REQUEST FOR BID #1800

SECTION 1: EFFECT

To the extent that the Special Provisions are in conflict with the General Provisions, the Special Provision shall control. To the extent that the Work Statement(s) and the Special or General Provisions are in conflict, the Work Statement(s) shall control.

SECTION 2: DEFINITIONS

As used throughout these General Provisions, the following terms shall have the meanings set forth:

2.0 Agency means Cochise Health Systems a division of Cochise Aging and Social Services.

2.1 Board of Supervisors means the County Board of Supervisors.

2.2 Contract means this document and CMS Rules and Regulations as promulgated in the C.F.R., Section 42, the AHCCCS Rules and Regulations including the AHCCCS AMPM and A.R.S. Title 36, the Request For Proposal, including instructions, all terms and conditions, plans, technical specifications, scope of work, attachments, and any amendments thereto; and the Proposal Response submitted by the Contractor in response to the solicitation and other Contract Documents.

2.3 Contractor means the person, firm or organization listed on the Cover Page of this Contract who is agreeing to provide the services specified by this contract in conformance with contract requirements, AHCCCS statue and rules and federal laws and regulations.

2.4 County means Cochise County.

2.5 Director means the Agency Director.

SECTION 3: GENERAL REQUIREMENT

3.0 All terms and conditions in Exhibit 2, AHCCCS Minimum Subcontract Provisions apply to the Contractor throughout this Contract.

3.1 The terms of this Contract shall be construed in accordance with Arizona law; any action thereon shall be brought in the appropriate court in the State of Arizona.

3.2 The Contractor shall, without limitation, obtain and maintain all licenses, permits, and authority necessary to do business, render services, and perform work under this Contract, and shall comply with all laws regarding unemployment insurance, disability insurance, and worker's compensation.

3.3 The Contractor is an independent Contractor in the performance of work and the provision of services under this Contract and is not to be considered an officer, employee, or agent of the County.

3.4 This agreement does not create an employee/employer relationship between the parties. It is the parties' intention that the Contractor will be an independent contractor and not the County's employee for all purposes, including, but not limited to, the application of the Fair Labor Standards Act minimum wage and overtime payments, Federal Insurance Contribution Act, the Social Security Act, the Federal Unemployment Tax Act, the provisions of the Internal Revenue Code, the provisions of the Arizona Department of Revenue, the provisions of the Arizona Board of Tax Appeals, the provisions of the Arizona Income Tax Act of 1978, the provisions of the Industrial Commission of Arizona including the Arizona Employers' Liability Law, Workmen's Compensation, and Unemployment Compensation Fund provisions. The Contractor will retain sole and absolute discretion in the judgment of the manner and means of carrying out the Contractor's activities and responsibilities hereunder. The Contractor agrees that it is a separate and independent enterprise from the public employer, that it has a full opportunity to find other business, that it has made its own investment in its business, and that it will utilize a high level of skill necessary to perform the work. This agreement shall not be construed as creating any joint employment relationship between the Contractor and the County, and the County will not be liable for any obligation incurred by the Contractor, including but not limited to unpaid minimum wages and/or overtime premiums.

3.5 Contractor employees are not subject to the provisions or benefits of the Merit System of the County. Contractor expressly waives any right to claim any benefit from the County for services performed hereunder not expressly provided for in this Contract.

3.6 All AHCCCS guidelines, policies, and manuals are hereby incorporated by reference into this contract including but not limited to, AHCCCS Provider Participation Agreement, the AHCCCS Medical Policy Manual (AMPM) and the AHCCCS Contractor Operations Manual (ACOM). The Contractor is responsible for complying with the requirements set forth within.

SECTION 4: AMENDMENTS

4.0 All amendments to this contract must be in writing, signed by both parties, and subject to approval by the Arizona Health Care Cost Containment System Administration (if applicable).

4.1 A proposed merger, reorganization or change in ownership of the Contractor shall require prior approval of Agency and a subsequent contract amendment.

SECTION 5: RETENTION OF RECORDS

5.0 All records shall be maintained to the extent and in such detail as required by AHCCCS Rules and policies. Records shall include but not be limited to financial statements, records relating to quality of care, medical records, prescription files and other records specified by AHCCCS.

5.1 The Contractor shall make at its office at all reasonable times during the term of this contract and the period set forth below any of its records for inspection, audit or reproduction by any authorized representative of AHCCCS, State or Federal government. The Contractor shall be responsible for any costs associated with the reproduction of requested information.

5.2 The Contractor shall preserve and make available all records for a period of five years from the date of final payment under this contractor except as provided below.

5.2.a If this Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for a period of five years from the date of any such termination.

5.2.b Records which relate to grievances, disputes, litigation or the settlement of claims arising out of the performance of this contract, or costs and expenses of this contract to which exception has been taken by AHCCCS, shall be retained by the Contractor for a period of five years after the date of final disposition or resolution thereof.

5.3 Records covered under HIPAA must be preserved and made available for six years per 45 CFR 164.530(j)(2).

SECTION 6: ADEQUACY OF RECORDS

6.0 The Contractor shall maintain all records relating to performance of the Contract in compliance with the specifications for recording keeping established by AHCCCS. All records shall be maintained in such detail as shall reflect each service provided and all other costs and expenses of whatever nature for which payment is made to the Contractor. Such material shall be subject to inspection, audit or copying by the Agency, State, AHCCCS, CMS and any other authorized representative of the state or federal governments during normal business hours at the Contractors place of business.

6.1 The Contractor shall comply with all applicable AHCCCS Rules and Audit Guide relating to the audit of the Contractor’s records and the inspection of the Contractors facilities.

SECTION 7: AUDIT DISALLOWANCES

7.0 The Contractor shall, upon written notice thereof, reimburse the County for any payments made under this Contract which are disallowed by a Federal, State or County audit in the amount of the disallowance, as well as court costs and attorney fees which the County spends to pursue legal action relating to such a disallowance. Court costs and attorney fees incurred will be specifically identified as applicable to the recovery of the disallowed costs in question.

7.1 If at any time it is determined by the Agency that a cost for which payment has been made is a disallowed cost, the Agency shall notify the Contractor in writing of the disallowance and the required course of action, which shall be at the option of the Agency either to adjust any future claim submitted by the Contractor by the amount of the disallowance or to require repayment of the disallowed amount by the Contractor forthwith issuing a check payable to the County.

SECTION 8: CONTRACT COMPLIANCE MONITORING

8.0 The Agency shall monitor the Contractor's compliance with, and performance under, the terms and conditions of this Contract and all applicable state and federal guidelines. On-site visits for Contract compliance monitoring may be made by the Agency and/or its grantor agencies at any time during the contractor's normal business hours announced or unannounced. The Contractor shall make available for inspection and/or copying by the Agency's monitors at no charge, all records and accounts relating to the work performed or the services provided under this Contract or similar work and/or service provided under other Grants and Contracts.

8.1 The Contractor agrees to take corrective action, which results from monitoring findings.

8.2 The Agency reserves the right to audit any financial and medical records of Contractor, which relates to service and billings made to the Agency. Such audits will be made at the Agency's expense at times and places convenient to Contractor.

8.3 The Agency shall retain the right to sanction providers for sub-contract performance or other breach of contract or procedural provisions (Refer to Agency policy ADM022 in the Provider Manual). The amount of the monetary penalty may vary depending on the nature of the Provider's action or failure to act. The maximum of $25,000 may be imposed per occurrence for actions as outlined in policy ADM022.

SECTION 9: AVAILABILITY OF FUNDS

9.0 The provisions of this Contract relating to payment for services shall become effective when funds assigned for the purpose of compensating the Contractor as herein provided are actually available to the Agency for disbursement. The Director shall be the sole judge and authority in determining the availability of funds under this contract and the Agency shall keep the Contractor fully informed as to the availability of funds.

9.1 If any action is taken by any State or agency, federal department or any other agency instrumentality to suspend, decrease, or terminate its fiscal obligations under, or in connection with, this Contract, the Agency may amend, suspend decrease or terminate its obligations under, or in connection with, this Contract. In the event of terminating, the Agency shall be liable for payment only for services rendered prior to the effective date of the termination, provided that such services performed are in accordance with the provisions of this Contract. The Agency shall give written notice of the effective date of any suspension, amendment, or termination under this section, at least thirty (30) days in advance. (See Section 11: Termination)

SECTION 10: CONTINGENCY RELATING TO OTHER CONTRACTS AND GRANTS

10.0 The Contractor will, during the term of this Contract, immediately inform the Agency in writing of the award of any other contract or grant including any other contract or grant awarded by the Agency where the award of such contract or grant may affect either the direct or indirect costs being paid/reimbursed under this Contract. Failure by the Contractor to notify the Agency of such award shall be considered a violation of the Contract and the Agency shall have the right to annul this Contract without liability.

10.1 The Agency may request, and the Contractor shall provide within a reasonable time, a copy of such other contract or grant, when in the opinion of the Agency the award of the other Contract or grant may affect the costs being paid or reimbursed under this Contract.

10.2 If the Agency determines that the award to the Contractor of such other contract or grant has affected the costs being paid or reimbursed under this Contract, the Agency shall prepare a Contract Amendment effecting a cost adjustment. If the Contractor protests the proposed cost adjustment, the protest shall be construed as a grievance within the meaning of Section 23: Grievance Process.

SECTION 11: TERMINATION

11.0 The Director may suspend, modify, or recommend termination of this Contract immediately upon written notice to Contractor in the event of a non-performance of stated objectives or other material breach of contractual obligations; or upon the happening of any event which would jeopardize the ability of the Contractor to perform any of its contractual obligations. Such determination will not be made until such time as the disputes process has been exhausted as specified in the Disputes Clause of the Special Provisions.

11.1 Either party may terminate this Contract at any time, with ninety (90) days notice in writing to the other party (unless terminated by Agency under Availability of Funds provision). Such notice shall be given by personal delivery or by Registered or Certified mail.

11.2 This Contract may be terminated by mutual written agreement of the parties specifying the termination date therein.

11.3 The Agency has the right to terminate this Contract upon twenty-four (24) hours notice when the Agency deems the health or welfare of a member is endangered or Contractor non-compliance jeopardizes funding source financial participation. If not terminated by one of the above methods, this Contract will terminate upon the expiration of the term of this Contract as stated on the Cover Page.

11.4 Pursuant to A.R.S. §38-511, the provisions of which are incorporated herein by reference, all parties are hereby put on notice that this Agreement is subject to cancellation by Cochise County or its departments if any person significantly involved in initiating, negotiating, securing, drafting or creating the contract on behalf of the County or its departments at any time while the contract or any extension of the contract is in effect, an employee or agent of any other party to the contract in any capacity or a consultant to any other party of the contract with respect to the subject matter of the contract.

11.5 Rights and Obligations Upon Termination. Upon termination of this Agreement, regardless of cause or reason, AHCCCS shall be notified and all rights and obligation of the parties relating to services during the term of and under this Agreement shall survive the termination.

11.6 Upon termination, Contractor’s obligations or right to render Covered Services to Members or right to receive payment in accordance with this Agreement shall immediately cease, except for payments due prior to termination. However, such termination shall not relieve Contractor of those obligations reasonably necessary to complete the treatment of Members then receiving treatment and to cooperate with Agency to arrange for the discharge or transfer of such Members. Such cooperation may require Contractor to extend performance beyond the termination notification period provided in this Agreement, or until the earlier of completion of such services or the expiration of twelve (12) months. In such an event, Agency will compensate Contractor for Covered Services at the contracted rate (unless capitated). If the Contractor has been paid under a capitated arrangement, services will be paid at the AHCCCS Fee for Service rate.

SECTION 12: SEVERABILITY

Any provision of this Contract which is determined to be invalid, void or illegal shall in no way affect, impair or invalidate any other provision hereof, and remaining provisions shall remain in full force and effect.

SECTION 13: STRICT COMPLIANCE

Acceptance by the Agency of performance not in strict compliance with the terms hereof shall not be deemed to waive the requirement of strict compliance for all future performance obligations. All changes in performance obligations under this Contract must be in writing.

SECTION 14: NON-LIABILITY

The County and its officers and employees shall not be liable for any act or omission by the Contractor and Subcontractor or any employee, officer, agent, or representative of Contractor and Subcontractor occurring in the performance of the Contract, nor shall these entities be liable for purchases or Contracts made by the Contractor in anticipation of funding hereunder.

SECTION 15: INDEMNITY

15.0 The Contractor agrees to indemnify, hold harmless, and defend the County, its officers, employees, from and against any and all claims, damages, demands, suits, proceedings, costs or expense of every type, including attorney's fees and litigation expenses, brought against or incurred by the County on account of any loss or injury arising out of any professional error or negligence of the Contractor, its employees, agents or Subcontractor in connection with the performance of this Agreement.

15.1 The Contractor shall indemnify, hold harmless the County, its officers and employees, from and against any and all claims, losses, costs and expenses of every type, including attorney's fees and litigation expenses, arising out of Worker's Compensation claims, Unemployment Disability Compensation claims, actions under the Fair Labor Standards Act or any similar federal or state law, by employees of the Contractor or Subcontractor of the County, acting in connection with the performance of this Agreement.

15.2 The County agrees to indemnify, hold harmless and defend the Contractor, its officers and employees, from and against any and all claims, demands, suits, proceeding, costs or expenses of every type, including attorney's fees and litigation expenses, brought against or incurred by the Contractor on account of loss or injury arising out of any professional error or negligence of the County, its employees, agents or contractors in connection with the performance of this Agreement.

15.3 The County shall indemnify and hold harmless Contractor, its officers and employees, from and against any and all claims, losses, costs and expenses of every type, including attorney's fees and litigation expenses, arising out of Worker's Compensation claims, Unemployment Disability Compensation claims, actions under the Fair Labor Standards Act or any similar federal or state law, by employees of the County or other contractors of the County acting in connection with the performance of this Agreement.

15.4 The extent of the foregoing liabilities shall be limited to and determined by the respective fault of the parties, their agents, subcontractors, and employees, in comparison with others (including, but not limited to the other party) who may have contributed to or in part caused any such claim to arise.

15.5 Survival. The provisions of this Section shall survive the termination of this Agreement.

SECTION 16: COVENANT AGAINST CONTINGENT FEES

The Contractor warrants that no person or selling agency has been employed or retained to solicit or secure this Contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee. For breach or violation of this warranty, the Agency shall have the right to annul this Contract without liability.

SECTION 17: SAFEGUARDING OF MEMBER INFORMATION

The use or disclosure by any party of any information concerning an Agency member served under this Contract is directly limited to the conduct of this Contract.

SECTION 18: RIGHTS IN DATA AND DATA EXCHANGE REQUIREMENTS

18.0 The parties hereto shall have the use of data and reports resulting from this Contract without cost or other restriction, except as may be established by law or applicable regulation. Each party shall supply to the other party, upon request, any available information that is relevant to this Contact and to the performance hereunder.

18.1 The Contractor shall meet any AHCCCS required technical and procedural requirements for data exchange interfaces between AHCCCS, the Agency and the Contractor. The Contractor shall comply with any technical requirements as mandated by AHCCCS from time to time and in formats prescribed by HIPAA.

SECTION 19: UNIVERSALITY

This Contract is awarded on behalf of the County and the Agency in its entirety. Any Department or Division within the County, that has need of the services identified herein, may utilize it.

SECTION 20: LAWS, RULES AND REGULATIONS

The Contractor understands and agrees that this Contract is subject to all the State and Federal laws, rules and regulations that pertain hereto. When this Contract is written for the purpose of providing services to persons that participate in the Arizona Health Care Cost Containment System (AHCCCS) and the Arizona Long Term Care System (ALTCS) then the requirements contained herein are superseded by the requirements of the AHCCCS Approved Subcontract Provisions appended hereto as Exhibit 2.

SECTION 21: NON COLLUSION

The Contractor expressly warrants that neither the Contractor nor its associates has directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of trade in conjunction with this Contract.

SECTION 22: ESCALATION

An increase in the cost of services must be mutually acceptable to the Agency and the Contractor and shall be in the form of a formal written amendment provided by the Agency and approved by the Board of Supervisors.

SECTION 23: GRIEVANCE PROCESS

23.0 All Providers of services and items to Cochise Health Systems' (CHS) members have the right to grieve any adverse action by CHS as specified in the Arizona Revised Statutes, §36-2903.01.B4; A.A.C. R9-34.

23.1 All Providers must comply with policies and procedures related to the grievance process in accordance with Federal and State laws, regulations and policies, including but not limited to, 42 CFR Part 438 Subpart F. All Providers must ensure that member care is not compromised or impacted by the providers pursuing the grievance process. Refer to Policies GRV001B and GRV002 in the pink section of the Provider Manual.

23.2 Cochise Health Systems will maintain Grievance Standards in compliance with the ALTCS Rules and Regulations.

23.2.a Grievance is defined as an expression of dissatisfaction about any matter other than an action. 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 enrollee’s rights.

23.3 Whenever possible, disputes between the Contractor and the Agency, unrelated to claims issues, should be resolved through the Informal Complaint Process. CHS staff may attempt to informally resolve all disputes presented to CHS, verbally or in writing, within ten (10) days from the date the dispute was initially presented without resorting to a formal grievance process.

23.4 If the dispute cannot be resolved through the Informal Complaint Process, the Contractor must file the grievance in writing and it must be received by the Agency’s Grievance Manager no later than 60 days after the date of the adverse action, decision, or policy implementation being grieved. Grievance must specify in detail the factual or legal basis for the grievance and the relief requested. Failure to detail the factual or legal basis may result in the denial of the grievance. Include any medical records or other documentation that may have a bearing on the Agency’s decision.

23.5 The Agency will make a final decision within thirty (30) days of receipt of the grievance, and advise the Contractor of its appeal rights and procedures if Contractor does not agree with the decision. The Contractor must inform the Agency of its desire to request a hearing within thirty (30) days of receipt of the grievance decision letter.

23.6 Disputes related to claims issues should also be resolved with Agency’s staff prior to the filing of a formal grievance. (Refer to the CHS Provider Manual, Section XIII for detailed instructions.)

23.7 All grievances challenging claim denials shall be filed in writing with the Agency not later than twelve (12) months after the date of the service (for a hospital inpatient, from the date of discharge) for which payment is claimed, twelve (12) months after the date that eligibility is posted or within sixty (60) days after the date of the denial of a timely claim submission, whichever is later. The grievance shall state the factual and legal basis and the relief requested, along with any documents (i.e. claim, claim denial form, remit, medical review sheet, medical records, correspondence, etc.) in support of the factual and legal basis for the grievance. Failure to comply with these requirements may result in denial of the grievance.

SECTION 24: CHANGES

24.0 The Director may, at any time, by written order, make changes within the general scope of this Contract in any one or more of the following areas:

24.0.a Work Statement activities reflecting changes in Funding Source or Agency regulations, policies or requirements.

24.0.b Administrative requirements such as changes in reporting periods, frequency of reports, or report formats required by Funding Source or Agency regulations, policies or requirements.

24.0.c Contract provisions as required by AHCCCS from the Agency, as amended.

24.1 Such order will not serve to increase or decrease the total compensation to be paid the Contractor. Additionally, such order will not direct substantive changes in services to be rendered by the Contractor.

24.2 Any dispute or disagreement caused by such written order shall constitute a "Dispute" and be resolved according to the Agency Grievance Process.

SECTION 25: AGENCY RIGHT TO EXTEND CONTRACT

25.0 Subject to the availability of funds and acceptable contractor performance, the Contractor hereby acknowledges and agrees the Agency shall have the unilateral right to extend this Contract except that cost may be subject to renegotiations.

25.1 The method of Contract extension shall be in the form of a formal Contract Amendment document provided by the Agency and approved by the Board of Supervisors of the County.

SECTION 26: SUBCONTRACTS

26.0 If Contractor carries out any of the provisions under this Contract through a subcontract with a value or cost of $10,000 or more over a twelve (12) month period with a related organization, such subcontract shall contain requirements identical to those set forth in this Contract.

26.1 All rights, liability, obligations or duties under this Contract cannot be assigned, delegated or subcontracted in its entirety, without the prior written approval of the Director and the Board of Supervisors.

26.2 The Contractor agrees that it shall fully cooperate with other Agency Contractors and carefully plan and perform its own work to accommodate the work of other Agency Contractors. The Contractor shall not commit or permit any act, which will interfere with the performance of work by any other Contractor with the exception of those necessary to protect members, members or inmates from circumstances which present a clear and present danger to them. The Contractor's employees shall wear appropriate identification whenever they provide service to a facility or service site.

SECTION 27: EXCLUSIONS

The Agency reserves the right to have service provided by other than the Contractor.

SECTION 28: INSURANCE AND LIABILITY

28.0 Insurance. Contractor shall be responsible for providing all health, accident, workers' compensation, liability and other appropriate insurance for its employees in connection with providing Covered Services under this Agreement.

28.1 Contractor Professional and General Liability. Throughout the term of this Agreement, Contractor shall maintain at Contractor's expense, for all PHP's employed under contract with the Contractor, general and professional liability coverage in a form and amounts acceptable to Agency. In the event such coverage is claims-made insurance, Contractor shall maintain such coverage continuously, and in the event of termination of services or termination of this Agreement, Contractor shall secure tail coverage with agreed limits of liability to provide continuous coverage for the period of the relevant statute of limitations for any claims that may arise against Contractor as a result of services rendered under this Agreement. Contractor shall give Agency thirty (30) days prior written notice of cancellation, modification or termination of any such insurance. Contractor shall give Agency prompt written notice of any claims against Contractor's liability coverage.

Required types and minimum amounts of insurance

Type Minimum

Professional Liability

Each Occurrence $1,000,000

Aggregate $2,000,000

General Liability

Each Occurrence $1,000,000

Aggregate $2,000,000

Auto & Truck*

General Liability $ 500,000

Property Damage $ 500,000

Combined Single Limit, each occurrence $1,000,000

Worker's Compensation Statutory

Unemployment Insurance Statutory

Standard minimum deductible amounts are allowable. Any deductible amounts are the responsibility of the Contractor.

* Required if Contractor vehicles are used to transport Agency members.

28.2 Certificate of Insurance. A certificate of insurance shall be the only method of proof of insurance. The certificate shall name Cochise Health Systems as additional insured on the certificate for professional and vehicle insurance. Contractor shall give Agency thirty (30) days prior written notice of cancellation, modification or termination of any such insurance. Contractor shall give Agency prompt written notice of any claims against Contractor's professional liability coverage.

28.3 Complaint, Inquiry, Investigation or Review. Contractor shall notify Agency immediately of the initiation of any complaint, inquiry, investigation, or review with or by any licensing or regulatory authority, peer review organization, or committee, organization or body which directly or indirectly evaluates or focuses on the quality of care provided by Contractor, whether in any specific instance or in general.

28.4 Survival. The provisions of this Section shall survive the termination of this Agreement.

SECTION 29: NOTIFICATION OF NON-AVAILABILITY OF FUNDS

The Agency shall provide the Contractor with at least thirty (30) days prior written notice of funds no longer being available to pay for services under this Agreement. Notwithstanding the Agency's availability of funds, Contractor does not hereby waive its right to be paid for all authorized covered services it provides to members referred to it by the Agency.

SECTION 30: PROVIDER REGISTRATION

30.1 The Contractor shall ensure that it is registered with AHCCCS as an approved service provider. All Providers are

required to maintain a valid AHCCCS Provider Number.

30.2 The National Provider Identifier (NPI) will be required on all claims submissions and subsequent encounters (from Providers that are eligible for a NPI.

30.3 The AHCCCS Provider Participation Agreement located on the AHCCCS website (eg billing requirements, coding standards, payment rates) are in force between Agency and Contractor.

SECTION 31: CORPORATE COMPLIANCE

Fraud is defined by Federal law (42 CFR 455.2) as "an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law."

In accordance with ARS § 36-2918.01, and the ACOM, Chapter 100, Contractor is required to immediately notify the AHCCCS, Office of Program Integrity (OPI) regarding any suspected fraud or abuse [42 CFR 455.17].

As stated in ARS § 13-2310, incorporated herein by reference, any person who knowingly obtains any benefit by means of false or fraudulent pretenses, representations, promises or material omissions is guilty of a Class 2 felony.

All Contractors shall notify the Agency Member-Provider Relations Supervisor or M/UM Manager in writing of any cases of suspected fraud and abuse. Contractor shall refer to the Fraud and Abuse Reporting Policy included in the CHS Provider Manual.

Federal False Claims Act

Contractor shall train their staff on the following aspects of the Federal False Claims Act provisions;

a) The administrative remedies for the false claims and statements

b) Any state laws relating to civil or criminal penalties for false claims and statements

c) The whistleblower protection under such laws.

Evidence of such training shall be documented in the employee's personnel files. Deficit Reduction Act (DRA) Compliance Training is available on the AHCCCS website. Please visit, www.azahcccs.gov for more information.

SECTION 32: MAINSTREAMING

Mainstreaming. Contractor shall take affirmative action so that members are provided covered services without regard to payer source, race, color, creed, gender, religion, age, national origin (to include those with limited English proficiency), ancestry, marital status, sexual preference, genetic information or physical or mental disability. Contractor must take into account a member’s literacy and culture when addressing members and their concerns. Contractor must also make interpreters, including assistance for the visual or hearing impaired, available to members to ensure appropriate delivery of covered services. (Refer to the pink section of the CHS Provider Manual, Policy ADM011.)

SECTION 33: TERM OF CONTRACT

33.0 This Contract shall begin on the date set forth above and shall continue until to September 30, 2010 unless continued or terminated as set forth below.

33.1 This Contract may be renewed under the same terms and conditions for five (5) additional one (1) year terms unless either the Agency or the Contractor gives written notice to the other no less that ninety (90) days prior to the expiration of the Term or any renewal Term.

33.2 All amendments to the Contract shall be in the form of a formal Contract Amendment document provided by the Agency and approved by the Board of Supervisors.

SECTION 34: EXHIBITS

The Exhibits 1-4 are a part of this Agreement and their term shall supersede those of other parts of this Contract in the event of a conflict.

SECTION 35: HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) (The Health Insurance Portability and Accountability Act (PL 104-191) also known as the Kennedy-Kassebaum Act, signed August 21, 1996.)

The Contractor shall comply with the Administrative Simplification requirements of Subpart F of the HIPAA of 1996 (Public Law 107-191, 110 Statues1936) and all Federal regulations implementing that Subpart that are applicable to the operations of the Contractor by the dates required by the implementing Federal regulations.

SECTION 36: SUSPENSION OR DEBARMENT

Contractor shall not employ, consult, subcontract or enter into any agreement for Title XIX services with any person or entity who is debarred, suspended or otherwise excluded from Federal procurement activity or from participating in non-procurement activities under regulations issued under Executive Order 12549 [42 CFR 438.610(a) and (b)] or under guidelines implementing Executive Order 12549. This prohibition extends to any entity, which employs, consults, subcontracts with or otherwise reimburses for services any person substantially involved in the management of another entity, which is debarred, suspended or otherwise excluded from Federal procurement activity.

Contractor shall not retain as a director, officer, partner or owner of 5% or more of the Contractor entity, any person, or affiliate of such a person, who is debarred, suspended or otherwise excluded from Federal procurement activity.

SECTION 37: AMERICANS WITH DISABILITIES ACT (ADA)

The Contractor shall meet all applicable ADA requirements when providing services to members.

SECTION 1: EFFECT

To the extent that the Special Provisions are in conflict with the General Provisions, the Special Provisions shall control. To the extent that the Work Statement(s) and the Special or General Provisions are in conflict, the Work Statement(s) shall control.

SECTION 2: DEFINITIONS

As used throughout this Contract, the following terms shall have the meanings set forth:

2.0 Abuse (of a member) means intentional infliction of physical, emotional or mental harm, caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault as defined by ARS § 46-451.

2.1 Abuse (by Provider) means provider practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the AHCCCS program as defined by 42 CFR 455.2.

2.2 ACOM means the AHCCCS Contractor Operations Manual available on the AHCCCS web site at www.azahcccs.gov

2.3 ADHS means Arizona Department of Health Services, the state agency mandated to serve the public health needs of all Arizona residents

2.4 Adult means an individual who is 18 years of age or older.

2.5 Agency means Cochise Health Systems.

2.6 AHCCCS means the Arizona Health Care Cost Containment System through which health care services are provided to an eligible person defined by ARS § 36-2902, et seq.

2.7 ALTCS means the Arizona Long Term Care System, a program under AHCCCS that delivers long term, acute, behavioral health care and case management services to eligible members, as authorized by ARS § 36-2932.

2.8 AMPM AHCCCS Medical Policy Manual available on the AHCCCS website at www.azahcccs.gov.

2.9 ARS Arizona Revised Statutes

2.10 Assessment is a report that includes, but is not limited to, the member's health profile, social history, informal/formal support systems, activities of daily living skills, mental and emotional status, and community and financial resources.

2.11 Attendant Care service provided by a trained attendant for members who reside in their own homes and is a combination of services, which may include homemaker services, personal care, coordination of services, general supervision and assistance, companionship, socialization and skills development. Attendant care services are not considered duplicative of hospice services.

2.12 Care Plan is a written plan of action that states the goals and objectives, and plans for their achievement for the member.

2.13 Claim Disputes means a dispute, filed by a Contractor involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance

2.14 Clean Claim means a claim that may be processed without obtaining additional information from the provider of service or from a third party; but does not include claims under investigation for fraud or abuse or claims under review for medical necessity, as defined by ARS § 36-2904.

2.15 Contract means this document and CMS Rules and Regulations as promulgated in the C.F.R., Section 42, the AHCCCS Rules and Regulations including the AHCCCS AMPM and A.R.S. Title 36, the Request For Proposal, including instructions, all terms and conditions, plans, technical specifications, scope of work, attachments, and any amendments thereto; and the Proposal Response submitted by the Contractor in response to the solicitation and other Contract Documents.

2.16 Co-payment means a monetary amount specified by Agency which the Member or eligible person pays directly to a contractor or subcontractor at the time Covered Services are rendered as defined in A.A.C. 22 Article 7.

2.17 CMS means Centers for Medicare and Medicaid Services, an organization within the U.S. Department of Health and Human Services which administers the Medicare, Medicaid and State Children’s Health Insurance Program.

2.18 Encounter means a record of health care related services rendered by the Contractor to a member who is enrolled with the Agency on the date of service.

2.19 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 : a) placing the patient’s health (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy b) serious impairment to bodily functions or c) serious dysfunction of any bodily organ or part [42 CFR 438.114(a)].

2.20 Enrollee (also called a member) mean a Medicaid recipient who is currently enrolled with the Agency [42 CFR 438.10(a)]

2.21 Funding Source is any Federal, State or Private Agency funding source which may impose conditions on the funding that will be passed on to the Contractor.

2.22 Grievance System means a system that includes a process for enrollee grievances, enrollee appeals, provider claim disputes, and access to the state fair hearing system.

2.23 Home Delivered Meal Aide is a person who helps to prepare or distribute home delivered meals.

2.24 Home Health Aide is the individual duly appointed to this position on behalf of the Contractor and who is certified as competent by ADHS to perform the Home Health Aide tasks.

2.25 Home Health Nurse is the licensed nurse duly appointed to this position and who provides intermittent skilled nursing services in the individual's place of residence. Skilled nursing services may include health maintenance, continued treatment, or supervision of a health condition.

2.26 Home Health Services are part-time or intermittent care for members who do not require hospital care; this service is provided under the direction of a physician to prevent re-hospitalization or institutionalization and may include skilled nursing, therapies, supplies and home health aide services

2.27 Hospice means a program that provides care to terminally ill patients who have six months or less to live. A participating Hospice must meet Medicare requirements and have a written provider contract with the Program Contractor. Program Contractors are required to pay nursing facilities 100% of the class specific contracted rate when a member elects the hospice benefit. Medicaid services provided to members receiving Medicare hospice services that are duplicative of Medicare hospice benefits (i.e., personal care, and homemaker services) will not be covered. Only when the service need is not related to hospice diagnosis can the service be covered by Medicaid.

2.28 Housekeeper is a person certified as competent by the Contractor to perform the Housekeeping tasks.

2.29 Housekeeping Supervisor is a person who meets the necessary qualifications under standards/licensure requirements and is designated by the Contractor to supervise Housekeepers.

2.30 Medicaid is a Federal program under Title XIX of the Social Security Act, which provides health insurance for financially eligible individuals.

2.31 Medical Director is the physician duly appointed to this position on behalf of the Agency.

2.32 Medical Provider is a physician, nurse practitioner, or physician assistant duly appointed by the member, member's private insurance plan or the Agency to provide medical care to member.

2.33 Medicare is a Federal program under Title XVIII of the Social Security Act, as amended.

2.34 Medication is defined as any drug, chemical compound, remedy or non-infectious biological substance, which may be dispensed or administered by prescription in accordance with state or federal law.

2.35 Member is an individual (also known as a "resident") who has been authorized by the Arizona Long Term Care System as eligible to receive health care services from the Agency.

2.36 Member Care Planning Meetings are meetings between Agency staff and the Contractor to review individual member situations and problems.

2.37 Nutritionist is a person who has a Bachelor's or Master's degree in Food and Nutrition.

2.38 Personal care means a service that provides assistance with personal physical needs such as washing hair, bathing, dressing, and includes maintaining personal cleanliness and assisting in the activities of daily living.

2.39 Personal Care Aide is a person certified as competent by the Contractor to perform the Personal Care Attendant tasks.

2.40 Personal Care Supervisor is a person who meets at least the necessary qualifications under standards/licensure requirements and is designated by the Contractor to supervise Personal Care Attendants.

2.41 Personal living skills are, but not limited to, walking, eating, grooming and toileting.

2.42 Personnel means all staff including any full or part time or temporary employees, any employees hired through a temporary hire agency or volunteers, performing services in direct or indirect contact with Agency members.

2.43 Physical Therapist is a person registered under provisions of A.R.S. Title 32, Chapter 19, to provide physical therapy.

2.44 Private Duty Nursing means nursing services for ALTCS members who require more individual and continuous care than is available for a nurse providing intermittent care. These services are available to all ALTCS members and are provided by a registered nurse or licensed practical nurse under the direction of the ALTCS member’s primary acre provider of record. Contractors who employ independent nurses to provide private duty nursing must develop oversight activities to monitor service delivery and quality of care.

2.45 Provider Manual means the Manual that contains the policies and procedures instituted by Agency for the use and direction of Contractor and participating Providers. Contractor agrees to be bound by the policies and procedures set forth in the Provider Manual as it may be amended from time to time. A copy of the Provider Manual shall be provided to Contractor upon execution of this Agreement.

2.46 Provider Meetings are meetings between Agency Staff and the Contractor to review Agency Contract situations and problems. The Agency may also conduct meetings with the Contractor to address issues related to federal and state requirements, changes in policy, reimbursement matters, and prior authorization.

2.46a Member/Provider Council-This is a meeting held quarterly with the purpose of promoting a collaborative effort to enhance the service delivery system in local communities while maintaining member focus. Participation is voluntary but encouraged for Contractors.

2.47 Reassessment is the review and re-evaluation of the appropriateness of the service plan considering the member's current condition and the modification of the service plan based on the conclusions from the review and re-evaluation.

2.48 Registered Dietitian is a person who meets all the requirements for membership in the American Dietetic Association and who has successfully completed the examination for registration and who maintains the continuing education requirements.

2.49 Registered Nurse is a person who is licensed to practice professional nursing by the Arizona Board of Nursing under the provision of Title 32, Chapter 15, Arizona Revised Statutes.

2.50 Respite Care means a service that provides a non-routine interval of rest and/or relief to a family member or other unpaid person(s) caring for the ALTCS member. It is available for up to 24-hours per day and is limited to 720 hours per year.

2.51 Service Plan is the page in the ALTCS Standardized Assessment Form where the units and classification of authorized service are stated.

2.52 Standardized Assessment Form is the form filled out by Case Management, which assesses the member's condition, need for services, and authorized specific services.

2.53 State means the State of Arizona.

2.54 Supervision means direct and immediate observation and direction of an activity or function. Supervision must comply with AHCCCS Policy.

2.55 Visit means the total amount of time needed to accomplish the ordered treatment and/or service which includes direct service and documentation time, excluding travel time.

2.56 Volunteer means one who renders a service while having no legal concern or interest, nor receiving any monetary compensation.

SECTION 3: MEDICAL RECORDS

3.0 The Contractor shall have written standards for documentation on the medical record for legibility, accuracy and plan of care, which comply with the AMPM.

3.1 Medical records shall be maintained in a detailed and comprehensive manner, which conforms to good professional medical practice, permits effective professional medical review and medical audit process and which facilitates an adequate system for follow-up treatment. Medical records must be legible, signed and dated.

3.2 The Contractor shall have written policies and procedures for the maintenance of medical records so that those records are documented accurately and in a timely manner, are readily accessible and permit prompt and systematic retrieval of information.

3.3 The member’s medical record is the property of the Provider who generates the record. Each member is entitled to one copy of his/her medical record free of charge. The Contractor shall have written policies and procedures to maintain the confidentiality of all medical records.

3.4 AHCCCS and is not required to obtain written approval from a member, before requesting the member’s medical record from the Contractor. The Agency may obtain a copy of the member’s medical records without written approval of the member, if the reason for such request is directly related to the administration of the AHCCCS program. AHCCCS shall be afforded access to all members’ medical records whether electronic or paper within 20 business days of receipt of request.

3.5 Information related to fraud and abuse may be released so long as protected HIV-related information is not disclosed (ARS § 36-664(I)).

3.6 The Contractor agrees that Agency representatives displaying acceptable Agency identification shall have the right, during normal daytime business hours, to enter the Contractor's facility for the purpose of examining records, or documents relating to the provision of materials and/or services performed under this Contract.

SECTION 4: UTILIZATION REVIEW AND QUALITY MANAGEMENT

The Agency will operate a utilization review and quality management process through which member care can be monitored on a continuing basis as specified in 42 C.F.R., Part 456-UTILIZATION CONTROL, as specified in the AHCCCS AMPM. The utilization review and quality management process will include review of documentation of member evaluation, diagnosis, treatment and follow-up care. The review process will be accomplished by a comparison of Contractor's medical care and/or provision of services with standardized norms and criteria. All information gathered and discussions held in this process will be confidential amongst the Agency Contractor and staff members of the Quality Improvement Committee (QIC). No medical information contained in medical records or obtained in the course of carrying out its Utilization and Quality Management function for members covered under this Contract shall be used or disclosed by the Agency, or its agents or employees except as it is essential to the performance of this Contract.

Compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any enrollee (42 CFR 438.210 (e)).

SECTION 5: DISCRIMINATION AGAINST AGENCY MEMBERS

The Contractor shall take all reasonable steps to insure that Agency members shall in no manner whatsoever be discriminated against by the Contractor or any agents or employees of the Contractor. The Contractor shall respond immediately to any charges of discrimination.

SECTION 6: USE OF CONTRACTOR'S NAME

The Agency may utilize Contractor's name as one of its providers in its marketing literature. Use of the Contractor's name for any other purpose requires Contractor's prior approval.

SECTION 7: ADVANCE DIRECTIVES

The Contractor must comply with the Federal and State laws on advance directives for Adult Members [42 CFR 438.6(i)(1)]. Requirements include:

7.0 Maintaining written policies that address the rights of adult members to make decisions about medical care, including the right to accept or refuse medical care and the right to execute an advance directive. If the Contractor has a conscientious objection to carrying out an advance directive, it must be explained in policies. (A health care provider is not prohibited from making such objection when made pursuant to ARS §36-3205.C.1.)

7.1 Provide written information to adult members regarding an individual’s rights under State law to make decisions regarding medical care and the health care provider’s written policies concerning advance directives (including any conscientious objections)[42 CFR 438.6(i)(3)].

7.2 Documenting in the member’s medical record whether or not the adult member has been provided the information and whether an advance directive has been executed.

7.3 Not discriminating against a member because of his or her decision to execute or not execute an advance directive, and not making it a condition for the provision of care.

7.4 Providing education to staff on issues concerning advance directives including notification of direct care providers of services, such as home health care and personal care, of any advanced directives executed by members to whom they are assigned to provide services.

7.5 Contractor shall provide a copy of the member’s executed advanced directive or documentation of refusal, to the member’s PCP for inclusion in the member’s medical record.

SECTION 8: LEVEL OF CARE

8.0 The Agency shall assess all members for level of care requirements prior to initial placement in the Contractor's facility/care, or in the case of roll-over members, prior to assumption of Agency financial responsibility, and shall at least annually, reassess the level of care requirements of all such members. The Agency, acting through its Case Managers, and the Agency Director shall, in consultation with the PCP and/or the Agency Medical Director, be the sole determiners of the level of care requirements of members. The level of care may be reviewed with the Contractor's Director of Nurses or other designated staff as necessary. Level of care assessments shall be made in accordance with the criteria prescribed in Exhibit 4 hereby incorporated into this Contract.

8.1 The contractor agrees to cooperate with Case Managers in performance of Level of Care assessments and to assist the Case Managers when a change requires a transfer into a facility. Contractor shall bring to the attention of the Case Manager changes in a member's condition, which may indicate a need for a level of care change.

SECTION 9: REFERRAL OF MEMBERS

9.0 The Contractor understands and hereby acknowledges that the Agency makes no representations nor guarantees the Contractor any maximum or minimum number of member referrals.

9.1 All members needing placement in a facility will be subject to Contractor’s admission policies, bed availability, State licensure restrictions, and in accordance with Exhibit 4 of this contract.

9.2 All member referrals reimbursable under this Contract shall be made solely by Case Managers of the Agency. The number and frequency of authorized services received by a member is determined through an assessment of the member’s needs by the case manager with the member and/or the member’s family, guardian or representative.

AUTHORIZATION DOES NOT GUARANTEE REIMBURSEMENT

Reimbursement for services depends on member's enrollment status on the date(s) of service, medical necessity, and plan limitations and exclusions as stated in rules and regulations governing the plan and plan policies and procedures. Plan exclusions include, but are not limited to, all services related to occupational illness and injuries, and excessive, inappropriate or unallowable charges.

9.3 The Contractor shall verbally notify the Agency immediately of its desire to discontinue services for any member when the Contractor considers these services unsafe or inappropriate. In addition, advance written notice must be submitted within 15 working days of the date that the Contractor intends to discontinue services. The notice period may be reduced by mutual agreement of the Contractor and the Agency. The Agency is required to give ten (10) working days notice to a member prior to termination, denial, or suspension of any service (refer to the Cochise Health Systems Provider Manual-Pink Section-Policy CM001A and UM002).

9.4 The Contractor agrees to refuse authorization for any Medicare reimbursable nursing service inadvertently requested by the Agency for any Medicare eligible member. The Agency will refer these members to a Medicare certified agency while the member is eligible to receive billable visits. The Contractor will notify CHS Case Managers of member changes in condition, which may affect Medicare coverage for visits.

SECTION 10: ACCESS TO MEMBERS

10.0 Contractor agrees that Centers for Medicare and Medicaid Services (CMS), or Agency representatives displaying proper agency identification shall have the right to enter the Contractor's facility and the right to examine members and medical records at any time for the purpose of providing or monitoring essential health care and social services to members.

10.1 The Contractor agrees that CMS, AHCCCS or Agency representatives and Contractors displaying proper agency identification shall have the right, during normal daytime business hours, to enter the Contractor's facility for the purpose of examining member's charts, records and related documents relating to members as well as providing health care services.

SECTION 11: MEMBER CARE PLAN EVALUATIONS

11.0 The Contractor agrees to complete a member care plan evaluation on all members at least quarterly or more frequently when requested by a Case Manager. Such plans shall be documented in the member chart.

11.1 The Agency shall be advised of member to be evaluated at least ten (10) working days in advance of the scheduled member care plan evaluation conference so that appropriate Agency staff (i.e., Case Managers) will be prepared, attend and participate in the conference.

11.2 The Contractor will attempt to schedule member care plan evaluation conferences to coincide with the Agency Case Managers' schedules and in the area of the Case Manager's office. Exceptions may be made by the Case Management Supervisor.

11.3 Development of the service plan must be coordinated with the member and/or member’s family/representative to ensure mutually agreed upon approaches to meet the member’s needs within the scope and limitations of the program.

SECTION 12: ADMINISTRATION

12.1 Within five (5) working days following staff changes of the Administrator and/or Director of Nurses (if applicable) and special unit coordinators, such changes will be reported, with an appropriate copy of the new supervising staff person's license and resume, to the Agency Director.

12.2 Normal service hours will be provided Monday through Friday, 7:00 am to 6:00 pm, with the exception of the following legal holidays: New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day. The contractor may perform services any other days or hours, at its option, however, there will be no holiday or weekend differential. Authorized units may be left unused for any Holidays that fall on a day that would have been a normal service day.

12.3 Weekend and Holiday service hours are those days and hours not included in “Normal Service Hours”. These services will not be paid unless specifically authorized by Case Management.

SECTION 13: STANDARDS/LICENSURE REQUIREMENTS

13.0 The Contractor shall comply with all Federal, State, and local legislation, rules and regulations relating to the provision of services under the terms of this agreement.

13.1 The Contractor shall obtain and maintain in effect appropriate facility licensure and Medicare / Medicaid Certification from the Arizona State Department of Health Services enabling it to provide the levels of care contracted. The Contractor shall provide the Agency with an updated copy of the license, when issued, throughout the term of the contract.

13.2 The Contractor shall provide in compliance with Medicare Title XVIII, Medicaid Title XIX, AHCCCS Rules & Regulations (Acute Care), ALTCS Rules & Regulations and Arizona Department of Health Services Rules & Regulations.

13.3 The Contractor shall meet the minimum Professional Service Standards set forth in the Medicare/Medicaid Operation Standards for Home & Community Based Services as defined in the Code of Federal Regulations, Title 42, and Arizona Department of Health Services Rules and Regulations.

13.4 The Contractor shall provide the Agency with a copy of the Annual Survey, including Contractors Plan of Correction (if any), conducted by the Arizona State Department of Health Services throughout the term of the Contract.

13.5 The Contractor agrees to provide the Agency with copies of any substantiated complaints made against the facility/Contractor throughout the term of the agreement.

13.6 The Contractor agrees to keep current all registrations required by law.

13.7 The Contractor must participate in Provider Meetings, as needed. The Contractor is encouraged to participate in the Member/Provider Council meetings held quarterly by the Agency.

13.8 The Contractor must perform services as authorized by the Agency Case Manager and as indicated on the current Service Plan, which must be kept in the member file. The Contractor agrees to provide materials and/or services defined in the Work Statement unit of this Contract to members as requested and authorized by the Agency.

13.9 Case records shall be maintained in locked files accessible to appropriate staff. Case records must contain:

13.9a Copy of ALTCS Standardized Assessment Form updated yearly.

13.9.b Copy of completed and current authorization(s).

13.9.c Copy of Contractor Assessment and Care Plan.

13.9.d Regular narrative entries on service delivery process and member status.

13.9.e Medical information completed by the member's primary care provider.

13.9.f Documentation of daily member services will be maintained which includes: name and AHCCCS I.D. number of member, name of caregiver, task performed, date and time of service (include month/day/year), the exact amount of time spent providing service (ie time in and time out and any variations and reasons why), and valid original member signature verifying service. The original documentation of the daily member services will be provided with the claim. If the member is physically or mentally unable to sign his/her own name, it must be noted in the member's file and one of the following procedures must be followed:

1) The member may sign with his/her mark "X" witnessed by a spouse, relative, friend, or the aide, who must write the member's first name before the mark and the last name after the mark. The witness must then write his/her name and relationship. Example: "Bill X. Smith as witnessed by Mary Smith, wife". An additional witness is also needed.

OR-

2) Another person (conservator, spouse, relative or legal representative) may sign for the member only if so designated within the member file and only if the signature looks like this: "Mary Smith, wife of Bill Smith."

13.9.g If the service is not provided, reasons for non-provision must be properly recorded. If the service is not provided, for any reason the provider shall not be reimbursed. For example if services are authorized for a member three hours per day four times per week but the member was not present due to hospitalization, medical appointment or other non-medical activities such as going for a hair cut or an outing for lunch, the Contractor shall not bill the Agency for services. An authorization for service does NOT guarantee payment. It is essential that providers accurately document and bill for services as rendered for members and members must be present to receive service.

13.10 Any member who is receiving this service must be assessed and followed by a Case Manager. A care plan, based on assessment of the member's level of functioning and need for service, must be developed for each person who receives this service.

13.10.a Units of service must be provided as authorized by the Case Manager on the current Service Plan.

13.10.b The Contractor's staff will notify the Case Manager of any changes in the member's physical, mental, or social conditions.

13.11 The Contractor must initiate services within five (5) working days from the date of referral or forty-eight (48) hours if an emergency.

13.12 Once services are authorized by the Agency, Contractor agrees to provide services without interruption as specified on the authorization.

13.13 Contingency Plan for Gaps in Service For any member who will receive attendant care, personal care, in-home respite, and/or housekeeping in their home, the Agency’s Case Manager and the member/member’s representative will develop a Written Contingency Plan that identifies the systematic process on the coordination of efforts between the Contractor and the Agency Case Manager when there is an interruption of services including the member’s choice on how the service gap will be handled as the need arises.

13.13a. At initial assessment, the member/member representative and the Agency Case Manager will discuss what services are needed and will develop a contingency plan. The member/member representative will be informed of his/her right to receive service as authorized. The Contractor should provide a substitute caregiver according to the member’s service preference level at the time the gap is reported. The substitution of an alternate service will be permissible as long as the member’s needs are met by the alternate service provider.

13.13.b. The Agency Case Manager will arrange for services to begin as soon as possible after the initial assessment, contact the Contractor needed and authorize the service/services.

13.13.c. The Contingency Plan will be faxed to the Contractor. The Contingency Plan will include information about actions that the member and/or representative should take to report any gaps and what resources are available to the member, including care-giving agency providers and the member’s informal support system, to resolve unforeseeable gaps (e.g., regular caregiver illness, resignation without notice, transportation failure, etc.) within two hours. The informal support system must not be considered the primary source of assistance in the event of a gap, unless this is the member’s/family’s choice. An out-of-home placement in a NF or ALF should be the last resort in addressing gaps. The plan will also list the Contractor and the phone numbers, as well as the Agency’s Case Manager phone number and the Agency’s 800 number that will be responded to promptly 24 hours per day, 7 days per week. If the member wishes an alternate caregiver from another Agency Contractor the alternate caregiver’s number will also be listed. The member or member representative will be provided the Critical Service Gap Report Form that can be mailed to the Contractor as an alternative to calling in the service gap. The member or member representative will be encouraged to call the provider and/or Case Manager rather than mailing the Critical Service Gap Report Form so that the service gap can be responded to more timely.

A copy of the Contingency Plan will be mailed to the member and remain in the member’s home and will be updated at each reassessment visit. If the Contingency Plan is changed at reassessment, the case manager will fax the updated plan to the Contractor and send a copy to the member.

In those instances where an unforeseeable gap in critical services occurs, it is the responsibility of the Agency and the Contractor to ensure that critical services are provided within two hours of the report of the gap. However, if the Contractor/ provider agency or case manager is able to contact the member or representative before the scheduled service to advise him/her that the regular caregiver is unavailable, the member or representative may choose an alternative time to receive the service from the regular caregiver and/or an alternate caregiver from the member’s informal support system instead of a substitute caregiver from the provider agency’s back-up staff. The member or representative has the final say in how (informal versus paid caregiver) and when care to replace a scheduled caregiver who is unavailable will be delivered.

13.13.d. If the member’s caregiver is unable to provide service for any reason, the member will call the Contractor and report the gap. The Contractor will identify the member’s service preference level at the time of the gap and the member’s wishes for the alternate plan according to the Contingency Plan.

When the Case Manager and/or Contractor/Provider is notified of a gap in services, the member or member representative must receive a response acknowledging the gap and providing a detailed explanation as to

The reason for the gap and the alternative plan being created to resolve the particular gap and any possible future gaps.

The written contingency plan for members receiving those critical services described above must include a Member Service Preference Level from one of the four categories shown below:

1. Needs service within two hours

2. Needs service today

3. Needs service within 48 hours, or

4. Can wait until the next scheduled service date.

Member Service Preference Levels must be developed in cooperation with the member and/or representative and are based on the most critical in-home service that is authorized for the member. The Member Service Preference Level will indicate how quickly the member chooses to have a service gap filled if the scheduled caregiver of that critical service is not available. The member or representative must be given the final say about how (informal versus paid caregiver) and when care to replace a scheduled caregiver who is unavailable will be delivered.

The case manager should assist the member or representative in determining the member’s Service Preference Level by discussing the member’s caregiving needs associated with his/her Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs, such as housekeeping, meal preparation and grocery shopping), abilities and cognitive, behavioral and medical status. The case manager should ensure the member or representative has considered all appropriate factors in deciding the member’s Service Preference Level, including the availability of the member’s informal support system. However, it should not be assumed that the presence of an informal support system will determine the member’s Service Preference Level.

The case manager must document the Member Service Preference Level chosen in the case file. This documentation should clearly indicate the member’s or representative’s involvement in contingency planning.

A member or representative can change the Service Preference Level from a previously determined Service Preference Level at the time of the service gap, depending on the circumstances at the time. The provider agency or Contractor should discuss the current circumstances with the member or representative at the time the gap is reported to determine if there is a change in the Service Preference Level. The plan to resolve the service gap must address the member’s choice at the time the gap is reported.

13.13.e. The Contractor will notify the Agency’s Case Manager of the gap in service, date and time of the gap, the member’s request to fill the gap, the action taken, the length of time taken to fill the gap as soon as possible, but not later than the next working day.

13.13.f. If for any reason, the Contractor cannot provide services, the Contingency plan will be implemented. If the Contingency plan dictates that services must be received within two hours and the Contractor is unable to replace the caregiver, the Contractor must notify the Agency’s Case Manager as soon as possible regarding the gap and the measures taken to resolve the gap. The Case Manager will, as a last resort, offer the member a respite stay in a facility until the services can be resumed.

13.13.g. The Contractor will send in the completed gap in service report to the Agency’s Case Management Supervisor and Case Management Clerk within five days of the end of the month. The Case Management Clerk will compile the data from all agencies and compile the results into one log. The log will be forwarded to AHCCCS DHCM by the fifteenth of the month. The gap in service log will be routed to Agency’s QM/UM for tracking and trending.

13.13.h.The Agency will forward analysis reports, trends and corrective actions taken regarding gaps in service, waiting lists and grievances related to gaps to AHCCCS, as required.

13.13.i There is no “gap in service” and reporting is not required if any of the following situations occur:

13.13.i.1 The member is not available when the caregiver arrives at the member’s home (a member no-show).

13.13.i.2 The member refuses the caregiver that arrives at the member’s home at the regularly scheduled time.

13.13.i.3 The member has refused services prior to the scheduled time.

13.13.i.4 The Contractor is able to find alternative staff for the regularly scheduled visit.

13.13.i.5 The Contractor is able to contact the member before the scheduled service, and the member agrees to an alternative time to receive the service.

13.13.i.6 The member and the caregiver agree, in advance to reschedule all or part of a service.

13.13.i.7 A caregiver refuses to go to or return to an unsafe or threatening environment. In these cases CHS will be notified immediately of the situation.

13.13.j A member refusal of a service will be reported on the gap log if the member notifies the Contractor of a caregiver absence, and then subsequently refuses the substitute service, or caregiver offered.

13.14 Supervision of caregivers is a requirement of all HCBS work statements. Cost of supervision is to be included in the per unit cost of services being authorized.

13.15 The Contractor must file claims with the Agency in accordance with EXHIBIT 1.

13.16 The Contractor must ensure that all licensed or certified staff hold valid and current licensures or certifications, as required by law. Personnel files shall include:

13.16a. Employee name, address, education and work experience.

13.16.b. A photocopy of the employee’s original license must be maintained in the employee’s personnel file. In cases where an employee, such as a CNA, does not have an original license, the facility must verify licensure directly with the Arizona State Board of Nursing and document verification in the employee’s personnel file.

13.16.c The Contractor shall maintain evidence of verification of licensure or certification from the licensing agency, including current standing upon hire and annually thereafter.

13.16.d The Contractor shall document evidence that the employee received orientation and annual in-service training.

13.16.e The Contractor must document evidence that the employee is free from Pulmonary Tuberculosis (TB) prior to employment and annually thereafter. Documentation shall include date of negative result.

13.16.f The Contractor must maintain procedure to ensure verification of licensure or certification for any temporary nursing care registry personnel, including CNAs, before such personnel care for Agency members.

13.16.g The Contractor must maintain procedures to ensure that any temporary nursing care registry personnel, including CNAs, are fingerprinted before such personnel care for Agency members, as required by ARS 36-411.

13.17h The Contractor must maintain evidence of compliance with the Fingerprinting regulations as specified in ARS 36-411 for all personnel. Fingerprint is required for all persons who provide direct care to a member. Documentation of this shall be recorded in the employee's personnel file. Provider shall have a process in place to periodically evaluate that each employee remains in good standing during the duration of the clearance certification.

SECTION 14: SERVICE GOAL

To enable a member who would otherwise be in an institutional setting to remain at, or return to, the home and attain the highest quality of health care. To increase or maintain self-sufficiency of members and maximum independence in the least restrictive environment, in order to facilitate the attainment of the member's optimal level of rehabilitation, and to augment care and services provided in our community.

SECTION 15: UNIT RATES

Program management, development, supervision costs and/or other cost incurred such as cost for travel and supplies are the responsibility of the Contractor and are to be included in the unit rate quoted. No additional units will be authorized for intake visits or supervision of caregiver travel time and/or supplies.

SECTION 16: MONEY HANDLING POLICY FOR CAREGIVERS

Contractor must submit to CHS for approval a policy regarding handling of member money by caregivers. Caregivers shall be advised of the policy and this shall be documented in the member's Care Plan. The policy should, at a minimum, address gifts, loans and personal checks. If the member's family approves the utilization of the member's funds by the caregiver for certain items, this must also be documented in the Care Plan.

SECTION 17: GRIEVANCE PROCEDURES

17.0 The Contractor shall maintain a grievance procedure consistent with AHCCCS policy.

17.1 If the Contractor is unable to resolve the issue, the grievant shall be informed that appeals to the Agency are available.

17.2 Agency members should be advised to attempt to resolve any complaints through their Case Manager, which is in accordance with the Agency’s Enrollee-Provider Grievance (Informal Complaint) Process.

SECTION 18: PRESCRIPTION MEDICATION

18.0 Medicare Modernization Act (MMA)

18.0.a AHCCCS will not cover prescription drugs that are covered under Part D for dual eligible member whether or not they are enrolled in Medicare D.

18.0.b Drugs Excluded from Medicare Part D: AHCCCS does cover those drugs ordered by a PCP, attending physician, dentist or other authorized prescriber and dispensed under the direction of a licensed pharmacist subject to limitations related to prescription supply amounts, contractor formularies and prior authorization requirements if they are excluded from Medicare Part D coverage. Medications that are covered by Part D, but are not on a specific Part D Health Plan’s formulary are not considered excluded drugs and will not be covered by AHCCCS.

18.0.c As the Medicare Modernization Act is fully implemented, there may be required changes to business practices of the AHCCCS and contractors or the contract. AHCCCS will identify potential impacts and work with contractors to implement necessary program changes.

18.1 The Contractor shall agree to obtain all CHS covered medications from the Agency contracted pharmacy provider.

18.2 Upon admission, the new resident shall be required to bring all unused medications from home for which the member has a current prescription and admitting physician orders, for use during the member's residency as a long term care client. Medications shall not be reordered unless the member has used 70% of the current prescription or the Contractor has failed in several attempts to have the family provide the medications in a timely manner.

18.3 Admissions to Medicare status shall receive their medications from the Contractor.

SECTION 19: ENROLLMENT AND DISENROLLMENT

19.0 AHCCCS has the exclusive authority to enroll and disenroll members. The Agency shall not disenroll any member for any reason unless directed to do so by AHCCCS.

19.1 Member Eligibility Verification. Agency shall maintain a twenty-four (24) hour per day, seven (7) days a week telephone or on-line service to assist Contractor in verifying the eligibility of a Member. Refer to the CHS Provider Manual for instructions on verifying eligibility.

For the sole purpose of this Attachment, the following definitions apply:

“Subcontract” means any contract between the Program Contractor and a third party for the performance of any or all services or requirements specified under the Program Contractor’s contract with AHCCCS.

“Subcontractor” means any third party with a contract with the Program Contractor for the provision of any or all services or requirements specified under the Program Contractor’s contract with AHCCCS.

Subcontractors who provide services under both the AHCCCS ALTCS and/or the Acute Care Program must comply with the following applicable rules and statues:

· Rules for the ALTCS are found in Arizona Administrative Code (AAC) Title 9, Chapter28. AHCCCS statues for long term care are generally found in Arizona Revised Statues (ARS) 36, Chapter 29, Article 2.

· Rules for the Acute Care Program are found in AAC Title 9, Chapter 22. AHCCCS statues for the Acute Care Program are generally found in ARS36, Chapter 29, Article 1. Rules for the KidsCare Program are found in AAC Title 9, Chapter 31 and the statues for KidsCare Program may be found in ARS 36, Chapter 29, Article 4.

All statues, rules and regulations cited in this attachment are listed for reference purposes only and are not intended to be all inclusive.

1. ASSIGNMENT AND DELEGATION OF RIGHTS AND RESPONSIBILITIES

No payment due the Subcontractor under this subcontract may be assigned without the prior approval of the Contractor. No assignment or delegation of the duties of this subcontract shall be valid unless prior written approval is received from the Contractor (AAC R2-7-305).

2. AWARDS OF OTHER SUBCONTRACTS

AHCCCS and/or the Contractor may undertake or award other contracts for additional or related work to the work performed by the Subcontractor and the Subcontractor shall fully cooperate with such other contractors, subcontractors or state employees. The Subcontractor shall not commit or permit any act which will interfere with the performance of work by any other contractor, subcontractor or state employee (AAC R2-7-308).

3. CERTIFICATION OF COMPLIANCE – ANTI-KICKBACK AND LABORATORY TESTING

By signing this subcontract, the Subcontractor certifies that it has not engaged in any violation of the Medicare Anti-Kickback statute (42 USC §§1320a-7b) or the “Stark I” and “Stark II” laws governing related-entity referrals (PL 101-239 and PL 101-432) and compensation there from. If the Subcontractor provides laboratory testing, it certifies that it has complied with 42 CFR §411.361 and has sent to AHCCCS simultaneous copies of the information required by that rule to be sent to the Centers for Medicare and Medicaid Services. (42 USC §§1320a-7b; PL 101-239 and PL 101-432; 42 CFR §411.361).

4. CERTIFICATION OF TRUTHFULNESS OF REPRESENTATION

By signing this subcontract, the Subcontractor certifies that all representations set forth herein are true to the best of its knowledge.

5. CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires laboratories and other facilities that test human specimens to obtain either a CLIA Waiver or CLIA Certificate in order to obtain reimbursement from the Medicare and Medicaid (AHCCCS) programs. In addition, they must meet all the requirements of 42 CFR 493, Subpart A.

To comply with these requirements, AHCCCS requires all clinical laboratories to provide verification of CLIA Licensure or Certificate of Waiver during the provider registration process. Failure to do so shall result in either a termination of an active provider ID number or denial of initial registration. These requirements apply to all clinical laboratories.

Pass-through billing or other similar activities with the intent of avoiding the above requirements are prohibited. The Contractor may not reimburse providers who do not comply with the above requirements (CLIA of 1988; 42 CFR 493, Subpart A).

6. COMPLIANCE WITH AHCCCS RULES RELATING TO AUDIT AND INSPECTION

The Subcontractor shall comply with all applicable AHCCCS Rules and Audit Guide relating to the audit of the Subcontractor's records and the inspection of the Subcontractor's facilities. If the Subcontractor is an inpatient facility, the Subcontractor shall file uniform reports and Title XVIII and Title XIX cost reports with AHCCCS (ARS 41-2548; 45 CFR 74.48(d)).

7. COMPLIANCE WITH LAWS AND OTHER REQUIREMENTS

The Subcontractor shall comply with all federal, State and local laws, rules, regulations, standards and executive orders governing performance of duties under this subcontract, without limitation to those designated within this subcontract.

( 42 CFR 434.70).[42 CFR 438.6(1)]

8. CONFIDENTIALITY REQUIREMENT

Confidential information shall be safeguarded pursuant to 42 CFR Part 431, Subpart F, ARS §36-107, 36-2932, 41-1959 and 46-135, AHCCCS Rules and Health Insurance Portability and Accountability Act (CFR 164).

9. CONFLICT IN INTERPRETATION OF PROVISIONS

In the event of any conflict in interpretation between provisions of this subcontract and the AHCCCS Minimum Subcontract Provisions, the latter shall take precedence.

10. CONTRACT CLAIMS AND DISPUTES

Contract claims and disputes shall be adjudicated in accordance with AHCCCS Rules.

11. ENCOUNTER DATA REQUIREMENT

If the Subcontractor does not bill the Contractor (e.g., Subcontractor is capitated), the Subcontractor shall submit encounter data to the Contractor in a form acceptable to AHCCCS.

12. EVALUATION OF QUALITY, APPROPRIATENESS, OR TIMELINESS OF SERVICES

AHCCCS or the U.S. Department of Health and Human Services may evaluate, through inspection or other means, the quality, appropriateness or timeliness of services performed under this subcontract.

13. FRAUD AND ABUSE

If the Subcontractor discovers, or is made aware, that an incident of suspected fraud or abuse has occurred, the Subcontractor shall report the incident to the prime Contractor as well as to AHCCCS, Office of Program Integrity. All incidents of potential fraud should be reported to AHCCCS, Office of the Director, Office of Program Integrity.

14. GENERAL INDEMNIFICATION

The parties to this contract agree that AHCCCS shall be indemnified and held harmless by the Contractor and Subcontractor for the vicarious liability of AHCCCS as a result of entering into this contract. However, the parties further agree that AHCCCS shall be responsible for its own negligence. Each party to this contract is responsible for its own negligence.

15. INSURANCE

[This provision applies only if the Subcontractor provides services directly to AHCCCS members]

The Subcontractor shall maintain for the duration of this subcontract a policy or policies of professional liability insurance, comprehensive general liability insurance and automobile liability insurance in amounts that meet Program Contractor’s requirements. The Subcontractor agrees that any insurance protection required by this subcontract, or otherwise obtained by the Subcontractor, shall not limit the responsibility of Subcontractor to indemnify, keep and save harmless and defend the State and AHCCCS, their agents, officers and employees as provided herein. Furthermore, the Subcontractor shall be fully responsible for all tax obligations, Worker's Compensation Insurance, and all other applicable insurance coverage, for itself and its employees, and AHCCCS shall have no responsibility or liability for any such taxes or insurance coverage. (45 CFR Part 74) The requirement for Worker’s Compensation Insurance doesn’t apply when a Subcontractor is exempt under ARS 23-901, and when such Subcontractor executes the appropriate waiver (Sole Proprietor/Independent Contractor) form.

16. LIMITATIONS ON BILLING AND COLLECTION PRACTICES

Except as provided in federal and state law and regulations, the Subcontractor shall not bill, or attempt to collect payment from a person who was AHCCCS eligible at the time the covered service(s) were rendered, or form the financially responsible relative or representative for covered services that were paid or could have been paid by the System.

17. MAINTENANCE OF REQUIREMENTS TO DO BUSINESS AND PROVIDE SERVICES

The Subcontractor shall be registered with AHCCCS and shall obtain and maintain all licenses, permits and authority necessary to do business and render service under this subcontract and, where applicable, shall comply with all laws regarding safety, unemployment insurance, disability insurance and worker's compensation.

18. NON‑DISCRIMINATION REQUIREMENTS

The Subcontractor shall comply with State Executive Order No. 99-4, which mandates that all persons, regardless of race, color, religion, gender, national origin or political affiliation, shall have equal access to employment opportunities, and all other applicable Federal and state laws, rules and regulations, including the Americans with Disabilities Act and Title VI. The Subcontractor shall take positive action to ensure that applicants for employment, employees, and persons to whom it provides service are not discriminated against due to race, creed, color, religion, sex, national origin or disability. (Federal regulations, State Executive order # 99-4)

19. PRIOR AUTHORIZATION AND UTILIZATION REVIEW

The Contractor and Subcontractor shall develop, maintain and use a system for Prior Authorization and Utilization Review that is consistent with AHCCCS Rules and the Contractor’s policies.

20. RECORDS RETENTION

The Subcontractor shall maintain books and records relating to covered services and expenditures including reports to AHCCCS AHCCCS and working papers used in the preparation of reports to AHCCCS. The Subcontractor shall comply with all specifications for record keeping established by AHCCCS. All books and records shall be maintained to the extent and in such detail as required by AHCCCS Rules and policies. Records shall include but not be limited to financial statements, records relating to the quality of care, medical records, prescription files and other records specified by AHCCCS.

The Subcontractor agrees to make available at its office at all reasonable times during the term of this contract and the period set forth in the following paragraphs, any of its records for inspection, audit or reproduction by any authorized representative of AHCCCS, State or Federal government.

The Subcontractor shall preserve and make available all records for a period of five years from the date of final payment under this contract unless a longer period of time is required by law.

If this contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for a period of five years from the date of any such termination. Records which relate to grievances, disputes, litigation or the settlement of claims arising out of the performance of this contract, or costs and expenses of this contract to which exception has been taken by AHCCCS, shall be retained by the Subcontractor for a period of five years after the date of final disposition or resolution thereof unless a longer period of time is required by law. (45 CFR 74.53; 42 CFR 431.17; ARS 41-2548)

21. SEVERABILITY

If any provision of these standard subcontract terms and conditions is held invalid or unenforceable, the remaining provisions shall continue valid and enforceable to the full extent permitted by law.

22. SUBJECTION OF SUBCONTRACT

The terms of this subcontract shall be subject to the applicable material terms and conditions of the contract existing between the Contractor and AHCCCS for the provision of covered services.

23. TERMINATION OF SUBCONTRACT

AHCCCS may, by written notice to the Subcontractor, terminate this subcontract if it is found, after notice and hearing by the State, that gratuities in the form of entertainment, gifts, or otherwise were offered or given by the Subcontractor, or any agent or representative of the Subcontractor, to any officer or employee of the State with a view towards securing a contract or securing favorable treatment with respect to the awarding, amending or the making of any determinations with respect to the performance of the Subcontractor; provided, that the existence of the facts upon which the state makes such findings shall be in issue and may be reviewed in any competent court. If the subcontract is terminated under this section, unless the Contractor is a governmental agency, instrumentality or subdivision thereof, AHCCCS shall be entitled to a penalty, in addition to any other damages to which it may be entitled by law, and to exemplary damages in the amount of three times the cost incurred by the Subcontractor in providing any such gratuities to any such officer or employee. (AAC R2-5-501; ARS 41-2616 C.; 42 CFR 434.6, a. (6))

24. VOIDABILITY OF SUBCONTRACT

This subcontract is voidable and subject to immediate termination by AHCCCS upon the Subcontractor becoming insolvent or filing proceedings in bankruptcy or reorganization under the United States Code, or upon assignment or delegation of the subcontract without AHCCCS’s prior written approval.

25. WARRANTY OF SERVICES

The Subcontractor, by execution of this subcontract, warrants that it has the ability, authority, skill, expertise and capacity to perform the services specified in this contract.

26. OFF-SHORE PERFORMANCE OF WORK PROHIBITED

Due to security and identity protection concerns, direct services under this contract shall be performed within the borders of the United States. Any services that are described in the specifications or scope of work that directly serve the State of Arizona or its clients and may involve access to secure or sensitive data or personal client data or development or modification of software for the State shall be performed within the borders of the United States. Unless specifically stated otherwise in specifications, this definition does not apply to indirect or “overhead” services, redundant back-up services or services that are incidental to the performance of the contract. This provision applies to work performed by subcontractors at all tiers.

27. FEDERAL IMMIGRATION AND NATIONALITY ACT

The Subcontractor shall comply with all federal, state and local immigration laws and regulations relating to the immigration status of their employees during the term of the contract. Further, the Subcontractor shall flow down this requirement to all subcontractors utilized during the term of the contract. The State shall retain the right to perform random audits of Program Contractor and subcontractor records or to inspect papers of any employee thereof to ensure compliance. Should the State determine that the Program Contractor and/or any subcontractors be found noncompliant, the State may pursue all remedies allowed by law, including, but not limited to; suspension of work, termination of the contract for default and suspension and/or debarment of the Program Contractor.

		PAGE

GENERAL INSTRUCTIONS		3

SECTION I	PROPOSAL REVIEW SCHEDULE	5

SECTION II	PROPOSAL EVALUATION CRITERIA	6

SECTION III	CONTRACT COVER SHEET AND STANDARD CONTRACT FORM	8
	EXHIBIT 2: AHCCCS MINIMUM SUBCONTRACT PROVISIONS

SECTION IV	SUBMITTAL LETTER	36

SECTION V	EXHIBIT 1: PRICING AND COMPENSATION	37

SECTION VI	SERVICE REQUIREMENTS, METHODOLOGY AND RESPONSE	42
	EXHIBIT 3: WORK STATEMENT(S)
	HOME HEALTH NURSE	44
	HOME HEALTH AIDE	47
	PERSONAL CARE SERVICES	50
	ATTENDANT CARE SERVICES	52
	HOMEMAKER SERVICES	57
	IN-HOME RESPITE	59

	EXHIBIT 4: UNIFORM ASSESSMENT TOOL MATRIX	62

	EXHIBIT 1240-1: MEDICAL SUPPLIES INCLUDED IN FFS HOME HEALTH NURSING VISITS	63
	EXHIBIT 1240-2: HOME HEALTH SKILLED NURSING/PRIVATE DUTY NURSING SERVICES	64

SECTION VII	ORGANIZATION EXPERIENCE	65
	FINANCIAL QUESTIONAIRE	67

SECTION VIII	PROPOSAL SUBMITTAL CHECKLIST	69

	ACTIVITY	DATE


1.	Request for Proposals (RFP) Released	February 17, 2010


2.	Deadline for Submission of Written Questions	March 4, 2010


3.	Deadline to Submit Proposals: 4:00 PM., M.S.T. to:
	ATTN: Cochise Health Systems / Attn: Provider Relations	March 10, 2010
	1415 Melody Lane, Bldg. A, Bisbee Arizona 85603

	Sealed proposals will be opened and the names of proposers read aloud.	March 10, 2010


4.	RFP review committee meets, review proposal(s) and makes	March 18, 2010
	Recommendations to the Agency


5.	Contact negotiations finalized	March 25, 2010


6.	Board of Supervisors Approval	March 31, 2010


7.	Contract Start Date	April 1, 2010