
credentials (mm/dd/yy) as required in OAR 410-
141-0120(1)(a).
16 SANCTION HISTORY A/N 50 Brief description of any sanctions, fines or
disciplinary actions that are currently active from
the appropriate licensing board(s), DHS including
DMAP, AMH, and SPD, DHS audit unit, Oregon
Medicaid Fraud Unit, Oregon Secretary of State,
Oregon Insurance Division, Oregon Department
of Justice, U.S. Attorney or Department of
Justice, CMS, or DHHS Office of Inspector
General. If this is not applicable, answer “not
applicable”.
17 CONTRACT START DATE A/N 25 mm/dd/yy Include a copy of new subcontracts
since last report as required in Exhibit D, Section
17 and 42 CFR 438.230.
18
CONTRACT END DATE A/N 25 mm/dd/yy. If contract is open-ended, answer
99/99/99 for end date.
4. Capacity by Service Area
a. Service Area as designated in this Contract Part V, Enrollment Limits – the individual Service
Areas listed in this Contract.
b. Total number of Primary Care Providers – the number of PCPs on panel for the designated
service area.
c. Total number of DMAP Members served – the unduplicated count of enrolled members
receiving service in the preceding 12-month period. A service must qualify as an “Encounter” as
defined in Exhibit H.
(1) DMAP Service Area as
designated in Part V
Enrollment Limits
(2) Total number of
Primary Care Providers
(3) Total number DMAP
Members served
Add lines as necessary for each Service Area.
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Contract #126667 Exhibit K Page 208 of 242
5. Publicly Funded Program Involvement Status Report:
The following table details Contractor’s involvement with publicly funded health care and service
programs. Include those publicly funded health care and service programs with which Contractor has
subcontracts.
Name of publicly
funded program
Type of
public
program (i.e.
county mental
health dept.)
County in
which program
provides
services
Description of
the services
provided in
relation to
Contractor’s
services
What has been the
involvement of the
public program in
Contractor’s
operations (on the
board, on Quality
Assurance
Committee, specify
if subcontract, etc.)?
6. Provider Type and Provider Specialty Code Listing:
Two tables are found below: 1) the Provider/ Type code table and 2) Provider specialty code table. Use
these codes to specify the required information on Contractor’s Provider Capacity Report file as outlined
in Section 3, Required Data Elements, line number 9 of this Exhibit.
Provider Type Code Table 1
Provider Provider Provider Provider
Type Code Type Type Code Type
AA Air Ambulance NF SNF/ICF
AC Alcohol and Drug NM Midwives, direct entry
AD Adult Day Health NP Nurse Practitioner
AF Adult Foster Care NT Nutritionist under MCM
AM Ambulance OD Optometrist
AS Ambulatory Surgical OP Optician, dispensing
AT Medical Air Transport OT Occupational Therapist
BC Birthing Center PB Public Clinic
BP Billing Provider PH Pharmacy
BR Transportation Broker PR Pre-natal Clinic
CD Contract Dentist PS Psychiatrist
CK Medicheck Screening Center PT Physical Therapist
CR Rural Health Clinic PX X-ray service
DC Chiropractor PY Psychologist
DM Dentist RA Personal Care RN
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Contract #126667 Exhibit K Page 209 of 242
Provider Provider Provider Provider
Type Code Type Type Code Type
DO Medical Doctor, Osteopath RC Residential Care Medical
DS Podiatrist RF Residential Care
DT Denturist RH Residential Care - HA
FC Family Planning Clinic RM Residential Care - MR
FQ FQHC RN Private Duty Nurse
HE Hearing Aid Dealer RT Residential Treatment - Med
HF Hemodialysis Facility SC Social Worker
HH Home Health SE Secured Transportation
HI HMO SH Audiologist/Speech Therapist
HK Homecare SL Specialized Living Facility
HO Hospital SM School Medical
HP Hospice SR Satellite Apartment-Medical
IA In Home Agency Provider SS Nursing Home Semi-Skilled
IH Indian Health Clinic TA Taxi
IL Independent Laboratory TC Targeted Case Management
KD Kidney Dialysis WC Wheelchair
LF Assisted Living Facility
MC MHO – AMH Provider
MD Physician
MH Mental Health
MM Miscellaneous Medical Svcs.
MS ICF/MR
NA Nurse Anesthetist
ND Naturopath
Provider Specialty/Sub-Specialty Code Table 2
Use the codes on the following page to specify the required information on Contractor’s Provider
Capacity Report file as outlined in Section 3, Required Data Elements, line number 10 of this Exhibit.
Specialty/ Sub-specialty Code Specialty/ Sub-specialty Code
Allergy AA Neuropathology NA
Abdominal Surgery AB Neoplastic Diseases ND
Audiologist AD Neurology NE
Adolescent AE Nephrology NF
Allergy and Immunology AL Pharmacy Dispensing to Nursing
Home
NH
Aviation Medicine AM Nuclear Medicine NM
Anesthesiology AN Neonatal-Perinatal Medicine NP
Bacteriology BA Nuclear Radiology NR
Broncho-Esophagology BE Neurological Surgery NS
Blood banking BL Nutrition NT
Billing Service Nonpayable BS Ophthalmology OA
Cardiology CA Obstetrics OB
Clearinghouse Nonpayable CB Orthodontist OD
Congregate Care CC Other Entity Nonpayable OE
Cardiovascular Diseases CD Obstetrics & Gynecology OG
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Contract #126667 Exhibit K Page 210 of 242
Specialty/ Sub-specialty Code Specialty/ Sub-specialty Code
Child Psychiatry CH Oral Surgery OL
Child Neurology CI Occupational Medicine OM
Federal Qualified Health Center CL Oncology ON
Critical Care Medicine CM Oral Pathology OP
Clinical Pathology CP Orthopedic Surgery OR
Colon & Rectal Surgery CR Oral Surgeon OS
Cardiovascular Surgery CS Otology, Laryngology, Rhino OT
Dermatology DE Otology OU
Diabetes DI Oxygen Supplies OX
Misc Med Equip/ Supplies DM Pathology PA
DME for Pharmacy DN Prosthodontics PC
Osteopathic Physician DO Pediatrics PD
Dermatopathology DP Periodontist PE
Diagnostic Radiology DR Pediatric Allergy PF
Endocrinology ED Pediatric Cardiology PG
Emergency Medicine EM Public Health PH
Endodontist EN Pediatric Endocrinology PI
Forensic Pathology FO Pediatric Radiology PJ
Family Practice FP Pediatric Surgery PK
Gastroenterology GD Plastic Surgery PL
Geriatrics GE Physical Medicine & Rehab PM
General Dentist GN Psychiatry, Neurology PN
General Practice GP Pediatric Hemotology-Onco PO
Gynecology GY Pediatric Nephrology PP
Hospital Administration HA Proctology PR
Hospital Based Clinic (PCCM) HC Psychiatry PS
Hearing Aids Dealer HE Pediodontist PT
Hematology HM Pulmonary Diseases PU
Head & Neck Surgery HN Preventive Medicine PV
Hand Surgery HS Psychoanalysis PW
House Calls, Inc Physician HV Psychosomatic Medicine PX
Hypnosis HY Pharmacology PY
Infectious Diseases ID Rheumatology RE
Immunology IG Rhinology RH
Internal Medicine IM Radioisotopic Pathology RI
Intensive Outpatient Services IO Radiology RR
Industrial Medicine IP Speech Therapist ST
Kidney Dialysis Facility KD General Surgeon SU
Laryngology LA Therapeutic Radiology TR
Legal Medicine LM Thoracic Surgery TS
Maxillofacial Surgery MF Traumatic Surgery TU
Enteral/ Parenteral for HH, MM,
PH, RN
MM UOHSC Practitioners UO
Medicheck Screen Clinic MS Urology UR
Manipulative Therapy MT Opticians Contractor VC
Vascular Surgery VS
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Contract #126667 Exhibit K Page 211 of 242
EXHIBIT K – Attachment 1 - Form K.1 – Data Certification Form
This form shall be submitted by FAX to (503) 947-5221, following the electronic transmission of
the Provider Capacity Report.
I, the undersigned, hereby attest that I have authority to certify the data and information and I,
the undersigned, hereby certify based on best knowledge, information and belief that the data and
information submitted to DMAP in the Provider Capacity Report is accurate, complete, and
truthful.
_______________________________________
Print Name/Title
_______________________________________ ____________
Signature Date
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Contract #126667 Exhibit L Page 212 of 242
EXHIBIT L – Member Grievances/Appeals Report
Contractor Name: __________________________________ Year:_______________
Report Period: Oct – Dec Jan – Mar Apr – Jun Jul - Sep
Instructions: Please report the total number of Grievances and Appeals (as defined in OAR 410-141-0000),
received by the Contractor in each of the following categories for the report period. This report is to be
submitted with documentation of the QI program of complaints (as noted in OAR 410-141-0200) to the Analysis
and Evaluation Unit not later than 60 calendar days from the end of each calendar quarter.
Categorically
(Plus
Eligible
Population)
Expansion Population
(Standard Population)
Special Needs
Phase II
Other
GRIEVANCES
Access
Quality of Clinical Care
Interpersonal Care/Quality of Service
Other
Grievances Totals
APPEALS
Payment for services denied
Authorization for services denied
Appeals Totals
OVERALL TOTALS
Attach documentation to indicate specifically how the Contractor analyzed Grievances and Appeals for
trends, identified persistent or significant Grievances and Appeals, and conducted follow-up actions for
this report quarter.
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Contract #126667 Exhibit L Page 213 of 242
Member Grievances / Appeals Report
Report Definitions
* In order to obtain consistent and comparative data, DMAP is requesting that the following
examples be used as guidelines for capturing both Grievances and Appeals submitted to plans.
* ALL member expressions of dissatisfaction must be categorized as a Grievance. NO filters.
* There is NO timeline for submission of
member Grievances.
GRIEVANCE RESOLUTIONS TRACKED APPEALS
Access Plan's Payment of Services Denied
Provider's office difficult to contact for appointment or
information Payment for emergency services denied
Provider's office has physical barrier Payment to Non-Participating Provider denied
Provider's office too far away, not convenient
Unable to schedule appointment in timely manner Plan's Authorization for Services Denied/Limited
Provider's office closed to new patients Benefit not covered
Referral denied / refused by Provider Urgent / emergent care not provided
Unable to be seen in timely manner for urgent / emergent careSpecialty / referral denied
Provider(s) not available to give necessary care Service denied as not medically necessary
Provider's office has language or cultural barriers DME equipment not covered
Cosmetic
Quality of Clinical Care Pain Management
Adverse outcome, Complications, Misdiagnosis Pharmacy
Testing / assessment insufficient, inadequate or omitted Physical Therapy / OT denied or reduced
Disagreement / member not involved with treatment plan Other
Medical record documentation issues
Medication management issues
Unsanitary environment or equipment
Allegation of abuse
Interpersonal Care / Quality of Service
Provider staff rude or inappropriate comments / behavior
Provider explanation / instruction inadequate, incomplete
Provider / staff unresponsive (unreturned phone calls)
Wait too long in office before receiving care
Concern over confidentiality
Provider office unsafe / uncomfortable
Other
Pharmacy related issues
Benefits, rights and/or financial responsibilities of member
Claims and billing related issues
Availability, delay, quality of materials and supplies (DME)
NOTE: Inquiries NOT considered as a Grievance. Eligibility question NOT considered a Grievance.
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Contract #126667 Exhibit M Page 214 of 242
EXHIBIT M – Physician Incentive Plan Regulation Guidance
1. Background/Authority:
This Contract requires that Contractor’s must disclose information about Physician Incentive
Plans (PIP) to DMAP. If Contractor utilizes compensation arrangements placing physicians or
Physician Groups at Substantial Financial Risk (as defined in this Exhibit) Contractor must also
assure provision of adequate PIP Stop-loss Protection and conduct beneficiary surveys.
These Contract requirements implement federal law and regulations to protect DMAP
Members against improper clinical decisions made under the influence of strong financial
incentives. Therefore, it is the financial arrangement under which the physician is operating
that is of interest and potential concern. Consequently, Contractors must report on the “bottom
tier” - that is, the arrangement under which the participating physician is operating. The
reporting requirement is imposed on Contractors because that is the entity or Physician Group
with which DMAP has a contractual relationship and the entity, which is ultimately
responsible, under the statute, for making sure that adequate safeguards are in place.
A Physician Incentive Plan (PIP) is defined as "any compensation to pay a physician or
Physician Group that may directly or indirectly have the effect of reducing or limiting services
furnished to any Contractor enrollee”. The compensation arrangements negotiated between
Subcontractors of an Managed Care Organization (MCO) (e.g., physician-hospital
organizations, IPAs) and a physician or group are of particular importance, given that the
compensation arrangements with which a physician is most familiar will have the greatest
potential to affect the physician’s referral behavior. For this reason, all Subcontracting tiers of
the Contractor’s arrangements are subject to the regulation and must be disclosed to DMAP.
Note that PIP rules differentiate between Physician Groups and Intermediate Entities. Examples
of Intermediate Entities include Individual Practice Associations (IPAs) that contract with one
or more Physician Groups, as well as physician-hospital organizations. IPAs that contract only
with individual physicians and not with Physician Groups are considered Physician Groups
under this rule.
2. Glossary of Terms:
As used in this Exhibit M, these terms have the following meaning wherever the term is used,
unless expressly defined otherwise in this Contract.
Bonus means a payment a physician or entity receives beyond any salary, fee-for-service
payments, Capitation or returned withhold. Bonuses and other compensation that are not based
on referral levels (such as Bonuses based solely on quality of care, patient satisfaction or
physician participation on a committee) are not considered in the calculation of Substantial
Financial Risk.
Capitation means a set dollar payment per patient per unit of time (usually per month) that is
paid to cover a specified set of services and administrative costs without regard to the actual
number of services provided. The services covered may include a physician's own services,
Referral Services or all medical services.
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Contract #126667 Exhibit M Page 215 of 242
Panel Size means the number of patients served by a physician or Physician Group. If the panel
is greater than 25,000 patients, then the Physician Group is not considered to be at Substantial
Financial Risk because the risk is spread over the large number of patients. PIP Stop-loss
Protection and Beneficiary Surveys would not be required.
Physician Group means a partnership, association, corporation, Individual Practice
Association (IPA), or other group that distributes income from the practice among members.
An IPA is a Physician Group only if it is composed of individual physicians and has no
subcontracts with other Physician Groups.
Intermediate Entities are entities, which contract between Contractor and one of its
Subcontractors and a physician or Physician Group, other than Physician Groups themselves.
An IPA is considered an Intermediate Entity if it contracts with one or more Physician Groups
in addition to contracting with individual physicians.
Physician Incentive Plan (PIP) means any compensation arrangement at any contracting level
between Contractor and a physician or Physician Group that may directly or indirectly have the
effect of reducing or limiting services furnished to DMAP Members. Contractor must report on
Physician Incentive Plans between the Contractor itself and individual physicians and groups
and also between groups or Intermediate contracting Entities (e.g., certain IPAs,
Physician-Hospital Organizations) and individual physicians and groups.
PIP Stop-loss Protection refers to insurance required to protect Physicians or Physician
Groups to whom Substantial Financial Risk has been transferred.
Potential Payments means the maximum anticipated total payments (based on the most recent
year's utilization and experience and any current or anticipated factors that may affect payment
amounts) that could be received if use or costs of Referral Services were low enough. These
payments include amounts paid for services furnished or referred by the physician/group, plus
amounts paid for administrative costs. The only payments not included in Potential Payments
are Bonuses or other compensation not based on referrals (e.g., bonuses based on patient
satisfaction or other quality of care factors).
Referral Services means any specialty, Inpatient, Outpatient or laboratory services that are
ordered or arranged, but not furnished directly. Situations may arise where services not
normally considered Referral Services will need to be considered Referral Services for
purposes of determining if a physician/group is at Substantial Financial Risk. For instance,
Contractor may require a physician/group to authorize "retroactive" referrals for emergency
care received outside the Contractor’s network. In so far as the physician/group can experience
an increase in Bonus (if emergency referrals are low) or a reduction in capitation/increase in
withhold (if emergency referrals are high), then these Emergency Services are considered
Referral Services and need to be included in the calculation of Substantial Financial Risk.
Also, if a Physician Group contracts with an individual physician or another group to provide
services, which the initial group cannot provide itself, any services referred to the contracted
physician/group should be considered Referral Services.
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Contract #126667 Exhibit M Page 216 of 242
Substantial Financial Risk (SFR) means an incentive arrangement that places the physician or
Physician Group at risk for amounts beyond the risk threshold, if the risk is based on the use or
costs of Referral Services. The risk threshold is 25%. Calculation of Substantial Financial Risk
shall be determined pursuant to Section 4 of this Exhibit.
Withhold means a percentage of payments or set dollar amounts that are deducted from a
service fee, capitation or salary payment, and that may or may not be returned, depending on
specific predetermined factors.
3. Reporting to DMAP:
In order to determine compliance with 42 CFR 422.208-422.210, Contractor shall report to
DMAP the following information for each medical group and physician providing health
services to the DMAP Members:
-Whether any risk is transferred to the Provider
-Whether risk is transferred to the Provider for Referral Services
-What method is used to transfer risk
-What percent of the total Potential Payment to the Provider is at risk for referrals
-What is the number of patients included in the same risk arrangement if the number of patients
is 25,000 or fewer, what is the type and amount of PIP Stop-loss Protection insurance
-Whether Contractor’s Physician Incentive Plan places physicians or Physician Groups at
“Substantial Financial Risk” as determined in Section 4 of this Exhibit M.
-If SFR is established:
a. the amount of PIP Stop-loss Protection required; and
b. the means for complying with survey requirements
CMS PIP Disclosure Form (OMB No. 0938-0700) or the Physician Incentive Plan Disclosure
Form (see Report G.12, Exhibit G), shall be filed with DMAP according to the provisions of
Exhibit B, Part IV, Section 1, Subsection e.
4. Calculation and Determination:
Contractor shall determine the amount of referral risk by using the following formula:
Amount at risk for Referral Services
Referral Risk = Maximum Potential Payments
The amount at risk for Referral Services is the difference between the maximum potential
referral payments and the minimum potential referral payments. Bonuses unrelated to
utilization (e.g., quality bonuses such as those related to member satisfaction or open physician
panels) should not be counted towards referral payments. Maximum Potential Payments is
defined as the maximum anticipated total payments that the physician/group could receive. If
there is no specific dollar or percentage amount noted in the incentive arrangement, then the
PIP should be considered as potentially putting 100% of the Potential Payments at risk for
Referral Services.
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Contract #126667 Exhibit M Page 217 of 242
The SFR threshold is set at 25% of "Potential Payments" for Covered Services, regardless of
the frequency of assessment (i.e. collection) or distribution of payments. SFR is present when
the 25% threshold is exceeded. However, if the pool of patients that are included in the risk
arrangement exceeds 25,000, the arrangement is not considered to be at SFR because the risk is
spread over so many lives. See pooling rules below.
The following incentive arrangements should be considered as SFR:
a. Withholds greater than 25 percent of Potential Payments.
b. Withholds less than 25 percent of Potential Payments if the physician or Physician
Group is potentially liable for amounts exceeding 25 percent of Potential Payments.
c. Bonuses that are greater than 33 percent of Potential Payments minus the Bonus.
d. Withholds plus Bonuses if the Withholds plus Bonuses equal more than 25 percent of
Potential Payments. The threshold Bonus percentage for a particular Withhold
percentage may be calculated using the formula: Withhold % = -0.75 (Bonus %)+25%.
e. Capitation, arrangements, if the difference between the maximum Potential Payments
and the minimum Potential Payments is more than 25 percent of the maximum Potential
Payments; or the maximum and minimum Potential Payments are not clearly explained
in the physician's or Physician Group's contract.
f. Any other incentive arrangements that have the potential to hold a physician or
Physician Group liable for more than 25 percent of Potential Payments.
5. If Contractor’s Physician Incentive Plan places physicians or Physician Groups at SFR,
Contractors shall:
- Establish and maintain PIP Stop-loss Protection, as required in this Section 5 and
- Conduct survey as required in Section 6, of this Exhibit
a. PIP Stop Loss Protection
Stop-loss Protection must be in place to protect physicians and/or Physician Groups to
whom SFR has been transferred. Either aggregate or per patient stop-loss may be
acquired. Aggregate insurance is excess loss coverage that accumulates based on total
costs of the entire population for which they are at risk and which provides
reimbursement after the expected total cost exceeds a pre-determined level. Individual
insurance is where a specific Provider excess loss accumulates based on per member
per year Claims.
The rule specifies that if aggregate stop-loss is provided, it must cover 90% of the cost
of Referral Services that exceed 25% of Potential Payments. Physicians and groups can
be liable for only 10%. If per patient PIP Stop-loss Protection is acquired, it must be
determined based on the physician or Physician Group’s patient Panel Size (calculated
according to Subsection b., of this Exhibit) and cover 90% of the referral costs which
exceed the following per patient limits:
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Contract #126667 Exhibit M Page 218 of 242
Panel Size Combined Institutional Institutional
Professional
Professional Deductible Deductible
Deductible
1-1000 $6,000* $10,000* $3,000*
1,001 - 5000 $30,000 $40,000 $10,000
5,001 - 8,000 $40,000 $60,000 $15,000
8,001 - 10,000 $75,000 $100,000 $20,000
10,001 - 25,000 $150,000 $200,000 $25,000
> 25,000 none none none
*The asterisks in this table indicate that, in these situations, PIP Stop-loss insurance
would be impractical. Not only would the premiums be prohibitively expensive, but the
protections for patients would likely not be adequate for panels of fewer than 500
patients. Contractors and Physician Groups clearly should not be putting physicians at
financial risk for Panel Sizes this small. It is our understanding that doing so is not
common. For completeness, however, we do show what the limits would be in these
circumstances.
The institutional and professional stop-loss limits above represent the actuarial
equivalents of the combined institutional and professional deductible. The Physician
Group or Contractor may choose to purchase whatever type is best suited to cover the
referral risk in the incentive arrangement.
b. Pooling Criteria
To determine the Patient Panel Size in the above chart, Contractor may pool according
to the specific criteria below. If Contractor meets all five criteria required for the
pooling of risk, Contractor is allowed to pool that risk in order to determine the amount
of stop-loss required by the regulation:
(1) Pooling of patients is otherwise consistent with the relevant contracts governing
the compensation arrangements for the physician or group;
(2) The physician or group is at risk for Referral Services with respect to each of the
categories of patients being pooled;
(3) The terms of the compensation arrangements permit the physician or group to
spread the risk across the categories of patients being pooled (i.e., payments
must be held in a common risk pool);
(4) The distribution of payments to physicians from the risk pool is not calculated
separately by patient category (either by Contractor or by Medicaid, Medicare,
or commercial); and
(5) The terms of the risk borne by the physician or group are comparable for all
categories of patients being pooled.
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Contract #126667 Exhibit M Page 219 of 242
c. Contractor shall establish a procedure under which their Subcontractors are required to
submit stop-loss documentation. Contractors shall collect Stop-loss information from
each Subcontractor and shall retain this information for a recommended three (3) years.
6. Surveys:
Contractor shall conduct a customer survey of both enrollees and disenrollees if any physician
or Physician Groups in the Contractor’s network are placed at Substantial Financial Risk for
Referral Services, as defined by the Physician Incentive Regulations. If a survey is required it
must be conducted in accordance with Section 8, of this Exhibit M.
7. Disclosure to DMAP Members:
At DMAP Member’s request, Contractor must provide information indicating whether it or any
of its contractors or Subcontractors use a PIP that may affect the use of Referral Services, the
type of incentive arrangement(s) used, and whether PIP Stop-loss Protection is provided. If
Contractor is required to conduct a survey, it must also provide DMAP Members with a
summary of survey results.
8. Monitoring:
a. Contractor shall file the CMS PIP Disclosure Form (OMB No. 0938-0700) or the
Physician Incentive Disclosure Form (see Exhibit G, Report G.12), with DMAP
according to the provisions of Exhibit B, Part IV, Section 1 Subsection e.
b. CMS PIP Disclosure Form (OMB No. 0938-0700) and the Physician Incentive
Disclosure Form (see Exhibit G, Report G.12), is subject to review by DMAP and
subject to correction/clarification.
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Contract #126667 Exhibit N Page 220 of 242
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 DMAP Members that includes at least:
(1) Written material describing the Contractor’s Grievance and Appeal 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 DMAP Member confidentiality
in the Grievance, Appeal and Administrative Hearing processes.
c. A DMAP Member or Member’s Representative may file a Grievance and an Appeal orally or
in writing, and may request an Administrative Hearing. The DMAP Member or Member’s
Representative may withdraw an Appeal or Administrative Hearing request at any time.
d. Contractor shall keep all information concerning a DMAP 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 DMAP Members full use of the Grievance System procedures. The
Contractor shall cooperate by providing to DMAP relevant information that may be required
for the Appeal and Administrative Hearing process.
g. Contractor shall treat as an Appeal a DMAP Member’s request for a DMAP Administrative
Hearing made to DMAP outside of the Contractor’s Appeal procedures upon notification by
DMAP as provided for in OAR 410-141-0264.
h. Under no circumstances shall Contractor discourage a DMAP Member or Member’s
Representative from using the DMAP Administrative Hearing process.
i. Contractor shall not request Disenrollment of a DMAP Member on the basis of
implementation of a DMAP Administrative Hearing decision or a DMAP 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
form and shall make the forms available in all Contractor administrative offices and in those
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Contract #126667 Exhibit N Page 221 of 242
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. A Representative, pursuant to 42 CFR 438.402(b) (ii), may act for the DMAP Member at any
stage in the Grievance System. Contractor shall document the basis on which an individual
acts as Representative of the DMAP Member.
2. Contractor Grievance Procedures
a. A Grievance procedure applies only to those situations in which the DMAP Member or
Member’s 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 DMAP 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
a DMAP Member or Member’s Representative, including:
(a) Acknowledgment to the DMAP Member or Representative of receipt of each
Grievance;
(b) Ensuring that DMAP 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;
(ii) Health Care Professionals who have appropriate clinical expertise in
treating the DMAP Member’s condition or disease, if the Grievance
concerns denial of expedited resolution of an Appeal or if the
Grievance involves clinical issues; and
(iii) Qualified to make denials based on lack of medical necessity.
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Contract #126667 Exhibit N Page 222 of 242
(2) Describe how the Contractor informs DMAP 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 DMAP 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 DMAP 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 DMAP 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 a DMAP 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 DMAP
Member;
(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 DMAP 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:
(1) The Contractor shall resolve each Grievance, and provide notice of the disposition, as
expeditiously as the DMAP Member’s health condition requires, within the
timeframes established below; and
(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:
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Contract #126667 Exhibit N Page 223 of 242
(a) Make a decision on the Grievance and notify the DMAP Member; or
(b) Notify the DMAP 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
DMAP 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 DMAP 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 DMAP 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 DMAP Member chooses to resolve through another process, and that
the Contractor is notified of, shall be noted in the Grievance log.
h. A DMAP Members who is dissatisfied with the disposition of a Grievance may present the
Grievance to the DMAP Ombudsman.
3. Contractor Appeal Procedures
a. The Contractor shall have a system in place for DMAP 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 DMAP Member, includes the right to ask for an
Administrative Hearing by DMAP to review the Notice of Appeal Resolution. If the DMAP
Member initiates an Appeal, it shall be documented in writing by the Contractor and handled
as an Appeal. If the DMAP Member asks for an Administrative Hearing made to DMAP, the
hearing request should be immediately transmitted to DMAP’s Hearing Unit. Upon
notification by DMAP 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.
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
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Contract #126667 Exhibit N Page 224 of 242
of Action. Appeals reviewed by the Contractor upon notification by DMAP based on an
Administrative Hearing Request form must be timely filed as required under OAR 410-141-
0264.
c. The DMAP Member or Member’s Representative, or a Provider acting on behalf of the
DMAP 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 DMAP 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 DMAP 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 DMAP Member’s condition or disease, if an Appeal of a denial is
based on lack of Medical Appropriateness or if an Appeal involves clinical
issues.
(7) Document Appeals in the log to be maintained by the Contractor in a manner
consistent with the requirements of OAR 410-141-0266.
e. The Contractor shall assure DMAP Members that Appeals 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 DMAP Member’s right to confidentiality of
information about the Appeal as follows:
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Contract #126667 Exhibit N Page 225 of 242
(1) Contractor shall implement and monitor written policies and procedures to ensure that
all information concerning a DMAP 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 is 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 DMAP,
without a signed authorization from the DMAP Member. The information may also
be disclosed to DMAP if the DMAP Member requests an Administrative Hearing
regarding the Appeal without a signed authorization from the DMAP 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 DMAP 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 (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 DMAP 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 DMAP Member or Member’s Representative of the limited time available in the
case of an expedited resolution);
(3) Provide the DMAP Member and Member’s Representative an opportunity, before and
during the Appeals process, to examine the DMAP 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 DMAP Member and Member’s Representative, or
the legal Representative of a deceased DMAP Member’s estate;
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 DMAP 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 DMAP Member or Member’s
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;
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Contract #126667 Exhibit N Page 226 of 242
(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
DMAP Member or Member’s 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 DMAP Member requests the extension; or
(b) The Contractor shows (to the satisfaction of DMAP, upon its request) that
there is need for additional information and how the delay is in the DMAP
Member’s interest.
(4) If the Contractor extends the timeframes, it shall, for any extension not requested by
the DMAP Member, give the DMAP 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
DMAP Member or Member’s 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 DMAP 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 DMAP as part of an
Administrative Hearing process, the right to request a DMAP Administrative
Hearing and how to do so, which includes attaching the Notice of Hearing
Rights (DMAP 3030) and the Hearing Request Form (DHS 443).
(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 DMAP
Member may be liable for the cost of any continued benefits.
(3) If the Appeal was referred to the Contractor from DMAP 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 DMAP
Hearings Unit.
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Contract #126667 Exhibit N Page 227 of 242
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 DMAP Member’s benefits if:
(a) The DMAP Member or 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 DMAP Member requests extension of benefits.
(3) Continuation of benefits pending Administrative Hearing – If, at the DMAP Member’s
request, the Contractor continues or reinstates the DMAP Member’s benefits while the
Appeal is pending 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 DMAP Member withdraws the Appeal; or
(b) The DMAP 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 DMAP 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 DMAP
Member, that is, upholds the Contractor’s Action, the Contractor may recover from the
DMAP Member the cost of the services furnished to the DMAP Member while the Appeal
and Administrative Hearing was pending, to the extent that they were furnished solely
because of the requirements of Subsection m, Paragraph (2) of this section and in accordance
with the policy set forth in 42 CFR 431.230(b).
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Contract #126667 Exhibit N Page 228 of 242
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
DMAP Member’s favor, even if the DMAP Member has lost 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 DMAP Member’s health condition requires.
(2) If the Contractor reverses a decision to deny authorization of services, and the DMAP
Member received the disputed services while the Appeal and Administrative Hearing
were pending, the Contractor or DMAP will pay for the services in accordance with
DMAP 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 section to the DMAP Member within the
timeframes specified in Subsection c., of this section.
b. The written Notice of Action must be a DMAP 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 this Contract, entitled
“Informational Materials and Education of DMAP Members and Potential DMAP Members,”
and must inform the DMAP Member of the following:
(1) Relevant information including, but not limited to, the following:
(a) Date of Notice of Action;
(b) Contractor name;
(c) Provider name;
(d) DMAP 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.
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Contract #126667 Exhibit N Page 229 of 242
(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 a DMAP Member at the time of the service or is not a
DMAP 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 OHP 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 Subsection (2) of this
section;
(5) The DMAP Member's right to file an Appeal with the Contractor or Administrative
Hearing, 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 DMAP 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 DMAP Member may be required to pay the costs of
these services; and
(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 OHP 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 Sections 2 or 3 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:
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Contract #126667 Exhibit N Page 230 of 242
(i) The Contractor, Subcontractor or Participating Provider receives a clear
written statement signed by the DMAP 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 DMAP Member has been admitted to an institution where he or
she is ineligible for Covered Services from the Contractor;
(iii) The DMAP 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 DMAP Member for Medicaid
services;
(v) A change in the level of medical care is prescribed by the DMAP
Member’s PCP;
(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 DMAP
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 DMAP Member’s health improves sufficiently to allow a more
immediate transfer or discharge, an immediate transfer or discharge is
required by the DMAP Member’s urgent medical needs, or a DMAP
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 by the DMAP 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 DMAP Member’s health
condition requires and within 14 calendar days following receipt of the request for
service, except that:
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Contract #126667 Exhibit N Page 231 of 242
(a) The Contractor may have a possible extension of up to 14 additional calendar
days if the DMAP Member or the Provider requests the extension; or if the
Contractor justifies (to DMAP upon request) a need for additional information
and how the extension is in the DMAP Member’s interest;
(b) If the Contractor extends the timeframe, in accordance with Item (a) above, it
shall give the DMAP Member written notice of the reason for the decision to
extend the timeframe and inform the DMAP 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
DMAP Member’s health condition requires and no later than the date the
extension expires.
(4) For prior authorization decisions not reached within the timeframes specified in
Paragraph (3) of this subsection, (which constitutes a denial and is thus an adverse
Action), on the date that the timeframes expire; and
(5) For expedited prior authorizations, within the timeframes specified in OAR 410-141-
0265.
5. Contractor Responsibilities in Relation to DMAP Administrative Hearings
a. An individual who is or was a DMAP Member at the time of the Notice of Action is entitled
to an Administrative Hearing by DMAP 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 DMAP Member initiates an Administrative Hearing directly with DMAP, the
decision in the Notice of Action is the document that will trigger the right to request
an Administrative Hearing.
(2) If the DMAP 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 an Administrative Hearing.
b. If, at the DMAP Member’s request for an Appeal or Administrative Hearing, the Contractor
continued or reinstated services while an Appeal was pending, the benefits must be continued
pending the Administrative Hearing until one of the following occurs:
(1) The DMAP Member withdraws the request for an Administrative Hearing;
(2) A final order is issued in a DMAP Administrative Hearing adverse to the DMAP
Member; or
(3) The time period or service limits of a previously authorized service have been met.
c. If the DMAP Member files an Administrative Hearing Request form (DHS 0443) with
Contractor, Contractor shall immediately transmit the request to the DMAP Hearings Unit.
Upon notification by DMAP after receipt of the hearing request, Contractor must review the
request as an Appeal in accordance with Section 3 of this Exhibit.
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Contract #126667 Exhibit N Page 232 of 242
d. If the DMAP Member files an Administrative Hearing Request form (DHS 0443) with
DMAP, DMAP will promptly (within two 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 DMAP 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 a DMAP 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 DMAP Hearings Unit finds
that the person for whom the review request was made is not a DMAP Member or that the
Administrative hearing request was untimely or that a request for continuation of benefit was
untimely, the DMAP Hearings Unit follow the process described in OAR 410-120-1860(4).
f. The DMAP Hearings Unit will refer the case to the Office of Administrative Hearings and the
hearing will be scheduled unless the DMAP Member withdraws the request for review.
(1) The parties to the hearing include the Contractor, as well as the DMAP Member and
his or her Representative, or the Representative of a deceased DMAP 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 DMAP ordinarily
within 90 calendar days from the earlier of the following: the date the DMAP
Member filed the Appeal request form with the Contractor or the date the DMAP
Member filed the Hearing Request form. The final order is the final decision of
DMAP.
g. If the final resolution of the Administrative Hearing is adverse to the DMAP Member, that is,
if the final order upholds the Contractor’s Action, the Contractor may recover the cost of the
services furnished to the DMAP 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.
h. 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 DMAP Member, or DMAP or the Contractor decides in the
DMAP Member's favor before the Administrative Hearing even if the DMAP Member has
lost eligibility or the benefit package has changed after the date the Action was taken,
including the following:
(1) If the Contractor, or a DMAP 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 DMAP Member’s health condition
requires;
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Contract #126667 Exhibit N Page 233 of 242
(2) If the Contractor, or the DMAP Administrative Hearing decision reverses a decision to
deny authorization of services, and the DMAP Member received the disputed services
while the Administrative Hearing was pending, the Contractor shall pay for the
services in accordance with DMAP policy and regulations in effect when the DMAP
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 DMAP Member) or the Provider indicates (in
making the request on a DMAP Member’s behalf or supporting the DMAP Member’s
request) that taking the time for a standard resolution could seriously jeopardize the DMAP
Member’s life, health, or ability to attain, maintain or regain maximum function.
b. The DMAP Member, it’s Representative or Provider may file an expedited Appeal either
orally or writing. No additional DMAP 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 a DMAP 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 DMAP 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
(2) Make reasonable efforts to give the DMAP 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 a DMAP Member, who believes that taking the time for a standard
resolution of an Appeal and Administrative Hearing could seriously jeopardize the
DMAP Member’s life or health or ability to attain, maintain or regain maximum
function, to request an expedited Administrative Hearing.
f. The Contractor shall submit relevant documentation to DMAP's Medical Director within, as
nearly as possible, two working days following the DMAP 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 DMAP
Member and the following additional information:
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Contract #126667 Exhibit N Page 234 of 242
(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 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 DMAP Member. The
Contractor shall retain documentation of Grievances and Appeals for 7 (seven) 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.
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Contract #126667 Exhibit O Page 235 of 242
EXHIBIT O – Enrollment Reconciliation
1. Contractor shall reconcile the DHS enrollment transaction file, sent by DHS to
Contractor monthly, to Contractor’s current enrollee information in its Health
Information System (HIS) for the same period.
2. Contractor shall report to the designated PHP Coordinator, using the Enrollment
Reconciliation Certification Forms, which are attached hereto and incorporated herein by
this reference as Attachment 1 to this Exhibit. Contractor shall report it’s determination
that discrepancies between each DHS enrollment transaction file to Contractor’s HIS
enrollment file do or do not exist as follows:
a. That no discrepancy exists, using Form 1 of the Enrollment Reconciliation
Certification, by completing, signing, dating and submitting Form 1 to the
designated PHP Coordinator with 10 (ten) business days of receipt of DHS’
enrollment transaction file, or
b. That discrepancies do exist, using Form 2 of the Enrollment Reconciliation
Certification, by completing, signing, dating and submitting Form 2 to the
designated PHP Coordinator with 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 Form 2, prior to the next enrollment transaction file.
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Contract #126667 Exhibit O Page 236 of 242
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 PHP Coordinator 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 files
and Contractor’s HIS enrollee information 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.
Signed ______________________________
Title ______________________________
Date ______________________________
* If you have the ability to send an “electronic signature document” please contact the designated
PHP Coordinator.
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Contract #126667 Schedule 1 Page 237 of 242
EXHIBIT O – Attachment 1 - 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 PHP Coordinator within 10 (ten) business
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 enrollee information have discrepancies that I have noted in this report Form 2, and I, hereby certify based
on best knowledge, information and belief that this determination submitted to DHS is accurate, complete and
truthful.
Signed ______________________________
Title ______________________________
Date ______________________________
* If you have the ability to send an “electronic signature document” please contact the designated PHP
Coordinator.
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Contract #126667 Schedule 1 Page 238 of 242
SCHEDULE 1 – CDO – Performance Measure – Assessed Pregnant Women For CDO Services
Submission Form
Measurement Year: Calendar Year 2007
Due August 1, 2008
Methodology
Methodology for calculating numerator:
Administrative data only
Chart data only
Combination of administrative and chart
data
Measures:
Number in Denominator
(provided by DMAP)
Number in
Numerator
Rate %
Total number of pregnant Deschutes
Co. CDO members who were assessed
for substance abuse.
Total number of pregnant Deschutes
Co. CDO members who were enrolled
into treatment.
Total number of pregnant Deschutes
Co. CDO members enrolled into
treatment who completed their
treatment plans.
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Contract #126667 Schedule 2 Page 239 of 242
SCHEDULE 2 – Performance Improvement Projects
The projects included in this Schedule 2 are designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time and are expected to have a favorable effect
on health outcomes.
If Contractor does not have performance improvement projects meeting the standards identified in
Exhibit B, Part II, Section 3, Subsection d.(1), Contractor must conduct a minimum of two
performance improvement projects to meet this requirement. For this Contract Year the performance
improvement project is the mental health/ physical health Collaborative PIP.
Contractor shall submit to DMAP the Collaborative project baseline minimum requirement of Activity
1, 2 and 3 (due March 15, 2009), worksheet, and re-measurement (due August 1, 2009) as instructed in
this Schedule 2. DHS will complete Activity 1 for the mental health/ physical health Collaborative PIP.
The project will be documented on a PIP worksheet found in the Conducting Performance
Improvement Projects and reproduced in this Schedule 2.
Program Requirements
The purpose is to promote and implement performance improvement initiatives and services for
Contractor’s DMAP Members through a health systems improvement process. Contractor must
demonstrate on-going activities and improvements over time. Contractor must designate at least one
staff person to participate in the Quality and Performance Improvement (QPI) Workgroup meetings.
This staff person is generally responsible for the implementation of the performance improvement
projects developed by the Quality and Performance Improvement Workgroup within Contractor’s plan
and will report how Contractor has met the minimum necessary requirements listed below:
1. Develop and implement performance improvement projects, as required in this Contract,
Exhibit B, Part II, Section 3, Subsection d.(1), or for the Collaborative PIP designed to
demonstrate significant improvement, sustained over time;
2. Provide presentations on the performance improvement projects to the Quality and
Performance Improvement Workgroup and, if requested, the OHP Medical Director’s Group;
3. Provide annual written performance improvement project baseline, worksheets and
remeasurement on each performance improvement topic to DMAP (see attached project
worksheet forms) and;
4. Projects must contain elements in the PIP Annual plan.
5. Evidence of sustainability of previous PIP projects must be documented and submitted to
DMAP by March 15 of each Contract Year, for the previous calendar year, as an inclusion of
the annual QI report.
Other prevention activities as identified and agreed upon by Contractor and DMAP, or as mandated by
CMS.
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Contract #126667 Schedule 2 Page 240 of 242
SCHEDULE 2 – Attachment 1 - Form 2.1 – The Collaborative PIP Instructions
CONDUCTING PERFORMANCE IMPROVEMENT PROJECT
WORKSHEET
Use this or a similar worksheet as a guide while designing and conducting performance improvement projects.
Document the completion of each step. Refer to the protocol for detailed information on each area.
Demographic Information
MCO/PIHP Name or ID:
Project Leader Name:
Telephone Number:
Name of Performance Improvement Project
Date of Study Period: / / to / / /
Type of Delivery System (check all that are applicable)
____ Staff Model
____ Network
____ Direct IPA
____ IPA Organization
____ MCO
____ PIHP
_____ Number of Medicaid Enrollees in MCO or PIHP
_____ Number of Medicare Enrollees in MCO or PIHP
_____ Number of Medicaid Enrollees in Study
_____ Total Number of MCO or PIHP Enrollees in Study
Number of MCO/PIHP primary care physicians ____________
Number of MCO/PIHP specialty physicians _______________
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Contract #126667 Schedule 2 Page 241 of 242
Number of physicians in study ____________
Component/Standard Number
Comments Date
Comp.
Activity 1. SELECT THE STUDY TOPIC(S)
1.1 Study topic is selected through data collection
and analysis of comprehensive aspects of
enrollee needs, care and services.
1.2 The topic(s), over time, address a broad spectrum
of key aspects of enrollee care and services.
1.3 The topics, over time, include all enrolled
populations: i.e., do no exclude certain enrollees
such as those with special health care needs
Activity 2. DEFINE THE STUDY QUESTION(S)
2.1 The study question(s) is/are clearly stated in
writing.
Activity 3. SELECT STUDY INDICATOR(S)
3.1. The study has objective, clearly defined,
measurable indicators.
3.2. The indicators measure changes in health status,
functional status, or enrollee satisfaction, or valid
proxies of these outcomes.
Activity 4. USE A REPRESENTATIVE AND GENERALIZABLE STUDY POPULATION
4.1. The at-risk population is defined.
4.2. If the study includes the entire population, the
data collection approach captures all enrollees to
whom the study question applies.
Activity 5. USE SOUND SAMPLING TECHNIQUES
5.1. The sampling technique considers and specifies
the true frequency of occurrence, the confidence
interval and the margin of error.
5.2. A sufficient number of enrollees are sampled.
5.3. Valid sampling techniques are used.
Activity 6. RELIABLY COLLECT DATA
6.1. The data to be collected are clearly specified.
6.2. The sources of data are clearly specified.
6.3. The methods of collecting data are clearly
defined.
6.4. The data collection instruments provide for
consistent, accurate data collection.
6.5. The study design specifies a data analysis plan.
6.6. Qualified staff and personnel are used to collect
the data.
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Contract #126667 Schedule 2 Page 242 of 242
Activity 7. IMPLEMENT INTERVENTION AND IMPROVEMENT STRATEGIES
7.1 Reasonable interventions are undertaken to
address causes/barriers identified through data
analysis and QI processes undertaken.
Activity 8. ANALYZE DATA AND INTERPRET STUDY RESULTS
8.1. Analysis of findings are conducted according to
the data analysis plan.
8.2. Results and findings present numerical data in a
way that provides accurate, clear and easily
understood information.
8.3. The analysis identifies initial and repeated
measurements, statistical significance, factors
that influence comparability of initial and repeat
measurements, and factors that threaten internal
and external validity.
8.4. The analysis includes an interpretation of the
extent to which the PIP was successful and
follow-up activities.
Activity 9: PLAN FOR “REAL” IMPROVEMENT
9.1. The same methodology as the baseline
measurement is used, when measurement is
repeated.
9.2. An analysis is conducted to determine if there is
quantitative improvements in processes or
outcomes of care.
9.3. An assessment is made to determine if
improvement in performance has face validity
9.4. An analysis is conducted to determine statistical
evidence of observed improvement.
Activity 10: ACHIEVE SUSTAINED IMPROVEMENT
10.1. Repeated measurements is conducted to
determine sustained improvement.